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9.3 Abdominal Pregnancy
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Fig. 9.25 (a) The
gestational sac is in
direct contact with the
anterior wall; (b)
placental implantation
site; (c) the gestational
sac; (d) fundal uterine
wedge resection; (e)
elimination of the
placental villi; (f) the
excised fundal
myometrium before
applying sutures; (g)
mattress sutures of the
excised fundal
myometrium; (h) the
excised placenta and the
fetus. (Reproduced with
permission from [186]
under the CC Attribution
License)
a
c
b
d
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9 Ruptured Ectopic Pregnancy
9.4 Primary Hepatic Pregnancy
9.4.1 Historical Perspective
Cornell and Lash, in 1933, collected records of
236 pregnancies involving placental attachment
to 641 sites, the great majority being in the pelvis. In eight cases, one attachment site was the
liver, but the note was not made whether this was
the sole area [192], probably meaning abdominal
and not primary hepatic pregnancy. Chester M
Echols in 1934 [193] and ME Barrett in 1952
[194] mentioned patients with the placental site
on several organs, one of which was the liver, but
these cannot be termed primary hepatic pregnancies. Billington and Goodchild in 1948 [195],
Serebryakova and Kanshin in 1952 [196], Van de
Loo in 1952, AHG Murley in 1956 [197], and
Norman G. Kirby in 1969 [198] described the
liver as the only placental site. Mear et al., in
1965, described a full-term living infant delivered at laparotomy (died after 45 min), but the
mother died after further severe bleeding from
the liver [199]. Luwiliza-Kirunda reported a lithopedion from a hepatic pregnancy in 1978 [200].
9.4.2 Incidence
Primary hepatic pregnancy is extremely rare.
Since 1956, there have been approximately 60
cases published [201–203]. The median age of
onset was 29.2years (18–46years) [202].
and hepatic pregnancy. Most splenic pregnancies
become symptomatic, commonly as bleeding up to
8weeks of pregnancy (see Sect. 24.2). On the contrary, hepatic pregnancy can be detected in more
advanced pregnancy, and the incidence of hemorrhagic shock or peritonism is present in 1/3 of
patients [202]. Live preterm fetuses can be delivered from hepatic pregnancy [207]. Most (93.5%)
hepatic pregnancies involve the right lobe, mostly
on its inferior surface [202]. Two mechanisms
explain such a high incidence of this location of
implantation: (1) peritoneal uid circulation from
the right paracolic gutter to the diaphragm due to
intestinal and diaphragmatic movements and (2)
effect of gravity—with the supine position, the
lower surface of the right lobe of the liver is the
lowest position of the abdominal cavity.
9.4.4 Clinical Presentation
Abdominal pain was the most common symptom, mainly in the right upper quadrant. Shoulder
pain is rare, more commonly on the right side.
Approximately 50% have amenorrhea or a history of vaginal bleeding with dark blood after
menstruation [203]. Hemorrhagic shock or peritonism is present in 1/3 of patients.
Gastrointestinal symptoms include vomiting,
nausea, and abdominal distension, while gynecological symptoms are vaginal bleeding and
discharge [202].
9.4.3 Risk Factors
andPathophysiology
Risk factors for any location EP are similar and
listed in Table9.1 [203]. An additional risk factor is
perihepatic adhesions from ascending pelvic inammatory disease entrapping fertilized eggs [204].
The liver and the spleen are favorable for
implantation because they are at organs, rich in
blood ow, and easily reached by the fertilized
ovum [205]. However, both cannot allow placental
attachment, resulting in rupture with massive
hemoperitoneum [206]. Still, there is a signicant
difference in bleeding incidence between splenic
9.4.5 Dierential Diagnosis
The leading symptom of upper right abdominal
pain, primarily without (awareness of) amenorrhea, may mislead to digestive and hepatobiliary
pathologies. Another misleading symptom is
dyspepsia due to the close relation of the gallbladder and the duodenum [198].
9.4.6 Diagnosis
9.4.6.1 Laboratory Findings
A complete blood count is mandatory for patients
with abdominal pain and signs of hypovolemic/
ab
9.4 Primary Hepatic Pregnancy
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hemorrhagic shock, including BUN, creatinine,
liver, and pancreatic enzymes. Amenorrhea mandates βHCG testing. Without rupture and intraperitoneal bleeding, complete blood count can be
normal [203].
