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 (ß-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.

Neglected intrauterine fetal demise for more than two decades leading to the development of a lithopedion: a case report.

BACKGROUND: Lithopedion is a word derived from the Greek words lithos, meaning stone, and paidion, meaning child, to describe a fetus that has become stony or petrified. Lithopedion is a rare complication of pregnancy which occurs when a fetus dies and becomes too large to be reabsorbed by the body. This entity in rare circumstances can be challenging for physicians to diagnose since it has a range of clinical manifestations. CASE PRESENTATION: We present a case of a 55-year-old, gravida IV para III, Ethiopian woman from Ethiopia with a retained fetus and vesicovaginal fistula after an obstructed labor and a neglected intrauterine fetal demise of approximately 22 years. The diagnosis was confirmed by suggestive clinical history, physical examination findings, and an abdominopelvic computed tomography scan. Laparotomy and removal of the lithopedion was done and our patient was sent to a fistula hospital for vesicovaginal fistula repair. CONCLUSION: This case is a rare phenomenon in which the dead fetus remained in the uterus for a long time after a neglected obstructed labor and uterine rupture.

Laparoscopic Removal of an Abdominal Pregnancy in the Pelvic Sidewall.

STUDY OBJECTIVE: To describe the presentation, diagnosis, and management of a patient with abdominal pregnancy and to illustrate the laparoscopic technique used to manage this patient. DESIGN: A descriptive study approved by our local Institutional Review Board. Consent was given from the patient. SETTING: A university hospital in Ashdod, Israel. PATIENT: On May 15th 2018, a gravida 3, para 2, 37-year-old asymptomatic patient was referred to our hospital's gynecologic emergency department due to a suspected ectopic pregnancy. The patient had no relevant medical or surgical history. Her obstetric history consisted of 2 spontaneous vaginal deliveries with no other significant gynecologic history. Her menses were regular every month. Her last menstrual period was 6 weeks before presentation. Her ß-human chorionic gonadotropin (hCG) level measured on the day before presentation was 24,856 IU/L. Physical examination was unremarkable except for a small amount of brownish vaginal discharge. A transvaginal ultrasound (TVUS) exam on presentation did not demonstrate an intrauterine gestational sac, but revealed a gestational sac and a fetus next to the right adnexa, with a crown-rump length of 1.3 cm, consistent with 7+3 gestational weeks. There was a minimal amount of fluid in the pouch of Douglas. INTERVENTION: Owing to an extrauterine pregnancy with high ß-hCG value, laparoscopic operative management was chosen. On entrance to the abdominal cavity, a normal uterus and 2 ovaries and fallopian tubes were observed. A small to moderate amount of blood was present in the pouch of Douglas. a 3- to 4-cm distension was noted over the right uterosacral ligament. Following delicate probing of the area, moderate to severe bleeding commenced, which was initially controlled with local pressure and oxidized regenerated cellulose. An intraoperative TVUS identified an abdominal pregnancy in the right pelvic sidewall. The gestational sac was completely dissected and removed following ureterolysis and separation of the right ureter from the specimen. Local injection of vasopressin was also used. The ß-hCG level before surgery of 19,008 IU/L decreased to 6339 IU/L on postoperative day 1. The patient was discharged in good condition on postoperative day 2. A final histopathological report confirmed a gestational sac. MEASUREMENT AND MAIN RESULTS: This patient referred for a tubal ectopic pregnancy was eventually diagnosed with an abdominal pregnancy and was treated operatively with complete excision of the abdominal pregnancy, which was located at the right pelvic sidewall. CONCLUSION: Abdominal pregnancy is a rare type of ectopic pregnancy with a reported incidence of 1:10,000 to 1:30,000 pregnancies, and accounts for approximately 1% of ectopic pregnancies [1]. It carries a high risk for maternal morbidity and mortality. Many different locations at different gestational ages have been reported in the literature, including the pouch of Douglas, pelvic sidewall, bowel, broad ligament, omentum, and spleen [2-4]. These varied locations and the rarity of this type of pregnancy make diagnosis and treatment challenging. The location of the growing fetal tissue may endanger the patient's life if it impinges on vital anatomic structures. In the present case, the gestational sac was very close to the right ureter, and we opted to surgically excise the gestational sac in its entirety.

