Multimodal management of ectopic hepatic pregnancy: a systematic review of the literature

Abstract

Purpose: Ectopic pregnancies with implantation in the upper abdomen are exceptionally rare. Here we provide a systematic review of hepatic ectopic pregnancies and the corresponding management strategies. Furthermore, this report details a case of ectopic hepatic pregnancy, successfully treated with primary methotrexate (MTX) followed by a two-staged robotic-assisted resection.

Methods: Two independent investigators performed a systematic review using the online search engine PubMed and MEDLINE database. The search utilized the following terms: 'Hepatic Ectopic Pregnancy,' 'Hepatic Extrauterine Pregnancy,' 'Hepatic Abdominal Pregnancy,' and 'Ectopic Liver Pregnancy.' Cross-referencing was employed to identify possible additional publications.

Findings: Forty-seven case reports on hepatic pregnancies were identified. Of these, 40 provided manuscripts in the English language. Most patients with hepatic pregnancy presented with mild to moderate abdominal pain, while only a minority exhibited signs of hemodynamically relevant intraperitoneal hemorrhage. Most cases were managed through open surgical removal, although in recent years, there has been an increase in laparoscopically managed cases. Conservative approaches using methotrexate are seldom employed.

Conclusion: Hepatic pregnancies present a rare and challenging clinical scenario. Until now, these cases have usually been treated primarily with open explorative surgery. As reported in this case, primary conservative treatment approaches with MTX before surgery hold promise as a strategy to reduce surgery-related bleeding and morbidity, particularly for asymptomatic or oligosymptomatic patients.

Keywords: Abdominal pregnancy; Ectopic pregnancy; Hepatic pregnancy; Liver pregnancy; Methotrexate.

Fig. 1

Imaging studies of the 24-year-old patient presenting with hepatic pregnancy. A Emergency transabdominal ultrasound on primary presentation showed a 9 × 5 × 4 cm inhomogeneously hyperechogenic tumor with hypoechogenic circumscribed areas on the right hepatic lobe. B Contrast-enhanced abdominal CT, coronal plane, exhibiting an intermediate- to low-density tumor measuring approximately 10 × 7 × 11 cm, attached to the right hepatic lobe with hilar involvement. C 1.5-Tesla-MRI, T2-HASTE, axial plane, displaying an 11 × 6 cm lobulated inhomogeneous tumor with solid and liquid components located in the Morison pouch. D 3-Tesla-MRI, T2-HASTE, axial plane, shows an increasingly circumscribed, roundish tumor with intermediate T2 internal signal, T2 hypointense encapsulation and septa-like central parts. The tumor has remained stable in size

Fig. 2

Time course of serum β-hCG levels. The y-axis displays the β-hCG serum levels on a logarithmic scale, while the x-axis represents the timeline in days. The time points of methotrexate (MTX) administration and surgery are indicated by magenta-colored boxes