ª Springer Science+Business Media New York 2014

Abdominal Imaging

Abdom Imaging (2014) DOI: 10.1007/s00261-014-0101-5

Contrast-enhanced multiphasic CT and MRI of primary hepatic pregnancy: a case report and literature review Shudong Hu,1,2 Qi Song,2 Kemin Chen,2 Yerong Chen1 1

Department of Radiology, The affiliated Renmin Hospital, Jiangsu University, No. 8, Dianli Road, Zhenjiang 212002, Jiangsu, China 2 Department of Radiology, Ruijin Hospital, Shanghai Jiao tong University, School of Medicine, No. 197, Ruijin Er Road, Shanghai 200025, China

Abstract Primary hepatic pregnancy is extremely rare and difficult to diagnose radiologically. We present a 32-year-old woman with primary hepatic pregnancy diagnosed by using multi-modality imaging techniques, including ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI), which highlights diagnostic challenges. These techniques can define tissue planes in detail and identify embryo implantation into the hepatic parenchyma, thereby allowing accurate preoperative diagnosis and preoperative planning by the surgical team. To the best of our knowledge, this study is the first in the English literature to report a case of primary hepatic pregnancy, in which diffusion-weighted and contrast-enhanced multiphasic MRI were utilized for diagnosis and evaluation. Key words: Ectopic pregnancy—Primary hepatic pregnancy—Magnetic resonance imaging; tomography—X-ray computed; ultrasonography

Ectopic pregnancy is a potentially life-threatening pregnancy outcome that requires prompt evaluation and treatment; this condition is an important cause of pregnancy-related mortality. Abdominal pregnancy is a rare type of ectopic pregnancy with an estimated incidence of 10.9 per 100,000 pregnancies and 9.2 per 1,000 ectopic pregnancies [1]. The site of implantation in an abdominal pregnancy is usually pelvic and rarely hepatic. To the best of our knowledge, only 20 published materials on ectopic pregnancy in the liver are reported as case reports

Correspondence to: Yerong Chen; email: [email protected]

in English literature [2–21], recorded primarily in the surgical literature, and only a few reports included modern imaging techniques. In addition, only three case reports in English literature presented diagnosis by using unenhanced MRI [12, 17, 19]. We reported a case of a 32-year-old woman with primary hepatic pregnancy on account of its rarity and multi-modality imaging findings. In our case, ultrasonography (US), contrast-enhanced multiphasic computed tomography (CT), and magnetic resonance imaging (MRI) were used to diagnose primary hepatic pregnancy. To the best of our knowledge, this study is the first in the English literature to report a case of primary hepatic pregnancy, in which diffusion-weighted and contrast-enhanced multiphasic MRI were utilized for diagnosis and evaluation.

Case report A 32-year-old woman, gravida 3, para 2, was admitted to our hospital in November 2011 via the outpatient department. She has a history of 58 days of amenorrhea, elevated serum human chorionic gonadotropin (hCG) level, and a 5-day history of epigastric pain. Transvaginal ultrasound scan of the pelvis noted the absence of an intrauterine gestational sac and an abnormal adnexal mass. Dilation and curettage were performed to rule out a radiologically undetected placental site trophoblastic tumor. The physical examination yielded normal findings except for diffuse abdominal pain without rigidity. With persistently rising hCG levels and no pregnancy identified in the uterus or pelvis, the entire pelvis and abdomen should be subjected to thorough evaluation. A right upper quadrant ultrasound examination revealed that the mass consists of a well-defined gestation sac-like structure (Fig. 1a) with a maximum diameter of 3.3 cm

S. Hu et al.: A case report and literature review

Fig. 1. Ultrasonography and color Doppler of the abdomen were performed. A Abdominal ultrasound showed a gestational sac that contains a well-defined fetus, with a maximum diameter

of 3.3 cm and located at the right lobe of the liver. Note crownrump length compatible with gestation of 7–8 weeks. B Color Doppler sonography showed the cardiac activity of the fetus.

in the right lobe of the liver. Color Doppler sonography showed the cardiac activity of the fetus (Fig. 1b). Therefore, an ectopic pregnancy in the right lobe of the liver was highly suspected. Contrast-enhanced multiphasic CT and MRI of the abdomen and pelvis were performed because of this unusual finding. Abdominal CT scan was performed by using our 64-row multidetector CT scanner (Discovery CT750HD, GE Medical Systems, Milwaukee, WI, USA). Unenhanced scan and dual phase (arterial and portal phase) were used. Coronal and sagittal multiplanar images can also be reconstructed from the axial CT data set for review. The major scanning parameters were as follows: 120 kV, 250 mAs, 1.0 pitch, 0.625-mm collimation, and 5-mm slice thickness and slice intervals. An unenhanced CT scan revealed a 3.3-cm long solid-cystic abnormal mass in the right lobe of the liver (Fig. 2a). During the arterial phase, the enhancement of the peripheral solid components of the lesion dramatically increased (Fig. 2b). In the portal phase, solid components showed a progressive fill-in enhanced pattern (Fig. 2c). Coronal multiplanar images reconstructed from the axial arterial phase CT data set showed that the mass appeared to be surrounded by hepatic parenchyma (Fig. 2d). MR of the abdomen was also performed by using a 1.5-Tesla MR Scanner (Signa HDx; GE Medical Systems, Milwaukee, WI, USA). Axial T1WI (fat saturation), T2WI (fat saturation), DWI (b value = 600 mm/s), and LAVA (dynamic contrast enhancement) were used. The lesion appeared to be a gestational sac-like mass with a thick hyperintense wall on T2WI with fat suppression (Fig. 3a) and a gestational sac-like mass with a thick hypointense wall in the right lobe of the liver on T1WI with fat suppression (Fig. 3b). The lesion diffusion had ring-like high signal intensity on DWI (Fig. 3c). The lesion showed a dramatic and progressive fill-in ring-like enhancement on LAVA dynamic contrast scanning (Fig. 3d, e). No other abnormal features were evident.