Incidentally Detected Lithopedion in an 87-Year-Old Lady: An Autopsy Case Report.

A lithopedion is a rare complication of pregnancy that occurs when a fetus in an intraabdominal location dies, and it is too large to be reabsorbed by the body. The case was an 87-year-old woman, and she was transferred to the morgue department in April 2014 to determine the cause of death. During autopsy, an intraabdominally located calcified dead fetus and a 12-cm diameter calcified cyst in the right ovary were incidentally detected. It was aged 25 to 29 weeks (according to femur and humerus measurements) with a size of 12.5 × 8 × 5 cm and a weight of 227 g. According to investigation reports, her husband died in 1990, and she had 3 deliveries, the most recent of which was in 1946. Because the menopause age of the case was not exactly known, the retention time of the lithopedion was supposed to be 24 to 68 years according to the date of the most recent pregnancy and the date of her spouse's death. It is the first case that has been incidentally detected and identified during an autopsy in Turkey and also one of the oldest cases in the literature.

Advanced abdominal ectopic pregnancy: lessons from three cases from Zimbabwe and a literature appraisal of diagnostic and management challenges.

We report three cases illustrating difficulties in diagnosis and challenges with management of the placenta in a low-resource country where ultrasound scanning, methotrexate, interventional radiology or blood products are often not accessible for the majority of patients. Even in situations where an ultrasound scan is available prenatally as in our three cases, the diagnosis is often missed. All the cases presented with vague abdominal symptoms, which are common in pregnancy anyway. Only one case was correctly diagnosed before surgery by ultrasound scan. For the two cases in the second trimester as expected the fetuses did not survive. The one advanced pregnancy had a good perinatal outcome. Maternal morbidity and mortality usually results from perioperative hemorrhage from the placental attachment site. The most important aspect of management is the management of the placenta. In the two cases with second trimester pregnancies, it was possible to remove the placentas, even though blood loss was significant, hemostasis was achieved at surgery. All three mothers recovered well and survived.

Secondary abdominal appendicular pregnancy: case report.

INTRODUCTION: The case report describes a 29-year-old nulliparous woman that was admitted at the Department of Gynecology and Obstetrics of the Clinical Hospital Osijek complaining of mild abdominal pain without vaginal discharge. CASE OUTLINE: The patient's menstrual cycle was irregular, from 30-45 days. An ultrasound examination showed suspicion of an ectopic pregnancy with a betaHCG level of 1358 IU/L. Due to the presence of liquid in the pouch of Douglas the patient underwent emergency laparoscopy, which showed the presence of tumor mass between the right Fallopian tube and the appendix. These two structures associated with adhesions corresponded to secondary implantation after spontaneous tubal abortion which was confirmed by histopathologic analysis. CONCLUSION: Laparoscopy has emerged as the"gold standard"in the diagnosis and treatment of ectopic pregnancy, in this case the secondary abdominal pregnancy. From the diagnostic point of view, all women of reproductive age should be considered pregnant until proven otherwise, also keeping in mind that ectopic pregnancies can have different locations and many clinical features.

Omental pregnancy: case report and review of literature.

