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\begin{document}

             \author[1]{Atoui  Hadi}

             \author[2]{El Haddad  Cynthia}

             \author[3]{Barakat  Habib}

             \author[4]{Darido  Jessie}

             \affil[1]{  Holy Spirit University of Kaslik, Lebanon}

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\date{\small \em Received: 7 December 2019 Accepted: 1 January 2020 Published: 15 January 2020}

\maketitle


\begin{abstract}
        


Renal angiomyolipoma (AML) is the most common benign tumor of the kidney. There are few case reports in the literature, especially those occurring during pregnancy.We, at this moment, are reporting a case of a 32-year-old female patient who presented at 21 weeks of gestation with right-sided flank pain, chills, macroscopic hematuria, and vomiting. On examination, she was hemodynamically stable, with no fever. Renal ultrasound showed the presence of a hyperechogenic vascularized fatty tissue on the right kidney, measuring 7.4 x 5.1 x 6.2 cms, with minimal pelvicalyceal dilatation. The MRI opted for an angiomyolipoma. Discharged home at day 4 of admission, the patient's continued the remaining weeks of her pregnancy uneventfully, until 37 weeks. She delivered her baby vaginally with no further complications during pregnancy or in the post-partum period.In conclusion, due to the insufficient data in the literature supporting the management of patients with AML, the individualization of the treatment is an essential strategy.