9.4.6.2 Transvaginal Ultrasound
With elevated βHCG levels, transvaginal US
denes the adnexa, the uterus, and gestational
status. A normal-sized uterus with a thickened
endometrium without an individual gestational
sac is suspicious of EP.
9.4.6.3 Transabdominal Ultrasound
Potential locations of EP should be checked,
especially when Fallopian tube EP is excluded.
Most hepatic gestations are subcapsular with
an irregular mass that exceeds the contour of
the liver, although some are located within the
liver (Fig.9.26). All conrmed cases included
hemodynamically stable patients. Doppler can
estimate the vascularity of the lesion
(Fig.9.27a).
9.4.6.4 Abdominal CT
Contrast-enhanced abdominal CT is indicated
when the transabdominal US is unequivocal in
hemodynamically stable patients. While
abdominal CT has been used in 32% of patients
with an accuracy of 100% for splenic pregnancy
[210], there are no data for hepatic pregnancy
[202]. Except for the size and location of the gestational sac, the extent of the hemoperitoneum,
primarily around the liver, can be dened (Fig.
15.27b–d). In more advanced pregnancy, fetal
parts and placenta in the liver are visualized on
CT [211] or MRI (Fig.9.28).
9.4.6.5 Abdominal MRI
For suspected pregnancy, MRI should be performed after the inconclusive US.It reveals the
location and size of the gestational sac (Fig.9.29).
Noncontrast MRI, using T2-weighted imaging, is
sensitive, specic, and accurate for hepatic EP.It
usually showed a round-like, high-signal mass,
mainly homogeneous, with unclear margins. At
T1-weighted imaging, MRI displayed a hepatic
round-like, low-signal mass with undened margins. With contrast enhancement in the arterial
phase, the hepatic pregnancy appears as a roundlike, low-signal mass with no intensication in
the central or peripheral portions. Noncontinuous
ring-like intensication is displayed during the
venous phase, with lower irregular intensication
in the center [213].
9.4.6.6 PET-CT
In one case report, PET-CT discovered unexpected hepatic pregnancy. The display indicated a
lesion with glucose metabolism increased in the
peripheral but not in the central portion
(Fig.9.30).
Fig. 9.26 (a) Transabdominal US shows uneven fatty
liver and a cystic echo mass (arrow) measuring
30×19×25mm, (b) with a hypoechoic nucleus attached
to the inferior surface of the right hepatic lobe.
(Reproduced with permission from [208])
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9 Ruptured Ectopic Pregnancy
Fig. 9.27 (a) Transabdominal US (no gestational sac in
the uterine cavity) shows a 5.4×4.6cm hyperechoic mass
(arrow) in the right hepatic lobe and a uid sonolucent
area of 2.7×2.1cm within the mass. The cystic sonolucent area within the uid sonolucent area suggests an
ectopic pregnancy. (b) CT reveals a mass in the right
hepatic lobe (arrow) with a slightly low-density peripheral portion and an oval lower-density central portion in
the plain scan. (c) CT in the arterial phase shows a peripheral portion with a signicantly increased density, a
peripheral portion with a slightly increased density
(arrow) compared with that of the liver parenchyma in the
(d) venous phase shows a non-enhanced lower-density
central portion in the enhanced scan (arrow). (Reproduced
with permission from [209])
9.4.7 Treatment
Management primarily depends on the hemodynamic stability and location of the lesion.
