Journal of Emergencies, Trauma, and Shock
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CASE REPORT  
Year : 2012  |  Volume : 5  |  Issue : 4  |  Page : 367-369
Primary hepatic pregnancy


Department of Obstetrics and Gynaecology, Lady Hardinge Medical College and Smt. Sucheta Kriplani Hospital, New Delhi, India

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Date of Submission07-Sep-2011
Date of Acceptance06-Aug-2012
Date of Web Publication15-Oct-2012
 

   Abstract 

A 25-year-old G2P1L1 woman with 18-week pregnancy presented with right hypochondriac pain and vomiting for the past 1 week. She had borderline vitals and a diffusely tender abdomen. Ultrasound revealed a live 18-week fetus attached to the undersurface of the liver with moderate ascites. Laparotomy was carried out which revealed 500 cc of hemoperitoneum with a primary hepatic pregnancy of the right lobe of liver and bleeding from the placental site. After extracting the fetus, the placenta was left inn situ and the abdomen was packed to control the bleeding as other hemostatic measures failed. Hepatic artery embolization was done after surgery followed by relaparotomy but the abdomen had to be repacked again as the patient was unstable with uncontrollable bleeding. The patient succumbed to DIC despite adequate replacement. In retrospect, the authors conclude that embolization could have been done before surgery and partial hepatic resection attempted in the first instance.

Keywords: Embolization, hepatic resection, methotrexate, primary hepatic pregnancy

How to cite this article:
Yadav R, Raghunandan C, Agarwal S, Dhingra S, Chowdhary S. Primary hepatic pregnancy. J Emerg Trauma Shock 2012;5:367-9

How to cite this URL:
Yadav R, Raghunandan C, Agarwal S, Dhingra S, Chowdhary S. Primary hepatic pregnancy. J Emerg Trauma Shock [serial online] 2012 [cited 2020 Apr 8];5:367-9. Available from: http://www.onlinejets.org/text.asp?2012/5/4/367/102417



   Introduction Top


Abdominal pregnancy is a rare type of ectopic pegnancy with an estimated incidence being 1 in 8,000 births and 1.4 % of all ectopic pregnancies. Most commonly, the site of implantation in an abdominal pregnancy is pelvic, but very rarely it may implant in the upper abdomen. The authors report such a case of primary hepatic pregnancy on account of its rarity and the therapeutic dilemmas.


   Case Report Top


A 25-year-old G2P1L1 woman with a 3-month history of amenorrhea presented to casualty with right hypochondriac pain and vomiting for the past 1 week. She had a normal vaginal delivery 9 months ago. On examination, her pulse rate was 96/min, blood pressure was 90/54 mmHg and she appeared mildly anemic. Abdomen was soft but diffusely tender. There was no guarding, rigidity, or palpable mass. On speculum examination, the cervix and vagina were healthy. On vaginal examination, the uterus was anteverted, bulky, mobile, and nontender, and bilateral fornices were free. Her urine pregnancy test was positive. On an ultrasound scan, the uterus was found to be enlarged with an endometrial thickness of 10 mm; bilateral adnexae were normal and free fluid was present in the abdomen. A sac with a live fetus corresponding to 17- to 18-week gestational age was seen attached to the inferior surface of the liver [Figure 1]. A provisional diagnosis of primary hepatic pregnancy was made. A decision was taken for laparotomy in view of suspected hemoperitoneum with borderline vitals. Her blood investigations showed Hb 9.4 g%, TLC 6000, platelets 237 × 10 3 , and INR 1.18. LFT and KFT were normal.

Laparotomy was carried out with a midline vertical incision which was extended subcostally on the right side, and 500 cc of hemoperitoneum was drained. The uterus and adnexa were normal looking. On exposing the liver, a 10-cm sac was seen on the undersurface of the right lobe [Figure 2]. There was fresh bleeding from the site of placental attachment. After rupturing the sac through an avascular area, a 300-g fetus [Figure 3] was extracted and the umbilical cord was ligated. The placenta was left in situ and attempts were made to secure the bleeding area with hemostatic sutures, but without any success. Finally, the area was packed and the abdomen was closed in a single layer. Perioperatively, there was a total blood loss of 2.5 l and four units of blood were transfused. Postoperatively, the patient was transferred to ICU on inotropes and ventilatory support. However, the patient continued to bleed through the dressings, and after consultation with the gastrointestinal surgeon and interventional cardiologist, a decision was made to proceed with embolization. Hepatic artery embolization was carried out 18 h after surgery. The patient continued to bleed despite embolization and further laparotomy was carried out to remove the packs to avoid the risk of sepsis.
Figure 1: Ultrasound showing the gestation sac below the liver

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Figure 2: Peroperative picture showing the gestation sac attached to the undersurface of the liver

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Figure 3: 18 weeks fetus being extracted

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At the time of the laparotomy, the abdomen was full of blood. Packs were removed slowly, but there was diffuse bleeding from the undersurface of the liver. The patient remained unstable, and it was decided to pack the abdomen again and to replace blood. She received a total of 76 units of blood and blood products at regular intervals.

