Dr Kate Zhang1, Dr Suji Prabhaharan1
1Townsville University Hospital, Townsville, Australia
Biography:
Kate is an Obstetric Medicine Registrar and General Medicine Advanced Trainee at Townsville University Hospital. She's working towards the SOMANZ Obstetric Medicine certificate and is passionate about physician education, she anticipates her role as Chief Medical Registrar. When not tackling pregnancy-induced hyperglycaemia, she enjoys exploring Far North Queensland's natural beauty.
Abstract:
Background: Renal angiomyolipomas (rAMLs) are benign heterogenous tumours that arise from the kidneys and can occur sporadically or as part of the rare genetic syndrome of Tuberous Sclerosis Complex (TSC) ¹ ². They are not entirely harmless, however, due to the risk of tumour rupture and bleeding especially if they enlarge or contain aneurysms. In fact, preventative intervention is usually recommended for tumours exceeding 4cm¹. Pregnancy with rAMLs is inherently high risk with several factors including hypothesized oestrogen mediated tumour growth, hyperdynamic circulation and increased intra-abdominal pressures contributing to potential catastrophic outcomes³. Minimal guidelines are available to direct management with most evidence arising from case studies and even this is conflicting.
Case: We present the case of a 32-year-old gravida 2 para 1 female with known bilateral rAMLs. The right sided tumour had increased in size to 67mm with evidence of intra-tumour bleeding on imaging prior to conception. Extensive monitoring and counselling occurred antenatally to establish an informed, patient centred, decision regarding the mode of delivery given the unquantifiable risk of haemorrhage peri-partum. The patient delivered at 40 weeks gestation via emergency lower section caesarean section for transverse lie in early labour without rAML related complications.
Conclusion: It is irrefutable that close monitoring is required during pregnancies complicated by rAMLs given the concerns for life threatening haemorrhage to allow for acute intervention. If detected pre-conception, counselling and prior intervention to minimise antenatal risk is the most ideal approach. Despite the above, further guidance is required surrounding timing and mode of delivery to ensure safe clinical outcomes.
Keywords
Angiomyolipoma, Pregnancy, Delivery
References
1. Soerensen FE, Nielsen TK, Madsen MG. Renal Angiomyolipoma in Pregnancy: a Case Report and Systematic Review. SN Comprehensive Clinical Medicine. 2022 Nov 4;4(1).
2. Northrup H, Aronow ME, Bebin EM, Bissler J, Darling TN, de Vries PJ, et al. Updated International Tuberous Sclerosis Complex Diagnostic Criteria and Surveillance and Management Recommendations. Pediatric Neurology. 2021 Oct;123:50–66.
3. Yu J, Astrinidis A, Howard S, Henske EP. Estradiol and tamoxifen stimulate LAM-associated angiomyolipoma cell growth and activate both genomic and nongenomic signaling pathways. American Journal of Physiology-Lung Cellular and Molecular Physiology. 2004 Apr;286(4):L694–700