9.4.7.1 Medical Treatment
The gestational sac of >3.5cm is a relative contraindication for MTX treatment [212]. Medical
treatment with IM MTX (1mg/kg) can be administered when blood pressure, pulse, and body
temperature are normal, in addition to a normal
Fernandez score. Guarding or rebound tender-
Fig. 9.28 Abdominal MRI shows an intrahepatic lesion
with fetal parts (arrow). A crescent-shaped area laterally
represents placental tissue. (Reproduced with permission
from [212])
ness should be absent. Laboratory ndings should
exclude acute bleeding; leukocyte count, platelet
count, liver transaminases, and renal function
9.4 Primary Hepatic Pregnancy
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Fig. 9.29 MRI characteristics of primary hepatic pregnancy. (a) T1 reveals a round low-signal focus (3×4.5cm)
between the inferior margin of the left hepatic lobe and
the lesser curvature of the stomach. Most edges of the
focus are clear. (b) T2 reveals the focus appears to be
obvious high signals, most of which are homogeneous. (c)
The focus appears to be low elliptical signals with
enhanced MRI during the arterial phase, and there is no
a b
Fig. 9.30 Positron emission tomography-CT. (a) A max-
imum intensity PET-CT shows hepatic pregnancy (blue
arrow) (the same patient from Fig. 9.27). (b) Orange
sign of intensication inside the focus and on the edge. (d)
Slight intensication is displayed in focus during the
venous phase; a bit of ring-shaped intensication may be
seen on the edge of the right frontal. (e) Coronal scan
reveals that the disease takes on a round-like low signal
with a slight noncontinuous ring-like intensication and
slight irregular intensication inside [213]
arrow points to the location of the hepatic pregnancy.
(Reproduced with permission from [209])
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9 Ruptured Ectopic Pregnancy
Fig. 9.31 Hepatic angiography of primary hepatic pregnancy. (a) before transcatheter arterial chemoembolization (TACE), hepatic angiography shows a hypervascular
lesion of residual trophoblast tissue in the right hepatic
should be normal. βHCG should be checked once
a week for several weeks [214].
lobe and its supply branch from the right hepatic artery;
(b) after TACE, Lipiodol on X-ray is densely deposited in
the lesion. (Reproduced with permission from [215])
slowly. After embolization, an X-ray conrms
the deposition of Lipiodol inside the lesion
(Fig.9.31b).
9.4.7.2 Radiological Intervention
Techniques
With bleeding hepatic pregnancy, selective embolization can stop the bleeding and stop the preg-
Another option is US-guided MTX or KCL
intragestational sac injection transhepatically
[212]. Both procedures eliminate surgical
complications.
nancy by ischemia (Fig. 9.31). Other methods
include US-guided fetal intracardiac potassium
chloride and MTX alone or combined, united
with maternal IM injection of MTX [212, 216].
Selective embolization is also indicated when (1)
hepatic nodule cannot be removed completely
because of deep implantation into the hepatic
parenchyma and hilum [215], primarily when a
hepatobiliary surgeon is unavailable; and (2)
postoperative βHCG is rising [215].
A common femoral artery approach is common. A mixture of 6mL of Lipiodol (iodized
oil; Guerbet, Roissy, France) and 50mg (1mg/
kg) of MTX is infused via the microcatheter as
close as possible to the feeding branch, followed by embolization of the feeding artery
with gelatin sponge particles (0.5–1.0mm). An
MTX–Lipiodol emulsion is used to localize the
MTX inside the hepatic lesion and release it
9.4.7.3 Surgical Treatment
Signicant bleeding or hemorrhagic shock should
be treated with surgical hemostasis. Until 2018,
84% were treated by laparotomy [202].
Intraoperatively, clot-like bulging is found on the
surface of the liver, with bleeding from that site
(Fig. 9.32). Different surgical procedures are
used, including omental transplantation, hepatic
artery ligation, liver packing, lobectomy with
fetus, and laparotomy combined with intraoperative intragestational injection of 20–25mg. MTX
(for gestational sac <35mm) or potassium chloride, laparotomy with a maternal postoperative
injection of MTX, and postoperative hepatic
artery embolization [202, 217].
The intragestational sac injections producing
fetal death by cardiac arrest eliminate the need to
extirpate a gestational sac in the liver. This mini-
9.4 Primary Hepatic Pregnancy
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Fig. 9.32 Bleeding from hepatic segment 6: a 3-cm bulging mass was detected. This area presented with a smooth
surface covered by Glisson’s capsule. Trophoblastic-like
material and active bleeding emerged from a break in the
continuity of 1cm (arrow). (Reproduced with permission
from [201])
235
mizes the possibility of hepatic bleeding or biliary tract injury. In more advanced pregnancies,
maternal MTX involutes the placenta and fetal
tissue and reduces the risk of bleeding. The timing of MTX administration related to surgical
procedures is not dened. It can be administered
preoperatively via IM injection, intraoperatively
into the location of implantation, or postoperatively via IM injection. Postoperative IM administration is routine or selective if postoperative
βHCG values rise [218].
