Symptomatic liver hemangioma with intra-tumor hemorrhage treated by angiography and embolization during pregnancy

Background: Cavernous hemangiomas are the most common benign tumors of the liver and are found in about 2% of autopsy patients. The vast majority are small (less than 4 cm) and asymptomatic, but there have been a few reported cases of these lesions leading to severe pain and even spontaneous fatal hemorrhage. Estrogen may cause the growth of liver hemangiomas, but there is a paucity of information concerning the effect of pregnancy upon these lesions. Case: A patient presented at 18 weeks’ gestation with the acute onset of vomiting and epigastric pain. A right upper-quadrant ultrasound scan found a 9-cm hypodense lesion within the liver, and magnetic resonance imaging (MRI) suggested a hemangioma. The lesion was believed to be inoperable, and selective catheterization of the common hepatic artery was performed. An angiogram demonstrated a round vascular mass 12 cm in diameter occupying much of the left side of the liver, with the vascular supply from the middle hepatic artery and to a lesser extent from the left hepatic artery. Embolization was performed, and a postembolization image demonstrated satisfactory occlusion of the vessels treated. The patient’s epigastric pain resolved after the procedure. The lesion was observed with monthly ultrasound and regressed to about 50% of its original size. The patient was scheduled for an elective primary cesarean delivery at 39 weeks to avoid possible rupture of the hepatic hemangioma during the second stage of labor. Her cesarean and postpartum course were uncomplicated. Conclusion: A symptomatic liver hemangioma with intratumor hemorrhage can be successfully treated with embolization during pregnancy. Because of the paucity of reported cases, it is uncertain whether vaginal birth is contraindicated in these patients.