SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2023 | VOLUME 21 | ISSUE 1 | 11 CASE STUDY Despite hepatocellular carcinoma (HCC) being the third leading cause of all cancer deaths globally, its occurrence in pregnancy is rare, with an annual incidence of 1 per 100 000. 1, 2 This is likely underestimated, particularly in sub-Saharan Africa (SSA) where hepatitis B virus (HBV), the most common aetiology of HCC, remains endemic. The course of HCC in pregnancy is thought to be accelerated due to several factors, and outcomes are generally worse than in the general population. 1, 2 We highlight this in a recent patient referred to our facility. Case A 29-year-old female, born in Zimbabwe and pregnant at 23 weeks’ gestation, was referred in June 2022. She was previously well with 3 prior uncomplicated pregnancies. All three pregnancies were carried to term. She had two uncomplicated normal vaginal deliveries in 2008 and 2011 and a caesarian section for prolonged labour in 2016. She had no history of smoking, alcohol, or other substance use. She was married and used the combined oral contraceptive pill (COC) between pregnancies. She was known to be HIV negative, confirmed on multiple previous tests, most recently during her current pregnancy. No record of hepatitis B or C screening was found when reviewing previous laboratory results from previous pregnancies and clinic visits, despite many primary care clinic contacts. She first noted some abdominal discomfort in January 2022. She was seen at her local clinic in February and treated with simple analgesics. A blood test confirmed that she remained HIV negative; her ALT was 30 U/L (normal <40), and her total bilirubin was 6 μmol/L (normal <18). She booked her pregnancy at her local clinic at the end of April 2022. In May 2022 a large epigastric mass was noted. She was referred to a secondary-level hospital where she was admitted at the end of May. Initial investigations were performed, including an abdominal ultrasound (US) which confirmed an abdominal mass but could not establish its origin. She was transferred to our hospital a week later. Blood tests on the 6th of June 2022 noted a total bilirubin of 7 μmol/L, albumin 34 g/L (normal 35- 52), ALT 16 U/L, AST 256 U/L (normal <40), GGT 348 U/L (normal <60) and an INR 1.3. Her white cell count was 11 x 109/L, haemoglobin 9.2 g/dL and platelets of 384 x 109/L. Hepatitis A IgM and hepatitis C antibody were both negative, but hepatitis B sAg was positive with a negative HBeAg and positive HBeAb. Her hepatitis B viral load was 1102 IU/ml, and her alpha- fetoprotein was 149 μg/L (normal <7 in non-pregnant patient). Importantly in the context of pregnancy this is difficult to interpret. A decision was made to perform abdominal magnetic resonance imaging (MRI) with gadolinium. The MRI confirmed a large hepatocellular carcinoma classified as a Liver Imaging Reporting and Data System (LI-RADS) 5 lesion (Figures 1 and 2). A low-dose computer tomography (CT) of the chest confirmed lower lobe pulmonary nodules consistent with pulmonary metastasis (Figure 3). Extensive multidisciplinary discussions were held together with obstetrics, hepatology, and hepatobiliary surgery to discuss management options. As the patient was BCLC stage C no curative intent treatment options were available, with the tumour being irresectable, outside transplant criteria and too large for ablation. A major clinical challenge was the size of the mass in an abdomen with an enlarging gravid uterus. The family declined a termination of the pregnancy, but active fetal monitoring was not performed. To try and decrease tumour size, a bland trans-arterial embolization was performed on the 7th of July 2022 (Figure 4). During her admission, recurrent episodes of hypoglycaemia were recorded and managed with both intravenous dextrose and a high-caloric diet. The patient and her husband were both aware of the poor prognosis and as a result requested that she be allowed to spend time at home, particularly with her other 3 children. She was discharged with an agreement that she would be seen weekly for follow-up. No foetal monitoring would be done, but a caesarian section was planned for 34 weeks. The patient was discharged with high-energy drinks and advice regarding frequent intake to combat episodes of hypoglycaemia. She attended one week later for review but unfortunately demised suddenly at home thereafter, likely secondary to tumour rupture or possible hypoglycaemia. Hepatocellular Carcinoma in pregnancy E Gatley 1 , M Sonderup 1 ,S Beningfield 2 , M Bernon 3 , G Human 2 , E Jonas 3 , S Sobnach 3 , CW Spearman 1 1 Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa 2 Department of Radiology, Faculty of Health Sciences, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa 3 Department of Surgery, Faculty of Health Sciences, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa Correspondence Elizabeth Gatley email: lizgatley@gmail.com