\end{abstract}


\keywords{?angiomyolipoma? ?renal tumor? ?pregnancy? ?surgery? ?embolization?.}

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\let\tabcellsep& 	 	 		 
\section[{Renal Angiomyolipoma during Pregnancy:}]{Renal Angiomyolipoma during Pregnancy:}\par
A Case Report Her medical, surgical, and obstetrical history consisted of kidney stones, one vaginal delivery, and one dilatation and curettage for incomplete abortion. She was on acetylsalicylic acid (ASA) during her current pregnancy.\par
On examination, she was hemodynamically stable, with no fever. A blood test was ordered and revealed, hemoglobin level at 11.5 (Hematocrit 33.7), White Blood Count (WBC) at 11.9, CRP 3.92, Creatinine 0.48. Urine analysis showed red blood cells at 80 at WBC at 5. Hepatic panel and electrolytes were within normal levels.\par
Abdominal examination revealed tenderness on the right groin. The urologist and infectious disease specialists were also in this case. Her pain was relieved by intravenous analgesics and relative bed rest.\par
The obstetrical ultrasound showed a single intrauterine pregnancy with positive cardiac activity commensurate with the gestational age; however, the renal ultrasound showed the presence of a hyperechogenic vascularized fatty tissue on the right kidney, measuring 7.4 x 5.1 x 6.2 cms, with minimal pelvicalyceal dilatation. There is no lithiasis or subcapsular hematoma (Image 1). A renal MRI completed the investigations.\par
Image 1: Ultrasound of the right kidney, as described above\par
The MRI result showed a well-defined, 75mm, multilocular renal mass occupying the middle segment of the right kidney with an image of a small pelvicalyceal dilatation and an intracavitary hemorrhagic content. Consequently, the MRI report evoked the diagnosis of angiomyolipoma. (Image 2, 3, 4)1 Year 2020 Introduction dilatation.\par
The MRI opted for an angiomyolipoma. Discharged home at day 4 of admission, the patient's continued the remaining weeks of her pregnancy uneventfully, until 37 weeks. She delivered her baby vaginally with no further complications during pregnancy or in the postpartum period.\par
In conclusion, due to the insufficient data in the literature supporting the management of patients with AML, the individualization of the treatment is an essential strategy.\par
Keywords: "angiomyolipoma" "renal tumor" "pregnancy" "surgery" "embolization". enal angiomyolipoma (AML) is the most common benign tumor of the kidney. It appears mainly in females during their procreation age and is affected by the hormonal changes occurring during pregnancy. It could be life-threatening when ruptured, leading to severe bleeding.\par
There are few cases in the literature concerning the optimal management taken in the case of AML, especially during pregnancy.\par
We, at this moment, are going to describe the evolution of AML during pregnancy in a 32 years old female, trying to maintain a normal renal function and a viable fetus until delivery. 
\section[{II.}]{II.} 
\section[{Case Presentation}]{Case Presentation}\par
It is the case of a 32 years-old female who presented at 21 weeks of gestation. She had a one-day history right-sided flank pain, chills, macroscopic hematuria, and vomiting. On day 4 of admission, the patient's condition remained stable, with no fever and less pain. Therefore, she was discharged on analgesics with a medical report of her state, so she can rest at home. The remaining weeks of her pregnancy were completely uneventful, and the patient delivered her baby vaginally at 37 weeks with an APGAR of 9/10, weighting 2500 g. There were no further complications during the pregnancy or in the post-partum period. 
\section[{III.}]{III.} 
\section[{Discussion}]{Discussion}\par
Angiomyolipoma is the most common benign mesenchymal tumor of the kidney, composed of adipose and vascular tissue in the association of smooth muscle.\par
Its prevalence varies between 0.12 and 0.14 percent in the general population. There is also a female predominance with a ratio of 4:1. Most of the time, it is the Right kidney that is affected \hyperref[b0]{[1]}.\par
The AML could appear either sporadically or in association with tuberous sclerosis. In the first case, AML is often solitary and accounts for 80\% of the AML. Generally, patients present with a mean age of 43 years old. On the other hand, in 20\% of the cases, AML is associated with tuberous sclerosis. In the latter case, the mean age at the time of diagnosis is 25 to 35 years. The lesions typically exceeds the isolated angiomyolipoma in size, and they are often bilateral and multiple. Angiomyolipoma occurs in 80\% of patients with tuberous sclerosis. Exceptionally, these renal tumors could rupture, leading to massive retroperitoneal hemorrhage and resulting in what we call the Wunderlich syndrome \hyperref[b1]{[2]}.\par
The classical clinical presentation of AML is flank pain, palpable mass, nausea, hematuria, and anemia. AML tends to appear during the pregnancy period, due to the hormonal influence of estrogen and progesterone in addition to the increased receptors on the surface of the AML associated with the expansion of the intraabdominal pressure during gestation.\par
The sonographic features of AML consist of a well-circumscribed and highly echogenic mass because of its high-fat content, multiple nonfatty interfaces, heterogeneous cellular architecture, and numerous vessels. Other renal tumors, such as lipoma, teratoma, Wilms tumor, oncocytoma, and renal cell carcinoma (RCC), may contain fat and can be difficult to be differentiated on imaging studies. A CT scan with thin (less than 5-mm) sectioning is recommended for the confirmation of diagnosis whenever AMLs are suspected \hyperref[b2]{[3]}. However, MRI does not appear to have an advantage over CT scan, except in pregnancy, and when the intravenous contrast administration is not indicated.\par