On the fourth postoperative day, patient's urine output decreased markedly, coagulation became deranged, and the vitals were unstable despite the use of inotropes. A decision was made to proceed with liver resection but the patient was too unstable and sadly she passed away on the fifth postoperative day due to multiorgan failure secondary to hemorrhage.


   Discussion Top


Primary hepatic pregnancy is a type of abdominal pregnancy which is extremely rare where the site of implantation is in the liver and it is associated with a very high mortality rate. The criteria for diagnosing primary abdominal pregnancy was first given by Studdiford which include (1) normal tubes and ovaries with no evidence of recent or remote injury; (2) absence of any evidence of uteroplacental fistula; (3) presence of pregnancy related exclusively to peritoneal surface; and (4) pregnancy recent enough to eliminate the possibility of secondary implantation following nidation in tubes.

All the criteria were fulfilled in our case. The onset of symptoms in primary hepatic pregnancy can be slow. Patients usually present with epigatric pain and gastrointestinal symptoms. So there can be delay in diagnosis based only on symptoms. However, with the early use of ultrasonography, early diagnosis can be made. MRI can help in the definition of the regional anatomy in greater details and is ideal in the identification of the placental implantation and can help in taking the decision whether to leave or remove placenta at the time of laparotomy. [1] In almost all cases reported, the placenta was attached to the inferior surface of the right lobe of the liver. The rich blood supply at this area is favorable for fetal growth. [2] Once the pregnancy gets disturbed, it is difficult to control the hemorrhage. The removal of placenta in abdominal pregnancy always carries a risk of hemorrhage. It is advised in the literature to leave the placenta. However in our case, the placental site was already bleeding so we had no option but to leave it. Methotrexate has been used in order to inactivate the trophoblast in reported cases. We also gave methotrexate on the first postoperative day.

Management reported in the literature varies from conservative management, i.e., leaving placenta and the use of methotrexate to cases of wedge resection and right hepatic lobectomy. [3] The insertion of arterial catheters just prior to surgery for embolization is also given as an option. Ramphal et al. [4] reported hepatic pregnancy which was managed conservatively. They diagnosed it at 18 weeks and continued the pregnancy till 34 weeks. The placenta was left inn situ. Bleeding from the membrane edges was controlled by interlocking sutures and the use of gauze packs, which were removed after 48 h. The postpartum period in their case was uneventful.

The present case was taken up for surgery by senior experienced personnel taking all measures such as the use of gel foam, packing, and hemostatics to control bleeding as well as timely replacement of blood and blood products. Methotrexate was given in the postoperative period and hepatic artery embolization was done within 18 h of primary surgery. Despite all the methods used, it was unsuccessful in controlling the bleeding.


   Conclusion Top


In retrospect, the authors conclude that a hepatic embolization could have been done before proceeding to surgery although its efficacy is doubtful. Second, a partial hepatic resection could have been done at the first instance when the patient condition was stable.

 
   References Top

1.Veress B, Wallmander T. Primary hepatic pregnancy. Acta Obstet Gynacol Scand 1987;66:563-4.  Back to cited text no. 1
[PUBMED]    
2.Tshivhula V, Hall DR. Expectant management of an advanced abdominal pregnancy. J Obstet Gynaecol 2005;25:298-314.  Back to cited text no. 2
    
3.Delke I, Veridiano NP, Tancer MC. Abdominal pregnancy: A review of current management and addition of 10 cases. Obstet Gynaecol 1987;60:2000-4.  Back to cited text no. 3
    
4.Ramphal SR, Moodley J, Rajarutham D. Hepatic pregnancy managed conservatively. Trop Doct 2010;41:121-2.  Back to cited text no. 4
    

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Correspondence Address:
Swati Agarwal
Department of Obstetrics and Gynaecology, Lady Hardinge Medical College and Smt. Sucheta Kriplani Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-2700.102417

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    Figures

  [Figure 1], [Figure 2], [Figure 3]

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[Pubmed] | [DOI]



 

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    Abstract
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