Laparoscopy is increasingly used for surgical hemostasis and EP removal in hemodynamically stable patients [201, 209, 218]. The trocar
position depends on the location of the gestational sac in specic liver segments (Fig.9.33).
The suction of blood clots and EP is followed
by hemostasis of the bleeding spot with topical
hemostats (Fig. 9.34). Pathophysiology of
evacuated contents conrms blood clots with
clusters of cytotrophoblasts and syncytiotrophoblasts, consistent with EP.The pathohistological analysis of resected gestational sac
reveals hepatic tissue and products of conception (Fig.9.35).
Fig. 9.33 The liver segment 6 gestational sac location
necessitates the left lateral decubitus position. The rst
trocar inserted by open technique is in the subcostal right
region at the midaxillary line (1). Another two trocars are
placed under direct visualization in the right ank (2) and
the epigastric region (3). ER epigastric region, MAL
midaxillar line, PAL posterior axillar line
9.4.7.4 Continuation ofPregnancy
andDelivery
Expectant management is possible in centers
with immediate recourse to emergency interventions and neonatal care. The transabdominal US
should detect a viable pregnancy with adequate
amnion and an absence of congenital abnormalities. The oligohydramnios on US and abdominal
pain warrant intervention [207].
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Fig. 9.34 Primary hepatic pregnancy (arrow) implanted on the liver hilum and removed (a) piecemeal and (b) with the
aid of suction. (Reproduced with permission from [218])
9 Ruptured Ectopic Pregnancy
through an avascular area to deliver a live newborn. No attempt is made to remove the placenta.
Bleeding from the membrane edges is controlled
by interlocking sutures and gauze packs. For
inadequate bleeding control, gauze packs were
removed after 48h [207].
9.4.7.5 Anesthetic andPerioperative
Management
See Chap. 2. The operative specimen should be
sent to the pathohistological examination,
which reveals gestational villi in the hepatic
mass. With retained placenta and gestational
Fig. 9.35 Histologic examination of the resected specimen shows chorionic villi inltrating into the liver tissue
(H&E, ×40). (Reproduced with permission from [208])
parts, serial serum βHCG and the transabdominal US during the rst several weeks detect the
continuation of hepatic pregnancy (Fig.9.36).
Maternal renal and liver function tests should
With fetal viability, operative delivery is indicated by median laparotomy or (extended) subcostal incision. Following the dissection of the
surrounding organs (mostly bowel) off the placental membranes, the amniotic cavity is entered
be checked before and after MTX administration. With the remaining gestational sac, successful intragestational injections result in the
disappearance of βHCG levels within 4weeks
[212, 217].
9.5 Primary Ovarian Pregnancy
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Intracardiac injection of MTX
90000
80000
237
70000
60000
50000
40000
30000
hCG (milli-international units/mL)
20000
10000
0
0123
Fig. 9.36 βHCG trend after fetal intracardiac injection of MTX (unsuccessful) and KCl (successful) after a week. MTX
methotrexate, KCl potassium chloride. (Reproduced with permission from [212])
9.5 Primary Ovarian Pregnancy
9.5.1 Historical Perspective
Intracardiac injection of KCI
456789
Weeks
9.5.2 Incidence
Paul Moulonguet-Doleris, in 1924, reported 77
cases [222], and CR Strother-Stewart, in 1953,
De Saint Maurice of Périgord (former province
of France, which corresponds roughly to the current Dordogne) was the rst to observe a case of
ovarian pregnancy in 1682. It was a letter in a
French journal composed by the Abbe de la
Rocque. It was translated to the Latin, in the
Bibliotèque Anatomique de Manget, tome premier, page 623. The fetus was lying in the
abdominal cavity after being torn from the ovary,
surrounded by blood. The laceration was visible
on the ovary. The patient died of intraperitoneal
hemorrhage, and the diagnosis was made postmortem [219]. Without exacting laboratory
examination, ovarian apoplexy [220] may often
be misconstrued as an idiopathic event when
early abortion of an ovarian pregnancy has
occurred. Another misdiagnosis was bleeding
corpus luteum [221].
reported at least 125 cases in the English litera-
ture [223]. The incidence of primary ovarian
EP is increasing. In the 1950s, it was estimated
from 1:25,000 to 1:40,000 [224]; in the 1980s
from 1/5000 to 1/8000 [225] and even 1:2850
[226]. Of all ovarian pregnancies, 75–90% are
primary [225, 227]. In the rst half of the
twentieth century, 75.5% were terminated dur-
ing the rst trimester, 12.2% during the second
trimester, and 12.2% lasted to the third trimes-
ter or beyond [224]. HP with ovarian EP is
exceedingly rare, comprising <2% of cases
[227]. The incidence of ovarian EP is still
likely underestimated due to the possibility
that certain cases were successfully treated
with MTX, but were denoted as tubal pregnan-
cies or pregnancies of unknown location [24,
227, 228].
