Hepatic, Biliary, and Pancreatic Disorders 1069 -This is an uncommon benign neoplasm but has a 5-percent risk of malignant transformation and a significant risk of rupture-associated hemorrhage, particularly in pregnancy. s just discussed, adenomas can usually be diferentiated from focal nodular hyperplasia by MR or CT imaging. Adenomas have a 9:1 predominance among women and are strongly linked with COC use. The rupture risk progresses with lesion size, and surgery is generally recommended for tumors measuring >5 cm (Agrawal, 2015). T ran and colleagues (2016) recommend sonographic surveillance of hepatic adenomas during pregnancy. In one review of 27 cases in pregnany, 23 became apparent in the third trimester .nd puerperium (Cobey, 2004). Bleeding complicated no tumors measuring <6.5 cm. However, 16 of27 women (60 percent) with an adenoma presented with tumor rupture that resulted in seven maternal deaths and six fetal deaths. Of note, 13 of 27 women presented within 2 months postpartum, and in hal, hemorrhage heralded rupture. Wilson and coworkers (2011) described two cases of bleeding hepatic adenoma during pregnancy. One was managed by laparoscopic segmental resection, and another, which followed liver biopsy, required open surgery. The authors discourage biopsy during pregnancy for suspected hepatic adenomas, and emphasize the feasibility of resection for problematic lesions.
In 2013 in the United States, 5921 adult liver transplants were performed, and 34 percent of patients were women (Kim, 2015b). Currently, more than 65,000 recipients of liver transplant are living, and one literature review cited 450 pregnancies in 3026 women who had undergone transplantation (Deshpande, 2012). Although their live-birth rate of 80 percent and miscarriage rate compare favorably with those of the general population, risks of preeclampsia, cesarean delivery, and preterm birth are significantly elevated. A fourth of pregnancies were complicated by hypertension, approximately a third resulted in preterm birth, and in 10 percent, there was one or more rejection episodes (Table 55-4). Importantly, 4 percent of mothers had died within a year after delivery, but this rate is comparable to that in nonpregnant liver transplantation patients. Ghazali and associates (2016) analyzed the National Inpatient Sample database and found 2.r1 liver transplants per 100,000 deliveries. Pregnancies after liver transplant had signiicantly greater risks of maternal and fetal complications, including hypertensive disorders, gestational diabetes, and postpartum hemorrhage. Rates of preterm birth, fetal growth restriction, and congenital anomalies were also increased. Mattila and colleagues (2017) found that half of the women they cared for had maternal complications.
In the United States, 20 percent of women older than 40 years have gallstones. Most stones contain cholesterol, and its overse cretion into bile is thought to be a major factor in stone forma tion. The cumulative risk of all patients with silent gallstones to require surgery for symptoms or complications is 10 percent at 5 years, 15 percent at 1° years, and 18 percent at 15 years (Greenberger, 2015). For these reasons, prophylactic cholecys tectomy is not warranted for asymptomatic stones. For symp tomatic gallstone disease, nonsurgical approaches have been used and include oral bile acid therapy with ursodeoxycholic acid and extracorporeal shock wave lithotripsy. Experience with these during pregnancy is lacking.