妊娠合并原发性肝癌3例临床分析及文献复习

目的探讨妊娠合并原发性肝癌的临床特点及处理,提高妊娠合并原发性肝癌诊断率,改善母儿不良结局。方法回顾性分析西安交通大学第一附属医院2013年1月至2020年7月收治的3例妊娠合并原发性肝癌患者的临床资料,结合文献对其诊断及治疗过程进行分析总结。结果妊娠合并原发性肝癌发病率低,临床表现不典型,与妊娠期生理改变及妊娠期特有疾病相似,导致妊娠合并原发性肝癌早期诊断困难。病例1:乙肝病史4年,孕早期出现血小板计数(PLT)为63×10⁹/L、肝功能持续轻度异常、中孕期唐氏筛查开放性神经管畸形高风险[甲胎蛋白(AFP)为128.8ng/mL,AFP校正:2.68MOM],均考虑与产科疾病相关,直至孕36⁺³周妊娠合并原发性肝癌诊断明确,孕37周剖宫产终止妊娠后转消化科治疗。病例2:乙肝病史9年余,原发性肝癌病史6年,停经4个月发现妊娠,中孕期唐氏筛查开放性神经管畸形高风险(AFP为962.76IU/mL、AFP校正:29.70MOM),考虑肝癌复发,建议终止妊娠,患者拒绝,于孕33周促胎肺成熟后剖宫产终止妊娠,术后行肝癌射频消融术。病例3:乙肝病史9年,因"反复乏力伴腹胀9年,呕血1周"行腹部增强电子计算机断层成像(CT)中发现妊娠,胎儿超声:活胎,相当于孕25+6周,PLT为37×10⁹/L;肝功轻度异常、凝血酶原时间为18.00s、AFP为372.2ng/L,全麻下剖宫取胎术+子宫次全切除术,术后行经颈静脉肝内门腔分流术(TIPS)+曲张静脉栓塞术+肝动脉化疗栓塞术(TACE)。结论妊娠合并原发性肝癌多见于乙肝表面抗原(HBsAg)阳性的孕妇,加强对HBsAg阳性患者的孕前咨询、孕期监测管理,重视乙肝标志物、影像学及血清AFP的综合检测,可提高妊娠合并原发性肝癌的诊断率,便于优化管理,做到早发现、早诊断、早治疗,改善预后。

Clinical analysis and literature review of 3 cases of pregnancy associated with primary liver cancer

Objective To investigate clinical features and management of pregnancy associated with primary liver cancer,improve diagnosis rate of the disease and maternal-fetal outcomes.Methods The clinical data of 3 pregnant women with primary liver cancer who admitted to The First Affiliated Hospital of Xi’an Jiaotong University from January 2013 to July 2020 were retrospectively analyzed,and the diagnosis and treatment processes were analyzed and summarized based on the literature review.Results The incidence of pregnancy associated with primary liver cancer was low and the clinical manifestations were not typical because they were similar to physiological changes and diseases specific to pregnancy,resulting in difficulty in early diagnosis.Case 1:This patient had four years history of hepatitis B,her platelet count(PLT)was 63×10⁹/L and had continous mild abnormal liver function in early pregnancy.She was told high-risk of open neural tube defects in Down’s syndrome screening in middle pregnancy[when alpha fetoprotein(AFP)was 128.8 ng/mL and corrected AFP was 2.68 MOM,which was considered being associated with obstetric diseases].Until 36+3 weeks of genitational age the diagnosis of pregnancy associated with primary liver cancer was determined.At 37 weeks of gestational age cesarean section was performed to terminate the pregnancy and then the patient was referred to the digestive department of our hospital for further treatment;Case 2:The patient had more than 9 years history of hepatitis B and 6 years history of primary liver cancer,and found pregnancy at four months after menopause.She was told high-risk of open neural tube defects in Down’s syndrome screening in middle pregnancy[when alpha fetoprotein(AFP)was 962.76 IU/mL and corrected AFP was 29.70 MOM,which was considered as recurrence of liver cancer and the pregnant woman was advised to terminate the pregnancy but she refused].At 33 weeks of gestational age,cesarean section was performed on her to terminate the pregnancy after fetal lung maturity promotion treatment was given.After ceserean section,the patient received radiofrequency ablation of liver cancer;Case 3:The patient had 9 years history of hepatitis B.Abdominal enhanced computed tomography(CT)due to repeated fatigue complicated with abdominal distension for 9 years and hematemesis for 1 week revealed the pregnancy and fetal ultrasound showed live fetus equivalent to 25+6 weeks of gestational age.Her platelet count(PLT)was 37×10⁹/L,and she had mild abnormal liver function.The prothrombin time(PT)was 18.00 s and AFP was 372.2 ng/L.Then she was performed on ceserean hysterectomy under general anesthesia.After the operation,she received transjugular intrahepatic portal shunt(TIPS),varicose vein embolization and hepatic artery chemoembolization(TACE)in turn.Conclusion Pregnancy associated with primary liver cancer occur in those pregnant women with positive HBsAg.Strengthening comprehensive mornitoring measures including pregestational consulting,antenatal monitoring and management,and detection of the markers of hepatitis B combined with imaging examination and serum AFP detection,can improve the diagnosis rate of pregnancy associated with primary liver cancer,facilitate to optimize the management,achieve early identification,early diagnosis and early treatment,thereby the prognosis of those HBsAg-positive patients would be improved.