Obstetrics & Gynaecology Forum Volume 29 | Issue 3 | 2019

O&G Forum 2019; 29: 29 - 30 CASE REPORT to 17mm. The findings of a subsequent dynamic computed tomog- raphy scan (CT) were consistent with a hepatocellular carcinoma. Repeat LFTs confirmed worsening liver derangement, and in view of the guarded prognosis, the patient was managed conservatively with opioid analgesia. An ultrasound guided liver biopsy was car- ried out. She became deeply jaundiced, hypotensive and tachycardic. Serial blood gas analysis showed worsening metabolic acidosis. Her Glasgow coma scale steadily deteriorated and she subsequently de- mised 11 days after initial admission. Discussion HCC predominantly develops in cirrhotic livers with men affected twice as often as women. 1, 2, 7, 8 In resource constrained settings (Asia and Africa) younger patients with chronic Hep B infection (usually non-cirrhotic) 4, 5, 8 or chronic Hep C infection are affected, 1, 7 whereas in affluent settings (West and Japan) older patients with cirrhosis related to hepatitis infection or excessive alcohol intake are affect- ed. Hep B related HCC commonly results from acquired infection at birth or early in life. 8 The patient presented in this report was HB- sAg- positive. HCC during pregnancy is extremely rare, resulting in limited knowledge regarding its management and outcomes. 1, 2 Whether pregnancy adversely affects the prognosis of HCC (due to elevated levels of sex hormones) is questionable. 1, 4-7 Choi et al. 3 in their 2011 analysis showed a marked improvement in the median survival of pregnant patients with HCC after 1995 as compared to those before 1995. It may well be that we are now seeing a reduction in HCC asso- ciated morbidity and mortality during pregnancy, due to improved diagnostic techniques enabling earlier diagnosis; and advances in medical and surgical management. Laboratory investigations such as LFTs and AFP, and imaging such as US, CT, and magnetic resonance imaging (MRI) are recom- mended for use in the diagnosis and surveillance of HCC. 3, 8, 9 Al- though half of the patients with HCC in pregnancy have abnormal LFTs, only a few have serious abnormalities. While our patient had abnormal LFTs and a markedly elevated AFP, there was no ascites or encephalopathy present. Choi et al. 3 showed that a well-preserved liver function was consistent with HCC in younger patients, and nei- ther ascites nor encephalopathy was evident in the 48 patients they reviewed. Using the AFP level for HCC screening is controversial and unre- liable in pregnant women. The maternal serum AFP (MSAFP) varies with each trimester; as well as maternal weight, ethnic group, age, and the presence of diabetes. HCC should be considered if a patient has an MSAFP above the normal multiple of the median and if the patient is HBsAg-positive, 3, 9 as was the case in our patient. US plays a major role in screening for and diagnosing HCC during pregnancy, 3 with a sensitivity of 90% for identifying liver tu- mours, but it is unreliable in differentiating solid liver masses. Nev- ertheless, its high sensitivity and safety for the foetus make US a good initial diagnostic method. MRI is recommended because it can distinguish most solid liver masses, 3, 8 but must be applied without contrast in pregnant women. CT is not recommended because of the risk of foetal radiation exposure. Percutaneous biopsy, not usually recommended because of the risk of haemorrhage and tumour cell seeding, can be used when the diagnosis is in doubt. 3 The management of HCC entails both non-surgical and surgical approaches. 3, 5, 8 Percutaneous ultrasound guided ethanol injection with subsequent necrosis of the tumour, is a widely used palliative procedure with large case series reporting good results. 