Ectopic pregnancy in the liver incidentally diagnosed by imaging: A case report

Diagnostic utility of contrast-enhanced computed tomography for ectopic pregnancy

INTRODUCTION

Contrast-enhanced computed tomography (CECT) is an emergent diagnostic imaging modality to identify the bleeding site and survey the abdominal cavity. The diagnostic utility of CECT for ectopic pregnancy (EP) has not been well-investigated. The objective of this study was to evaluate the characteristics of CECT findings in patients with EP and extract specific findings that could contribute to the identification of implantation sites.

METHOD

We conducted a retrospective study, reviewing suspected EP cases between April 2015 and March 2018 in our hospital. Clinical symptoms, blood test results, transvaginal sonography findings, and surgical and pathologic findings from the medical records were assessed. CECT images were evaluated by a certified radiologist and gynecologist retrospectively in consensus. The following were selected as positive findings for specific determination of the ectopic implantation site: the ectopic gestational sac, lateralization of the hemoperitoneum around the adnexa on either side, and extravascular leakage of the contrast agent outside the uterine cavity.

RESULTS

CECT was performed in 41 women with an EP. The ectopic implantation site was detectable on CECT in 90.2% (37/41), whereas it was noted in 70.0% (32/41) on transvaginal ultrasonography (TVS). Of nine patients with an EP with an undetectable implantation site on TVS, six were positive for the specific determination of the ectopic implantation site on CECT.

CONCLUSION

CECT has the potential to predict ectopic implantation sites with high-level sensitivity. As CECT is an urgent diagnostic imaging tool to be used in an emergent setting, it may be a good option for EP diagnosis when the availability of magnetic resonance imaging is limited.

Hepatic ectopic pregnancy with hemorrhage secondary diaphragmatic adhesion: A case report

BACKGROUND

Primary abdominal pregnancy is an extremely rare form of ectopic pregnancy. Ectopic pregnancies that occur in the liver and diaphragm are even rarer, limited case reports are available in the literature.

CASE SUMMARY

A woman of childbearing age was transferred to the emergency department due to lumbar and abdominal pain radiating to the back toward the lower right. After a series of physical and auxiliary examinations, she was clinically diagnosed with hepatic ectopic pregnancy. Laparoscopic surgery was performed to remove the pregnancy tissue and achieve hemostasis. After a period of follow-up, the patient was successfully cured.

CONCLUSION

Paying attention to the patient's signs and utilizing imaging examination methods can help avoid missed diagnoses of liver pregnancy.

Updates in emergency medicine: Ectopic pregnancy

INTRODUCTION

Ectopic pregnancy is a serious condition that can have significant morbidity and mortality.

OBJECTIVE

This review highlights the pearls and pitfalls of ectopic pregnancy, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Ectopic pregnancy is a pregnancy that implants outside the normal uterine cavity. It most commonly presents with vaginal bleeding, abdominal or pelvic pain, and amenorrhea. Risk factors for ectopic pregnancy include abnormalities of the fallopian tube, prior ectopic pregnancy, and age over 35 years, but a significant number of patients with confirmed ectopic pregnancy will not have an identifiable risk factor. In patients with suspected ectopic pregnancy, evaluation includes quantitative serum hCG, blood type, and ultrasound. Ultrasound is necessary regardless of the hCG level. If the patient is hemodynamically unstable, resuscitation with blood products and early consultation of obstetrics/gynecology is necessary. Patients with confirmed ectopic pregnancy but who are otherwise stable may be managed medically or surgically. If a yolk sac or fetal pole is not seen in the uterus on ultrasound, this is considered a pregnancy of unknown location (PUL), which may represent an early, failed, or ectopic pregnancy. Stable patients with a PUL who can reliably follow up are managed with close specialist follow up and repeat 48 h HCG level. These patients need to have an hCG level repeated every 48 h until diagnosed with a viable pregnancy, failed pregnancy, or ectopic pregnancy.

CONCLUSIONS

Knowledge of the latest advances in managing ectopic pregnancy will help clinicians more quickly and accurately diagnose patients presenting with this potentially fatal condition.