A diagnosis of primary hepatic pregnancy was considered based on elevated serum b-hCG levels and multimodality imaging. Exploratory laparotomy with termination of the pregnancy was recommended to the patient because of the risk of rupture and subsequent hemorrhage. The patient was managed by exploratory laparotomy. On exposing the liver, there was no fresh bleeding in the peritoneal cavity. The mass was treated by partial hepatectomy in the right lobe of the liver. There was a total blood loss of 2,400 ml and four units of blood were transfused. Surgical exploration revealed a gestation of 7–8 weeks located in the right lobe of the liver. The patient’s postoperative course was uneventful, and serum hCG returned to normal. No surgical morbidity occurred after surgery. Pathological examination of the excised liver nodule revealed normal chorionic villi, consistent with the diagnosis of primary hepatic pregnancy. The patient remained well after her operation at 24month follow-up with no evidence of morbidity on repeated abdominal US scan.

Discussion This study is the first in the English literature to report a case of primary hepatic pregnancy, in which diffusionweighted and contrast-enhanced multiphasic MRI were utilized for diagnosis and evaluation. Abdominal pregnancies have been defined as serosal pregnancies occurring within the peritoneal cavity but excluding those pregnancies that are tubal, ovarian, intraligamentous, or the result of a secondary implantation of primary tubal implantation [22]. The maternal mortality rate was 7.7 times higher than that observed in tubal ectopic pregnancies and 90 times higher than in an intrauterine pregnancy. One of the factors contributing to the high maternal mortality rate may be that abdominal ectopic pregnancies are commonly misdiag-

S. Hu et al.: A case report and literature review

Fig. 2. Unenhanced and dual-phase dynamic-enhanced CT scanning was performed by using 64-row spiral CT. A Unenhanced CT scanning revealed a solid-cystic low attenuation mass located at the right lobe of the liver. B In the arterial phase, the lesion showed a dramatic enhancing ring-like mass that

represents gestational sac without hemoperitoneum. C In the portal phase, the gestational sac exhibited a progressive fill-in enhanced pattern. D Coronal multiplanar images in the artery phase showed a solid-cystic abnormal mass with contrast medium pooling in the right lobe of the liver.

nosed [23]. Thus, early diagnosis with timely individualized intervention can help improve outcomes [1]. Both clinical and radiological diagnosis of primary hepatic pregnancy is difficult because symptoms and clinical findings are usually vague and variable. In previously reported cases, primary hepatic pregnancies are more difficult to locate, and diagnosis is usually made intraoperatively and after surgery. With persistently rising hCG levels and no pregnancy identified in the uterus or pelvis, the entire pelvis and abdomen should be subjected to thorough evaluation. Sonography is now the primary screening modality for ectopic pregnancy. Sonography can demonstrate the anatomic location of the fetus and evaluate fetal activity, parts, age, and placental location. Color Doppler is useful in determining whether or not the mass is vascular. The most specific US criterion of ectopic pregnancy is the presence of an extrauterine gestational sac with either a

yolk sac or an embryo, with a specificity of 100% [24]. However, this criterion has a limited sensitivity (26%) [25]. Therefore, ectopic pregnancy cannot be definitively excluded with US in a number of cases. Multidetector CT and MR can define the regional anatomy in detail and identify the ectopic gestational sac when it is not identified with US [24, 26]. Multi-detector CT in emergency radiology is a useful tool in the diagnosis and management of acute female abdominal pain. MRI is an effective modality for diagnosing ectopic pregnancy with a high detection rate of extrauterine gestational sacs [12, 24]. DWI imaging is useful for diagnosing ectopic pregnancy because it shows a ring-like or dot-like high signal intensity in the gestational sac [24]. Contrast-enhanced MRI is also useful for diagnosing ectopic pregnancy because it shows enhancement in the gestational sac [12, 24]. In most cases of hepatic pregnancy, including ours, the attachment site of gestational sac-like and the placenta is