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Both ovaries are equally affected [225,
227, 229], except in women with IUCDs,
where the right side is almost exclusively
affected [230–232], although left-sided
cases exist [221].
9.5.3 Risk Factors
andPathophysiology
Risk factors for EP that include ovarian pregnancy [224, 225] are presented in Table 9.1.
The most common are previous abdominal surgery, endometriosis, and IVF [233]. The IUCD
is present in 4–68% of ovarian pregnancies
[225, 227, 229, 234]. The association between
ovarian pregnancy and IUCD use was recognized in 1930 [235]. The Lippes’ loop’s free
end pointed towards the affected side in each
case [236]. Most cases occurred with the Lippes
Loop* in place and a single one with a Dalkon
Shield [230]. From 1966 to 1983, 27% of ovarian pregnancy cases were associated with the
IUD in the USA and involved the Cu-7 IUD
[237], while in others, copper-based IUCS was
present in 88% [229]. It has been suggested that
Cu-7 does not increase or decrease the risk of
ovarian pregnancy relative to inert plastic
IUCDs [237]. During the 1960s and 1970s, the
ratio of ovarian pregnancies to EP in IUCD
users ranged between 1:7 and 1:13 [226, 229,
238, 239]; its prevalence in the general popula-
tion is smaller but still increasing—from 1:332
[232], over 1:150 to 1:200 [225, 234], over
1:117 [224] to 1:40–1:63 [227]. Approximately
25% do not have known risk factors for (ovarian) EP [227].
Prostaglandin-mediated hypercontractility of
the tubes in IUCD users may impair the pickup of
the ovum [221, 240]. An IUCD causes alterations
in the level of prostaglandins in the different segments of the Fallopian tube with inverse peristalsis and reversed suction [236]. Changes in tissue
levels and the ratio between the concentration of
prostaglandin E and prostaglandin F are essential
for tubal peristalsis [241]. Also, a signicantly
larger number of mast cells is present in the tubal
9 Ruptured Ectopic Pregnancy
stroma of IUCD users than in controls [242].
Prostaglandins are mast cell mediators [23]. The
mast cells are situated nearer to the smooth muscle cells in the tube than to the small vessels due
to their role in tubal peristalsis [22]. Different
types (including composition, hormones, and
concentrations) of IUCDs could have different
inuences on ovarian pregnancy rates [229].
In 1876, Ferdinand Hueppe, in an inaugural
dissertation, established the conditions to consider an ovarian pregnancy: (1) fecundation on
the ovary, the ruptured follicle closing itself afterwards, and the fetus developing in the interior of
the ovary as a cyst; (2) the ruptured follicle does
not close itself, but the placenta retains its implantation in the ovary [243].
Spiegelberg criteria from 1878 differenti-
ate an ovarian pregnancy from a tubal preg-
nancy [244]:
• gestational sac is in the region of the
ovary,
• EP is attached to the uterus by the ovarian ligament,
• histologically proven ovarian tissue in
the wall of the gestational sac,
• Fallopian tube of the involved side is
intact.
Norris, in 1909, further amplied the rst postulate by stating that the tube must show no
microscopic evidence of pregnancy [245].
Stander enlarged the fourth postulate by requiring ovarian tissue to be found in several places at
some distance from each other in the sac wall
[246]. Further modication of Stander’s modication is that ovarian tissue must be demonstrated
in the sac walls in several places at some distance
from each other and intervening between fetal
tissues and any adherent extraneous tissue [224].
Baden and Heins suggested functional classication of “primary ovarian pregnancy” based on
the implantation site and later development of the
fertilized ovum. Ovarian tissue forms an intact
layer around the embryonic tissues. It is subdi-
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