Ectopic pregnancy implanted under the diaphragm: A rare case report

BACKGROUND

Abdominal pregnancy is a rare type of ectopic pregnancy. We describe here a case of ectopic pregnancy implanted under the surface of the diaphragm, presenting the particular features of imaging findings from ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI).

CASE SUMMARY

A 30-year-old woman presented with complaint of intermittent abdominal pain, that had begun 5 d earlier. She had no current or abnormal vaginal bleeding, and her serum human chorionic gonadotropin level (13372.08 IU/L) indicated pregnancy. Vaginal ultrasound showed a mixed echogenic mass in the right ovary. CT (plain) scan showed a curved high density mass beneath the subhepatic space. MRI scan showed a curved mixed signal, with restricted diffusion beneath the subhepatic space. Abdominal ultrasound demonstrated a mixed echogenic mass in the right lobe of the liver near the apex of the diaphragm, with a visible yolk sac and germ cell region with a bud. Subsequent laparoscopy visualized a dark red mass under the right diaphragm, which was resected completely. Histopathological examination of the resected mass confirmed an ectopic pregnancy. The recovery was swift and uneventful, and the patient was discharged to home.

CONCLUSION

Ectopic pregnancy should be in the differential diagnostic workup (via multiple imaging modalities) of childbearing woman with unexplained abdominal pain.

Ruptured Hemorrhagic Ectopic Pregnancy Implanted in the Diaphragm: A Rare Case Report and Brief Literature Review

The mortality and morbidity rates of non-tubal ectopic pregnancies with abdominal hemorrhaging are 7-8 times higher than those of tubal pregnancies. Diaphragmatic pregnancy is a rare non-tubal ectopic form, causing acute abdominal hemoperitoneum. Here, we present a case of a primary diaphragmatic ectopic pregnancy with hemorrhage that was immediately diagnosed and successfully managed with laparoscopic surgery. Rapid and accurate diagnosis using appropriate imaging modalities is critical for improving the prognosis of a child-bearing woman with an abdominal pregnancy.

Primary hepatic ectopic pregnancy in a patient with polycystic ovary syndrome: A case report

RATIONALE

Hepatic ectopic pregnancy is an extremely rare ectopic pregnancy. This study aimed to report a case of primary hepatic pregnancy in a patient with polycystic syndrome.

PATIENT CONCERNS

A 30-year-old woman presented with vaginal bleeding after 63 days of amenorrhea.

DIAGNOSIS

The patient was initially diagnosed with liver ectopic pregnancy using abdominal ultrasound and abdominal computed tomography (CT).

INTERVENTIONS

The patient underwent laparoscopic exploration to reconfirm the gestational sac in the liver and abdominal surgery to remove liver gestation. The postoperative review of abdominal CT and the level of serum human chorionic gonadotropin (hCG) was performed.

OUTCOMES

The postoperative pathological examination revealed a fluffy tissue in the liver tissue and a blood clot. The patient's vital signs were normal, and she was advised regular follow-up after discharge from the hospital. One month later, the serum hCG level reduced to 0.32 mIU/mL (reference range 0-5 mIU/mL).

LESSONS

If the level of beta-human chorionic gonadotropin (β-HCG) is higher than normal in women of childbearing age and no gestational sac is found in the uterine cavity, the location of pregnancy and gestational sac should be positively confirmed. Also, the possibility of ectopic pregnancy in the abdominal cavity should be considered, and the relevant imaging and biochemical examinations should be improved to avoid delay in diagnosis and treatment.