5, 8 Thrombot- ic agents also achieve similar results. Chemo-embolization has been shown to cause partial or complete necrosis of even large HCCs, al- though randomised trials have failed to show any benefit over con- servative therapy. 5, 8 The side-effects of these treatment modalities are similar and include abdominal pain, abscess, haemorrhage, and tumour cell seeding. 8 Favourable tumour-related factors (which our patient lacked) in- clude single tumours, small tumours, low AFP levels, an absence of portal-vein thrombosis, and a lack of severe coagulopathy or ascites. The surgical approach involves tumour resection. 5 For HCCs occur- ring in cirrhotic livers, patients are in danger of decompensating or liver failure if an over aggressive resection is attempted. However, liver resection is recommended as the best therapeutic modality for HCC, even in pregnant women. 1, 3, 5, 8 In the report by Choi et al., 16 patients who underwent surgery appeared to have had complete re- section. 3 Liver transplantation is also a feasible therapy, but there is no report of liver transplantation to treat HCC in pregnancy. 3 The diagnosis of HCC in pregnancy presents a dilemma with re- gards to continuing or terminating the pregnancy. Termination may be appropriate if the diagnosis is made early, whereas if diagnosed late, commencing therapy after induced or abdominal delivery may be preferable. 1-5 Vaginal delivery followed by resection appears to be acceptable, avoiding the need for two operations. If a patient refuses termination following early diagnosis, then resection and pregnan- cy continuation may be appropriate, with the patient being coun- selled that liver resection carries a risk of miscarriage. 3, 5 Since our patient presented late in gestation and went on to deliver vaginally, she would have been a possible candidate for resection had she not undergone such rapid deterioration in her clinical condition. HCC during pregnancy may no longer be associated with high levels of morbidity and mortality in affluent settings, however in resource constrained settings late presentation with rapid progression and a high mortality still remains a problem. Acknowledgements We acknowledge Dr C. Tiloke for the assistance in the manuscript preparations. References 1. Mnyani N, Hull JC, Mbakaza MB, Krim AOA, Nicolaou E. Delayed presentation and diagnosis of metastatic hepatocellular carcinoma in pregnancy. S Afri Med J 2015; 105 (10): 877. DOI:10.7196/ SAMJnew.8781 2. Kutty DN, Kanchana MP. A Rare Case of Haemoperitoneum in Pregnancy. J Clin Diagn Res 2016; 10 (4): 13-15. DOI:10.7860/ JCDR/2016/17715.7603 3. Choi KK, Hong YJ, Choi S B, Park YN, Choi JS, Lee WJ, Kim KS. Hepatocellular carcinoma during pregnancy: is hepatocellular carcinoma more aggressive in pregnant patients? J Hepatobiliary Pancreat Sci 2011; 18: 422-431. 4. de la Rosa MA, Nicolás-Pérez D, Muñiz-Montes JR, Trujillo-Carrillo JL. Evolution and management of a hepatocellular carcinoma during pregnancy. J Obstet Gynaecol Res 2006; 32 (4): 437-439. 5. Hung C, Wu C, Cheng S, Hsia J, Wang J, Lui W, P’eng F. Surgical resection for hepatocellular carcinoma in pregnancy: A case report. Asian J Surg 2012; 35:124-126. 6. Chen H, Li J, Huang P, Chen R, Lai ECH, Lau WY. Synchronous right hepatectomy and cesarean section in a pregnant lady with hepatocellular carcinoma. Int J of Surg Case Rep 2013; 4: 112-114. 7. Amr S, Emily A, Larocci EA, Nasr GR, Saleh D , Blancato J, Shetty K, Loffredo CA. Multiple pregnancies, hepatitis C, and risk for hepatocellular carcinoma in Egyptian women. BMC Cancer 2014, 14: 893.http://www. biomedcentral.com/1471-2407/14/893 8. Llovet JM, Burroughs A, Bruix J. Hepatocellular carcinoma. Lancet 2003; 362: 1907-1917. 9. Jeng LB, Lee W Wang C, Chen M, Hsieh T. Hepatocellular carcinoma in a pregnant woman detected by routine screening of maternal α-fetoprotein. Am J Obstet Gynecol 1995; 172: 219-221. OBSTETRICS & GYNAECOLOGY FORUM 2019 | ISSUE 3 | 30