Pregnancy, the implantation of a fertilized ovum outside the endometrial cavity, occurs in 1.5%-2% of pregnancies. It is one of the major causes (about 6%) of maternal death during the first trimester of pregnancy. The remaining 5% implant in the ovary, peritoneal cavity, within the cervix, and the omental pregnancy is the least common form of abdominal pregnancies. A review of the literature on Medline for the period 1958-2012 reported only 16 cases of omental pregnancy. Here we report a case of primary omental pregnancy in a nulliparous woman. A 24 year-old woman gravid 1, para 0, with lower abdominal pain. Her last menstrual period occurred 8 weeks before the visit. The physical examination revealed abdominal tenderness in the lower quadrants, she was not bleeding. Transvaginal ultrasound showed: a free anechoic/hypoechoic area of 30 x 57 mm in the pouch of Douglas and the endometrium was homogeneus with a thickness of 12 mm and no evidence of gestational sac in the uterine cavity. Laboratory data revealed a normal cell blood count and beta hcg levels of 8047 IU / L. Because of continuing abdominal pain and a diagnosis of ectopic pregnancy a diagnostic laparoscopy was performed, which showed hemoperitoneum. Further inspection of abdominal cavity revealed a bloody lesion that was tenaciously adherent to the omentum, using non traumatic laparoscopic forceps and bipolar scissors we carefully removed a friable mass of about 30 mm from the omental attachments. Histological examination showed the presence of blood clot material mixed with trophoblastic tissue. Ultrasound evaluation and and hCG assessment are important to determine the extrauterine location of the ectopic pregnancy but the early diagnosis of abdominal pregnancy requires also a laparoscopic evaluation and, as our case has highlighted, thorough abdominal exploration especially in the absence of adnexal findings when ectopic pregnancy is highly suspected. Early diagnosis of omental pregnancy is difficult but essential to reduce the high mortality risk for the mother.

Successfully treated abdominal pregnancy causing hemoperitoneum using combined surgical and systemic methotrexate therapy: a case report and review of cases treated at Kyushu University Hospital.

Abdominal pregnancy is a rare condition that accounts for only 1% of all ectopic pregnancies but results in high maternal morbidity and mortality. We present a case of abdominal pregnancy with massive peritoneal bleeding successfully treated using systemic methotrexate (MTX). A 34-year-old woman with amenorrhea for 8 weeks and a positive pregnancy test was referred for evaluation of ectopic pregnancy. Transvaginal ultrasonographic scan showed a gestational sac measuring 25 mm in diameter containing a viable embryo in the cul-de-sac and a considerable amount of free fluid in the patient's lower abdomen and pelvis. Laboratory parameters showed that her hemoglobin concentration was 5.8 g/dl and serum human chorionic gonadotropin concentration was 13,195 mIU/ml. Emergency surgery revealed an abdominal pregnancy in the cul-de-sac and a massive intra-abdominal hemorrhage. After a hemostasis procedure, the patient was successfully treated using systemic MTX. We also present the review of abdominal pregnancy cases treated using systemic MTX at our institution over 10 years. Systemic MTX treatment for abdominal pregnancy is safe and effective and makes it possible to avoid the risk of excessive bleeding by surgical resection of the implantation site.

Laparoscopic management of early primary omental pregnancy.

OBJECTIVE: To describe the successful laparoscopic management of an omental pregnancy. DESIGN: Case report. SETTING: University of Schleswig-Holstein, Campus Luebeck, Department of Gynecology and Obstetrics. PATIENT(S): A 25-year-old patient with an omental pregnancy. INTERVENTION(S): Laparoscopic partial omentectomy. MAIN OUTCOME MEASURE(S): Successful laparoscopic management of an omental pregnancy. RESULT(S): A 25-year-old woman reported having abdominal pain. Her urine pregnancy test was positive. She had been using an intrauterine copper device for a period of 2.5 years. Gynecologic examination revealed normal results, in the uterus and fallopian tubes especially, where no signs of pregnancy were found through clinical and sonographic examination. Because the patient had had increasing pain, a laparoscopy was performed. There was approximately 500 mL of dark blood found in the cul de sac. The uterus and fallopian tubes appeared normal and without any signs of pregnancy. However, there was a cavity detected in the omentum majus. A partial omentectomy then was performed laparoscopically. An omental pregnancy was confirmed by beta-hCG-positive trophoblast cells in the omentum majus. CONCLUSION(S): Omental pregnancy can be rather difficult to identify. If there is no evidence of tubal pregnancy, laparoscopy may help to confirm the diagnosis of omental pregnancy and simultaneously offer minimal invasive therapy.

