A 29‐year‐old woman was admitted with chief complaints of amenorrhea for 48 days and right lumbar discomfort for 2 days. She had undergone a cesarean section 11 years ago. She had three medical abortions (the last medical abortion was in October 2020) in the past. Her serum human chorionic gonadotropin (HCG) was 14,516 mIU/ml. Ultrasonography revealed a cystic mass at the lower edge of the hepatic segment V (S5). It was a 12 × 6 mm cyst with fetal structure inside the cyst. Color Doppler Flow Imaging study did not show any vascular blood flow signals inside the mass (Figure 1A). Computed tomography showed a low‐density cystic lesion in the hepatic segment V (Figure 1B). On magnetic resonance imaging examination, long T1 and long T2 abnormal signal shadows of the gestational sac were observed at the anterior lower margin of the liver, and nodular isosignal T1 and T2 signal shadows were observed within the cyst, with limited diffusion changes (Figure 1C). Under the impression of primary hepatic pregnancy (PHP), which is a type of abnormal ectopic pregnancy with high mortality rate, a laparoscopic examination was performed. A well‐demarcated gestational sac (24 × 27 × 19 mm) with no pulse was found in hepatic segment V (Figure 1D). Intraoperativemacroscopic diagnosis confirmed primary ectopic pregnancy in segment V of liver. Laparoscopic segment V wedge resection was subsequently performed (Figure 1E). Subsequently, the specimen bag was used to remove the gestational sac completely, and the embryo inside the gestational sac was found by section (Figure 1F). Rapid pathology showed the presence of placental villus tissue in the liver tissue (Figure 1G). A silicone drainage tube was placed at the lower edge of the liver. All surgical incisions were cemented with medical glue (Figure 1H).
FIGURE 1.
The diagnosis and treatment process of primary hepatic pregnancy (PHP). (A) Ultrasound images of PHP: Color Doppler flow imaging shows sparse blood flow signal around the block, and no blood flow signal in the cavity (black arrow). (B) Computed tomography (CT) image of PHP (black arrow). (C) Magnetic resonance imaging (MRI) image of PHP (black arrow). (D) The gestational sac in hepatic segment V (black arrow). (E) No hemorrhage and biliary leakage in the liver wound after wedge resection of section V. (F) Embryo inside the gestational sac. (G) Rapid pathology showing placental villus tissue in the liver tissue. (H) Silicone drainage tube placed at the lower edge of the liver; all surgical incisions were cemented with medical glue.
The incidence of PHP is much lower than that of ectopic pregnancy in the fallopian tube or pelvic cavity. The reported risk factors for PHP include intrauterine device or long‐term oral contraceptive use, chronic inflammation of fallopian tubeor pelvic cavity, and uterine scar caused by previous cesarean section surgery. 1 , 2 Since decidua reaction does not occur, abortion is often carried out within 12 weeks and acute or chronic bleeding caused by rupture of the gestational sac may induce hypovolemic shock. The fatality rate of PHP is approximately five to seven times higher than that of other forms of ectopic pregnancy. 3 Patients with PHP may present with amenorrhea, nausea, vomiting, abdominal distension, acute and chronic abdominal pain, right upper abdominal mass, and acute peritonitis. Detection of abnormally elevated HCG level and use of multimode imaging modalities can facilitate early diagnosis of PHP. The patient could have been treated with intramuscular injection of methotrexate or intracellular injection of methotrexate or potassium chloride to kill the embryo under the guidance of B‐ultrasound. 4 However, the placental remnant may have required reoperation due to secondary complications such as ileus, peritonitis, and abdominal abscess. 5 Therefore, we decided to directly perform laparoscopic wedge resection of segment V of the liver, leveraging the advantages of laparoscopic surgery.
CONFLICT OF INTEREST
All authors declare no conflict of interest.
Funding information the Health and Family Planning Commission of Jiangsu Province, Grant/Award Number: Z2020069; the Health and Family Planning Commission of Nanjing, Grant/Award Number: YKK20172
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