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Management of Cholangiocarcinoma in Pregnancy: A Case Report.
Abstract Number: RF2BB-100
Abstract Type: Case Report Case Series
Cholangiocarcinoma is the second most common primary hepatic malignancy . Treatment includes surgical resection, orthotopic liver transplantation, and chemotherapy . This is a case of metastatic cholangiocarcinoma diagnosed during pregnancy.
A 37-year-old female, G7P2042, at 29 weeks gestation with a history for heroin abuse on methadone who presented with progressive right upper quadrant pain, nausea, vomiting, and jaundice for 2 months. A RUQ ultrasound with subsequent MRCP was performed with results of distal common bile duct obstruction and two liver lesions with concern for malignancy. The patient was started on hydromorphone PCA with addition of home methadone dose, supplemental ketorolac and oxycodone ER. She was transitioned to morphine PCA for trial of opioid rotation given her continued complaint of severe pain. Soon after, the patient underwent an IR-guided liver lesion biopsy with final pathology of intrahepatic cholangiocarcinoma. Of note, INR increased from the beginning of admission.
An interdisciplinary meeting was held, and the decision was made to proceed with imminent delivery due to maternal concerns out weighing fetal concerns, given the patient's consumption of numerous drugs, including heroin, the ongoing intractable pain, and deteriorating liver function including coagulation.
Prior to initiation of the planned delivery, the patient noted spontaneous preterm premature rupture of membranes. She received two doses of vitamin K 10mg with subsequent normalization of coagulation including INR and prothrombin. Induction of labor was started and a combined spinal epidural was placed for analgesia, at L2-L3 interspace without any complications. The patient had an uncomplicated vaginal delivery. Eventually, pain management consisted of morphine PCA, IV morphine prn, methadone, gabapentin, and ketorolac.
ERCP with stent placement was accomplished on postpartum day 3. The patient underwent endoscopic ultrasound guided celiac plexus neurolysis on postpartum day 5 given her persistent abdominal pain. The patient was weaned off of IV-PCA and transitioned to methadone, gabapentin, oxycodone, flexeril, diclofenac, fentanyl patch, and lidocaine patch. Inpatient chemotherapy was started on postpartum day 10. The patient was discharged on postpartum day 17 with plan for outpatient chemotherapy and palliative care.
Cholangiocarcinoma is an uncommon and aggressive malignancy associated with a median survival of 3-6 months and an incidence of 0.58 per 100,000 . This case highlights the potential anesthetic challenges in a pregnant patient with cholangiocarcinoma including potential contraindication to regional anesthesia/analgesia and difficult pain control in the peri-partum period.
1. Blechacz, B. Gut and Liver, Vol. 11, No. 1, January 2017, pp. 13-26.
2. Doherty B, Nambudiri VE, Palmer WC. Curr Gastroenterol Rep 2017;19(01):2