Twin lithopaedions: a rare entity.

Lithopaedion (stone baby) is the name given to an extrauterine pregnancy that evolves to foetal death and calcification. There are around 300 cases reported in the world medical literature to date. We report the case of a 40-year-old woman who presented with features of acute intestinal obstruction (abdominal distention, vomiting and absolute constipation) for a week. She had a past history of a missed abortion in the fifth month of gestation, eight years prior to this presentation, one which we thought to be irrelevant to the present illness. However, complementary investigations, including scout abdominal radiographs and ultrasonography of the abdomen and pelvis, were done before the operation. The abdominal radiograph showed two opaque globular masses on either side of the lower abdomen with distended small intestinal loops. Exploratory laparotomy was performed and a portion of strangulated small bowel attached to a solid globular mass behind the left ovary was removed, with a subsequent resection of the gut and end-to-end anastomosis. Upon removal of a thick membrane from the globular mass, a dead five-month-old calcified foetus was recovered. In the right iliac fossa, a similar mass was removed and another dead calcified foetus of similar age was recovered.

A 14-week abdominal pregnancy after total abdominal hysterectomy.

BACKGROUND: Pregnancy after hysterectomy is rare. Because this clinical phenomenon is so uncommon, the diagnosis is not always considered in the evaluation of pain in a reproductive-aged woman after hysterectomy. Delay in diagnosis can result in potentially catastrophic intra-abdominal bleeding. CASE: A 31-year-old multigravida underwent a total abdominal hysterectomy for menometrorrhagia. She experienced several weeks of postoperative abdominal pain and ultimately was diagnosed with a 14-week size intra-abdominal pregnancy. Surgical evacuation of the fetus and products of conception were complicated by significant intra- operative bleeding. CONCLUSION: In reproductive-aged women undergoing hysterectomy, it is vital to obtain preoperative urine hCG levels immediately before surgery and to consider ectopic pregnancy in the differential diagnosis of these women when severe or persistent abdominal pain occurs postoperatively.

Lithopedion presenting as intra-abdominal abscess and fecal fistula: report of a case and review of the literature.

A rare case of unrecognized and long-standing lithopedion ("stone baby") with erosion into the bowel with fecal fistula formation is described. A literature review is also presented.

Pregnancy in the broad ligament.

Pregnancy in the broad ligament is a rare form of ectopic pregnancy, and one type of abdominal pregnancy. The diagnosis is seldom established before surgery. A 38-year-old, 11-week pregnant woman, gravida 3, para 2, presented with vaginal bleeding. She had undergone two cesarean sections 10 and 6 years earlier. Pregnancy in the right broad ligament was diagnosed from clinical and transvaginal ultrasonographic findings. Emergency laparotomy and excision of a pregnancy in the right broad ligament and right salpingectomy were performed. She was well at discharge and at the 6-week follow up. We suggest the use of clinical and ultrasonographic findings for the suspicion of pregnancy in the broad ligament.

Extrauterine placental site trophoblastic tumour in association with a lithopedion.

AIM: We describe an unusual case of extrauterine placental site trophoblastic tumour located in pouch of Douglas in association with a lithopedion. METHODS AND RESULTS: A 35-year-old female presented with acute abdomen and peritonitis following rectal perforation. The patient gave a history of 5 months amenorrhoea followed by vaginal bleeding 5 years prior to admission. At laparotomy, a lithopedion was found in pouch of Douglas with rectal perforation and peritonitis. The lithopedion was removed, rectal perforation was sutured and a colostomy was performed. The colostomy was closed later and tumour was seen in the colostomy wound as well as attached to the lithopedion removed previously. The patient presented with a repeated episode of rectal perforation and the tumour had spread to colon, small intestine, omentum, mesentery and right ovary. CONCLUSION: A high-grade malignant placental site trophoblastic tumour with aggressive clinical course occurred at an extrauterine site. It complicated calcified abdominal pregnancy and resulted in repeated rectal perforation and peritonitis.