K.V.S. Prasad, MD

A case report of primary hepatic pregnancy  in a peripheral hospital in Oman, Dr K.V.S.Prasad, Dr.Monisha Seth, Dr.  Rupa Umesh, Dr. Farag al Farag, Dr.Shivakumar Department of Surgery and  Obstetrics, Ministry of Health Hospital, P O.Box: 3, Postal Code: 418,  Sinaw, Sultanate of Oman.
 
 

Ectopic Pregnancy is a potentially fatal condition if not diagnosed  and treated on time. The incidence of Abdominal Pregnancy is 1.4% of all  ectopic pregnancy, of which Primary Intrahepatic Pregnancy constitutes  only 0.03 %.  Clinical suspicion is important in the early diagnosis of  an Ectopic Pregnancy. Following a positive urine or serum B-HCG, a  transvaginal ultrasonography should be performed early to rule out an  ectopic gestation. IUCD use marginally increases the ectopic risk.  Undetected Ectopic Pregnancy of 6 to 8 weeks gestational age may present  suddenly with acute abdominal pain, followed by a syncopal attack. This  sequence usually heralds rupture of Ectopic Pregnancy and    intraperitoneal hemorrhage, requiring aggressive management.

We attempt here to present a similar case of undiagnosed Primary  hepatic Pregnancy presenting in a collapsed state at our peripheral  hospital, on 5.2.2003. 
 
 

A 30Year old G4P2 L1A1 presented to the ER in a collapsed state on  05-02-03 with history of sudden onset of severe pain in the Right flank  and lower abdomen.

Patients LMP was on? 05-01-03(scanty flow lasting for 2days). Patient had visited a health center  the previous day, urine pregnancy test was positive and a pelvic  ultrasound showed evidence? Shadow of early intrauterine gestational sac  with normal adnexa and was advised to follow-up in the hospital the  next day.

History of IUCD usage present, removed one year back.

Obstetric history: A living male child 5years old, history of IUD at eight months and history of evacuation and curettage for missed abortion. 
 
 

 
 Pallor present, Tachycardia, and BP:  90/70mmhg.
 P/A: Severe tenderness present in the right flank and lower abdomen with guarding.
 P/V: Os closed, Uterus normal size. Tenderness was present in the Right  fornix with fullness in both fornices, cervical excitation test was  positive. No evidence of any bleeding per vagina.
 Ultrasonography: showed evidence of free fluid in the pelvis, right paracolic gutter and sub hepatic space.
 
 As the patient started deteriorating, patient was posted for laparotomy  after initial resuscitation in view of hemoperitoneum with positive  pregnancy test.
 
 


 Laparotomy was done by a midline incision.
 About three liters of blood was found in the peritoneal cavity.
 Uterus and both the adnexa were normal. No evidence of any bleeding/tubal abortion.
 On exploration the source of bleeding was found to be from the inferior margin of right lobe of liver.
 Fetus was seen floating in close proximity to the liver and profuse bleeding from the site of implantation in the liver.
 The size of the fetus was corresponding to 6-8weeks approximately.
 The vessels in the bed were ligated to attain hemostasis with suturing of the liver parenchyma.
 As the hemostasis was not satisfactory a decision to do perihepatic  packing with insertion of a tube drain was taken in view of the hospital  setup and the patient was transferred to a secondary care hospital. 
 The patient was re-explored after 24hrs after the general condition of the patient stabilized and the packs were removed, on re-exploration the bleeding had totally arrested.
 The postoperative period was uneventful and the patient was discharged on the 6th postoperative day.
 The patient had received seven units of blood during the course of resuscitation and the procedure.
 
 The histopathology confirmed the presence of fetus with sac and placental tissue.
 
 

Immediate surgical management is required in the above-mentioned  situation to save the life of the patient. The scanty flow that occurred  one-month prior was not corresponding to the LMP as the size of the  fetus was corresponding to 6-8weeks of gestation. This suggests that  history has to be supplemented with the other investigations at the  earliest for early intervention.

Articles

Ectopic Pregnancy is a potentially fatal condition if not diagnosed and treated on time. The incidence of Abdominal Pregnancy is 1.4% of all ectopic pregnancy, of which Primary Intrahepatic Pregnancy constitutes only 0.03 %.

K.V.S. Prasad, MD

Articles

Primary Hepatic Pregnancy