Primary hepatic pregnancy: a case report with a history of cesarean section and oral contraceptives, with review of literature

Primary hepatic pregnancy is an extremely rare event which is difficult to diagnose due to its unusual location; moreover the potential mortality rate is five to seven times higher than the rate found in other ectopic pregnancies. We report a case of primary hepatic pregnancy in a 23-year-old woman, who presented with a history of one cesarean section and had taken oral contraceptives within half a year prior to her presentation. Interestingly this patient has no history of amenorrhoea, and no clinical symptoms of chills, fever, nausea, vomiting and diarrhea. Imaging findings showed an abnormal mass on the lower part of the right lobe. The patient was misdiagnosed with a liver tumor prior to operation. Histopathologic examination found that chorionic villi with trophoblasts infiltrated the hepatic tissue. A few trophoblasts were detected in some hepatic veins. HCG immunostaining showed positive reactivity in the trophoblasts. We believe that some risk factors of primary hepatic pregnancy such as the history of cesarean section and oral contraceptive should be taken into serious consideration and raise the index of suspicion, especially in the women of reproductive age, with or without a history of amenorrhoea. Timely diagnosis should be made in order to avoid mortality from rupture of the gestational sac.

An audit of the management of ectopic pregnancies in a district hospital, Gauteng, South Africa

Background

Ectopic pregnancy (EP) is a life-threatening condition; at Odi Hospital, approximately 7–10 EPs are managed weekly. Our study is the first to assess the management of this life-threatening condition at Odi Hospital.

Aim

This study aimed to determine the incidence of EP and to assess the profile of women who presented with EP at Odi District Hospital from 01 January 2010 to 31 December 2014.

Setting

The study was conducted at Odi District Hospital, located in Mabopane, a township in Gauteng province, 45 km north of Tshwane, South Africa (SA).

Methods

This was a cross-sectional study.

Results

We analysed 263 completed patient records. The incidence rate was 22 per 1000 live births. The mean age was 28.9 years (SD ± 6.09), 57% were within the age group of 25–34 years, 90.9% were single and 85.2% were unemployed. Abdominal pain was the most common presenting complaint (81.1%). Ninety-nine (37.8%) were in a state of haemorrhagic shock. Possible risk factors were not documented in the patient files for 95%. A third (34.2%) were operated on within 4 hours of consultation. Early management was associated with poor record-keeping (p = 0.02). There was a delay in confirming the diagnosis in 48.7%. It was associated with gestational age (p = 0.0017), previous abdominal surgery (p = 0.0026), normal haemoglobin level at the time of consultation (p = 0.0024), considerable haemoperitoneum at operation (p < 0.00001) and per vaginal bleeding (p = 0.003).

Conclusion

The study highlighted the need to emphasise the importance of good record-keeping and documentation in patients, as well as the urgent need for ultrasound skills training among clinicians to implement the Essential Steps in Managing Obstetric Emergencies programme at this hospital to improve the management of EP and other obstetric emergencies.

Diagnostic utility of CT in differentiating between ruptured ovarian corpus luteal cyst and ruptured ectopic pregnancy with hemorrhage

Background

To evaluate the performance of computed tomography (CT) as a diagnostic aid to differentiate between ruptured ovarian corpus luteal cyst (ROCLC) and ruptured ectopic pregnancy with hemorrhage (REPWH).

Methods

A total of 36 patients treated at our hospitals for ROCLC and REPWH from June 2014 to August 2017 were included in this study. Based on the diagnosis, the study population was divided into ROCLC group (n = 21) and REPWH group (n = 15). CT scans were performed for all patients prior to treatment. The size of the cystic shadows and the depth of the pelvic effusion were analyzed and compared with independent sample Student’s t test and Fisher’s exact test.

Results

Cystic shadows with maximum diameters ≥3.0 cm presented in 16 patients with ROCLC and 1 patient with REPWH, while 4 patients with ROCLC and 9 patients with REPWH exhibited cystic shadows with maximum diameters <3.0 cm. The mean diameters along the major and minor axes in the two groups were 3.76 ± 1.11 cm and 2.93 ± 0.98 cm, 1.96 ± 0.65 cm and 1.60 ± 0.55 cm, respectively (p < 0.001). The mean depth of the pelvic effusion in patients with ROCLC and REPWH were 5.20 ± 2.47 cm and 6.96 ± 2.07 cm, respectively (p = 0.038).

Conclusion

The cystic shadow of ROCLC is larger than that of the REPWH. The depth of the pelvic effusion of REPWH is deeper than that of the ROCLC. CT can help differentiate between ROCLC and REPWH based on the size of the cystic shadow and the depth of pelvic effusion in the adnexal area.