Keywords

Angiomyolipoma , ultrasound , second trimester

Introduction

Angiomyolipoma is a benign kidney tumour made up of fat, blood vessels and smooth muscle tissue. It is of benign nature but at times the tumour can spread into and destroy surrounding tissue[1]. It can also cause sudden bleeding (haemorrhage) from the kidney into the abdomen leading to massive intraperitoneal hamemorrhage. Bleeding is more likely to occur with tumours that are larger than 4 cm in size. Many tumors in pregnancy manifest as pain on either flank, with abdominal or colic–like pain. Signs like arterial hypertension or symptoms like haematuria and dysuria may occur. Tumors can be discovered at an early stage or before first clinical symptoms present themselves. Overall incidence is 0.3 % in the general population[2]. Maternal and fetal health should be taken in consideration before any further management as it is a challenging diagnostic and curative problem[3]. CASE: A 28 year old primigravida 18 weeks of gestation came with acute pain in right lumbar region. Physical examination revealed tenderness in the right lower abdominal quadrant without evident peritoneal signs and positive right Goldflamm sign. Serum C–reactive protein was elevated up to 3 times the normal value with accompanying leucocytosis and low hemoglobin concentration – 8.6 g/l and elevated urinary ketonic bodies. On abdominal ultrasound a heterogenous right renal mass was 65 x 48 mm seen. No signs of invasion of adjacent tissues were present on ultrasound. The fetal ultrasound did not display any pathological findings. Conservative management was done till 27th week when suddenly the size of mass was found increasing and patient complained of agonising pain[4]. An MRI in the 27th week showed rapid growth of the tumor with measurements 79 x 67 mm and polycystic tumor with multiple thick–walled cysts with inhomogeneous contents and signs of fresh intracystic bleedings in some cysts. An India ink artifact was visible, which pointed to angiomyolipoma (AML). The attendants along with the patient were counseled for emergency laparotomy and consent well taken. Perinatal complications due to prematurity were explained. After evaluation, premature termination of pregnancy along with right radical nephrectomy through subcostal incision was done. The mother’s postoperative course was uneventful. The baby was cyanotic at birth with low apgar score , may be due to asphyxia, acidosis and maternal inflammatory process.The resected tissue was sent for histopathological examination which confirmed our provisional diagnosis of angiomyolipoma.

Axial T2 weighted MR image

Intra operative picture of radical nephrectomy

Histopathology report

Discussion

Neoplasms such as Renal angiomyolipoma are rarely found in pregnant women[5].Such neoplasms generally remain asymptomatic but can also present with abrupt bleeding during pregnancy leading to increased morbidity. These lesions should be followed weekly or fortnightly with serial imaging studies, and if significant variations are present or the patient is at risk for flank trauma, elective intervention should be initiated as soon as possible so as to increase the chances of renal salvage prior to the development of symptoms and potential complications.This overall reduces morbidity and mortality.

Conclusion

Early diagnosis of this tumor might have led to a better outcome in respect of maternal and fetal morbidity if the mother was operated in early pregnancy or even before becoming pregnant[6]. This fact underlines the usefulness of abdominal and pelvic ultrasound especially in early pregnancy. MRI can yield clinical information as to the local spread of the tumor and help in proper decision making. MRI can be safely performed using Gadolinium contrast agents[7]. Second trimester is the most appropriate time for any surgical intervention.The method of diagnosis, option for management and opti mal time for Surgical intervention depends on maternal and fetal condition.