COMMENTARY

Updated Advice on Managing Liver Disease During Pregnancy

Rowen K. Zetterman, MD

Disclosures

September 15, 2017

In This Article

Liver Disease Coincident With Pregnancy

Liver mass. A liver mass during pregnancy may be identified on ultrasound or physical examination. Hemangioma is the most common benign tumor of the liver and is typically present in the right lobe. Patients with a hemangioma are usually asymptomatic, although abdominal pain can occur if the hemangioma is large.[21] An increase in the size of hemangiomas during pregnancy can occur but is uncommon.

Hepatic focal nodular hyperplasia can also be found during pregnancy. These lesions are well circumscribed, not encapsulated, and rarely associated with significant symptoms. The growth of focal nodules is unaffected by pregnancy.[21]

Hepatic adenoma is a benign tumor of the liver that may develop in women on oral contraceptives, those taking anabolic steroids, or those with uncommon genetic conditions.[22] When identified in nonpregnant women on oral contraceptives, the contraceptives should be stopped and the adenoma periodically evaluated with ultrasound to ensure that it is decreasing in size. Adenomas > 5 cm diameter may require resection.[22] Although adenomas may not change in size during pregnancy,[23] the known risk for intraperitoneal hemorrhage and liver fracture with adenoma growth[24] indicates that patients with known adenomas be evaluated by ultrasound during pregnancy.

ACG recommendations: "Asymptomatic hemangioma and focal nodular hyperplasia do not need routine imaging or surveillance during pregnancy."

"Hepatic adenomas should be monitored with ultrasound during pregnancy for growth."

"...large adenomas (>5 cm) should be referred for resection before pregnancy."[1]

Biliary disorders. Another factor potentially complicating pregnancy is biliary disorders. Gallstones occur during pregnancy, although most will remain asymptomatic.[25] Should it develop, gallstone pancreatitis can be severe with risk for both the mother and the fetus.[26] ERCP can be used when needed,[27] with proper shielding of the fetus during radiography. Cholecystitis may also occur, and current recommendations suggest that laparoscopic cholecystectomy be used rather than conservative management.[26,28]

ACG recommendations: "ERCP can be performed when indicated in pregnant women (for)...biliary pancreatitis, symptomatic choledocholithiasis, and/or cholangitis."

"Minimizing fetal exposure to fluoroscopy is imperative."

"Symptomatic cholecystitis should be managed with early surgical intervention with laparoscopic cholecystectomy."[1]

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