In the case of rupture, hemodynamic stability is of critical importance for the selection of an optimal treatment strategy. In the case of hemodynamically unstable patients, emergent surgery (nephrectomy) or   Renal Angiomyolipoma during Pregnancy: A Case Report arterial embolization (if available) are the main options of treatment \hyperref[b3]{[4]}. The Embolization consists of an alternative after 12 weeks of gestation with minimal fetal radiation exposure. Concerning the asymptomatic pregnant patients, the conservative approach may be of choice in these cases \hyperref[b4]{[5]}. As for the definitive treatment, it may be delayed after the delivery. According to the literature, most of the patients with renal angiomyolipoma, delivered their babies via cesarean section (56\%), whereas only 19\% delivered vaginally (Table \hyperref[tab_0]{1}). However, vaginal delivery is a safe approach for these patients, and the cesarean does not affect the risk of rupture. Consequently, the mode of delivery should be decided based on obstetrical indications only. Vacuum extraction can also be an alternative in order to reduce the time of the second stage of labor.\par
Seeing that our patient was hemodynamically stable, along with the normal development of her fetus, a multidisciplinary approach decided that the patient proceeds to the term of delivery. She underwent a successful vaginal delivery without complications. 
\section[{IV.}]{IV.} 
\section[{Conclusion}]{Conclusion}\par
Due to the insufficient data in the literature supporting the management of patients with AML, the individualization of the treatment is an essential strategy.\par
We need to have more experience with these strategies and to initiate more studies, so it can be the basis of any recommendation for the optimal treatment method. 
\section[{Conflict of Interest}]{Conflict of Interest}\par
No conflict of interest to declare 
\section[{Consent and Ethical Approval}]{Consent and Ethical Approval}\par
Obtained from the patient to publish the case. 
\section[{Financial Funding}]{Financial Funding}\par
No funding was obtained for this publication.\begin{figure}[htbp]
\noindent\textbf{}\includegraphics[]{image-2.png}
\caption{\label{fig_0}}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{1} \par 
\begin{longtable}{P{0.20352112676056336\textwidth}P{0.0751564945226917\textwidth}P{0.03325508607198748\textwidth}P{0.03392018779342723\textwidth}P{0.041236306729264476\textwidth}P{0.05121283255086072\textwidth}P{0.2374413145539906\textwidth}P{0.17425665101721438\textwidth}}
Author\tabcellsep \multicolumn{2}{l}{Year Maternal Age}\tabcellsep GW\tabcellsep Tumor size (cm)\tabcellsep Rupture\tabcellsep RA Management\tabcellsep Pregnancy Management\\
Lee [6]\tabcellsep 1994\tabcellsep 29\tabcellsep 27\tabcellsep NR\tabcellsep Yes\tabcellsep Nephrectomy\tabcellsep Fetal death\\
Yanai [7]\tabcellsep 1996\tabcellsep NR\tabcellsep 39\tabcellsep NR\tabcellsep Yes\tabcellsep Embolization\tabcellsep Term delivery\\
Oka [8]\tabcellsep 1999\tabcellsep 32\tabcellsep 36\tabcellsep NR\tabcellsep Yes\tabcellsep Nephrectomy\tabcellsep Term C/S\\
Tanaka [9]\tabcellsep 2001\tabcellsep 23\tabcellsep 27\tabcellsep 7\tabcellsep Yes\tabcellsep Conservative +Later Embolization\tabcellsep Vaginal delivery\\
GimenoArgente [10]\tabcellsep 2006\tabcellsep 40\tabcellsep 33\tabcellsep NR\tabcellsep Yes\tabcellsep Nephrectomy\tabcellsep CS\\
Raft [11]\tabcellsep 2006\tabcellsep 40\tabcellsep 34\tabcellsep NR\tabcellsep Yes\tabcellsep conservative\tabcellsep Preterm C/S\\
Storm [1]\tabcellsep 2006\tabcellsep 32\tabcellsep 39\tabcellsep 8\tabcellsep Yes\tabcellsep Conservative\tabcellsep Vaginal delivery\\
Koh [12]\tabcellsep 2007\tabcellsep 31\tabcellsep 12\tabcellsep NR\tabcellsep Yes\tabcellsep Nephrectomy\tabcellsep Term C/S\\
Illescas Molina [13]\tabcellsep 2007\tabcellsep 36\tabcellsep 28\tabcellsep NR\tabcellsep Yes\tabcellsep conservative\tabcellsep Term C/S\\
Kontos [14]\tabcellsep 2008\tabcellsep 28\tabcellsep 33\tabcellsep 7\tabcellsep Yes\tabcellsep Nephrectomy\tabcellsep PreTerm C/S\\
Binkowska [15]\tabcellsep 2009\tabcellsep 26\tabcellsep 20\tabcellsep 17,4\tabcellsep Yes\tabcellsep Embolization\tabcellsep Term C/S\\
Komeya [16]\tabcellsep 2010\tabcellsep 39\tabcellsep 38\tabcellsep 8\tabcellsep Yes\tabcellsep Embolization\tabcellsep Term C/S\\
Zapardiel [17]\tabcellsep 2011\tabcellsep 30\tabcellsep 35\tabcellsep 11\tabcellsep Yes\tabcellsep Embolization\tabcellsep PreTerm C/S\\
Gyimadu [18]\tabcellsep 2011\tabcellsep 21\tabcellsep 25\tabcellsep 11,5\tabcellsep Yes\tabcellsep Conservative +Later Embolization\tabcellsep Term C/S\\
Lopater [19]\tabcellsep 2011\tabcellsep 34\tabcellsep 30\tabcellsep 4\tabcellsep No\tabcellsep Nephrectomy\tabcellsep Term C/S\\
Govendik Horny [20]\tabcellsep 2011\tabcellsep 30\tabcellsep 20\tabcellsep 8\tabcellsep No\tabcellsep Nephrectomy\tabcellsep NR\\
Bolufer [21]\tabcellsep 2012\tabcellsep 26\tabcellsep NR\tabcellsep 12\tabcellsep Yes\tabcellsep Nephrectomy\tabcellsep Vaginal delivery\\
Ferianec [22]\tabcellsep 2013\tabcellsep 30\tabcellsep 9\tabcellsep 21\tabcellsep Yes\tabcellsep Nephrectomy\tabcellsep Therapeutic Abortion\\
Iruloh [23]\tabcellsep 2013\tabcellsep 23\tabcellsep 31\tabcellsep 12\tabcellsep Yes\tabcellsep Embolization +Nephrectomy\tabcellsep Term C/S\\
Pontis [24]\tabcellsep 2013\tabcellsep 33\tabcellsep 34\tabcellsep 4,8\tabcellsep Yes\tabcellsep Nephrectomy\tabcellsep Preterm C/S\\
Davis [25]\tabcellsep 2013\tabcellsep NR\tabcellsep NR\tabcellsep NR\tabcellsep NR\tabcellsep NR\tabcellsep NR\\
\multicolumn{2}{l}{dos Santos [26] 2014}\tabcellsep 40\tabcellsep 18\tabcellsep 5\tabcellsep Yes\tabcellsep Conservative\tabcellsep Preterm C/S\\
Preece [27]\tabcellsep 2015\tabcellsep 45\tabcellsep 24\tabcellsep 15\tabcellsep Yes\tabcellsep Embolization +Nephrectomy\tabcellsep Term C/S\\
Bidault [28]\tabcellsep 2015\tabcellsep 31\tabcellsep NR\tabcellsep 9\tabcellsep No\tabcellsep Nephrectomy\tabcellsep -\\
Cetin [29]\tabcellsep 2015\tabcellsep 26\tabcellsep 44\tabcellsep 11\tabcellsep No\tabcellsep Nephtectomy\tabcellsep Vaginal delivery\end{longtable} \par
  {\small\itshape [Note: NR: Not Reported; GW: Gestational week; RA: Renal Angiomyolipoma; C/S: Caesarean section.]} 
\caption{\label{tab_0}Table 1 :}\end{figure}
 			\footnote{© 2020 Global JournalsRenal Angiomyolipoma during Pregnancy: A Case Report} 		 		\backmatter  			  				\begin{bibitemlist}{1}
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\end{bibitemlist}
 			 		 	 
\end{document}
