PRIMARY HEPATIC ECTOPIC PREGNANCY: DIAGNOSIS AND LAPAROSCOPIC MANAGEMENT.

OBJECTIVE: To demonstrate and discuss a case of primary hepatic ectopic pregnancy and laparoscopic management DESIGN: Case presentation with demonstration of surgical hepatic wedge resection SETTING: Tertiary referral centre in Manchester, United Kingdom INTERVENTION: A 33 year old women Gravida 13 Para 2 with a BMI of 55, previous 2 caesarean sections and a laparoscopic cholecystectomy presented emergency services following a private ultrasound scan showing a pregnancy of unknown location (PUL) and a serum hCG of 18336 iu/ml. A diagnostic laparoscopy was performed but fallopian tubes were normal with no signs of ectopic pregnancy seen. An abdominal ultrasound scan was performed but did not identify the ectopic pregnancy. Due to worsening symptoms of pain and rising hCG levels she underwent a further laparoscopy converted to laparotomy and a left salpingo-oophorectomy for suspected left ovarian pregnancy. However, serum HCG levels continued to rise after the surgery, reaching 36960 iu/ml. An MRI scan of her abdomen and pelvis was arranged which showed a 4 cm cystic lesion in the segment V of the liver. Further ultrasound correlation showed a hyperechoic lesion with echogenic components suspicious of an ectopic pregnancy with a fetal pole. Fetal heart action was not visualised. A multidisciplinary team approach was adopted with involvement of the hepato-biliary surgical team and the options of medical management with methotrexate and surgical excision was considered. A decision was made for surgical excision based on the accessible location of the ectopic pregnancy on segment V as well as the more controlled and predictable outcome with surgical excision. A pre-operative CT scan confirmed the lesion in segment V of liver in keeping with liver capsular implantation of ectopic pregnancy. At laparoscopy the ectopic pregnancy was visualised on the inferior surface of liver close to the inferior margin with a band of overlying omental adhesion. The overlying omental adhesions were sealed and cut with advanced bipolar diathermy, keeping a safe margin from the ectopic pregnancy to minimise any bleeding. The liver capsule was then opened with monopolar diathermy and the small segment of liver with the ectopic pregnancy was excised using a combination of Bowa-Lotus liver blade (Bowa medical Ltd). Haemostasis was controlled using FlosealTM haemostatic matrix and applied pressure laparoscopically. Total operating time was 80 minutes with an estimated blood loss of 500ml. The patient was discharged on day 3 post-operatively and follow-up serum hCG excluded residual trophoblastic disease.

DISCUSSION: On review of the clinical case, earlier imaging of the upper abdomen when confronted by a persistent PUL with high levels of serum HCG would have prevent the second laparoscopy, laparotomy and salpingo-oopherectomy. In similar cases it would also help exclude poorly differentiated malignancies as a source of serum HCG.

CONCLUSION: Only 27 cases of ectopic pregnancy on the liver have been identified in English literature since 1952, based on a Medline and Embase enquiry and further review of all case reports by the authors to avoid duplicates. Estimated incidence of hepatic implantation is 1 in 15000 pregnancies. 4 cases reports of laparoscopic liver resection has been identified and another case managed by suction form the liver surface1,2 . The key principle demonstrated is to resect the ectopic pregnancy with a safe margin of liver tissue and any adhesions to avoid catastrophic bleeding form direct handling of the ectopic pregnancy.