S. Hu et al.: A case report and literature review

Fig. 3. Abdominal MR was performed by using a 1.5-Tesla MR scanner. A Axial T2WI with fat suppression showed the gestational sac-like mass with a thick hyperintense wall in the right lobe of the liver. B Axial T1WI with fat suppression showed the gestational sac-like mass with a thick hypointense

wall. C DWI revealed the gestational sac-like mass with a ring-like hypointense wall. D In the arterial phase, and E the delay phase clearly exhibited a gestational sac-like mass with dramatic and progressive fill-in ring-like heterogeneous enhancement.

the lower surface of the right lobe of the liver. The rich vascular supply in this location makes it a favorable site for fetal growth [13, 15]. No optimal management strategy for the clinical management of hepatic pregnancy is currently available. Ideally, management strategy should be associated with a minimal risk of bleeding and a rapid decline of serum b-hCG. Previous reports on hepatic pregnancies, which

described surgical treatment by laparoscopy or laparotomy, were usually undertaken because of signs of significant intra-abdominal hemorrhage. Other management options include direct injection of methotrexate into the gestational sac at the time of laparotomy and preoperative arterial embolization before laparotomy, followed by postoperative methotrexate administration for the retained placenta.

S. Hu et al.: A case report and literature review

Conclusion We described an extremely rare case of primary hepatic pregnancy diagnosed by using multi-modality imaging before treatment, which highlights the diagnostic challenges. These techniques can define tissue planes, thereby allowing accurate diagnosis and preoperative planning by the surgical team. Acknowledgments. This study was supported in part by a Grant-in-aid for scientific research from the Science and Technology Commission of Shanghai Municipality (Project No. 11JC1407400, 10JC1410900, and 10411953000),Technology Plan of Zhenjiang (Project No. SH2013083) and National Natural Science Foundation of China (Project No. 81071281 and 81271682).

References 1. Atrash HK, Friede A, Hogue CJ (1987) Abdominal pregnancy in the United States: frequency and maternal mortality. Obstet Gynecol 69(3 Pt 1):333–337 2. Murley AH (1956) Liver pregnancy. Lancet 270(6930):994–995 3. Kirby NG (1969) Primary hepatic pregnancy. Br Med J 1(5639):296 4. Luwuliza-Kirunda JM (1978) Primary hepatic pregnancy: case report. Br J Obstet Gynaecol 85(4):311–313 5. Krause DW (1979) Hepatic tumor or hepatic pregnancy? AJR Am J Roentgenol 133(2):355–356. doi:10.2214/ajr.133.2.355 6. Hietala SO, Andersson M, Emdin SO (1983) Ectopic pregnancy in the liver. Report of a case and angiographic findings. Acta Chir Scand 149(6):633–635 7. Mitchell RW, Teare AJ (1984) Primary hepatic pregnancy. A case report and review. S Afr Med J 65(6):220 8. Shukla VK, Pandey S, Pandey LK, Roy SK, Vaidya MP (1985) Primary hepatic pregnancy. Postgrad Med J 61(719):831–832 9. Paulino-Netto A, Roselli A (1986) Hepatic ectopic pregnancy: successful surgical treatment of a patient with hepatic pregnancy and acute hemorrhage. Mt Sinai J Med 53(7):514–517 10. Veress B, Wallmander T (1987) Primary hepatic pregnancy. Acta Obstet Gynecol Scand 66(6):563–564 11. Borlum KG, Blom R (1988) Primary hepatic pregnancy. Int J Gynaecol Obstet 27(3):427–429 12. Harris GJ, Al-Jurf AS, Yuh WT, Abu-Yousef MM (1989) Intrahepatic pregnancy. A unique opportunity for evaluation with

13. 14. 15. 16. 17. 18. 19. 20. 21.

22. 23.

24. 25. 26.

sonography, computed tomography, and magnetic resonance imaging. JAMA 261(6):902–904 Barbosa Junior Ade A, de Freitas LA, Mota MA (1991) Primary pregnancy in the liver: A case report. Pathol Res Pract 187(2– 3):329–331 ((discussion 332–323)) Nichols C, Koong D, Faulkner K, Thompson G (1995) A hepatic ectopic pregnancy treated with direct methotrexate injection. Aust N Z J Obstet Gynaecol 35(2):221–223 Delabrousse E, Site O, Le Mouel A, Riethmuller D, Kastler B (1999) Intrahepatic pregnancy: sonography and CT findings. AJR Am J Roentgenol 173(5):1377–1378. doi:10.2214/ajr.173.5.10541123 Chui AK, Lo KW, Choi PC, Sung MC, Lau JW (2001) Primary hepatic pregnancy. ANZ J Surg 71(4):260–261 Shippey SH, Bhoola SM, Royek AB, Long ME (2007) Diagnosis and management of hepatic ectopic pregnancy. Obstet Gynecol 109(2 Pt2):544–546. doi:10.1097/01.AOG.0000247293.32523.c3 Chin PS, Wee HY, Chern BS (2010) Laparoscopic management of primary hepatic pregnancy. Aust NZJ Obstet Gynaecol 50(1):95– 98. doi:10.1111/j.1479-828X.2009.01113.x Ramphal SR, Moodley J, Rajaruthnam D (2010) Hepatic pregnancy managed conservatively. Trop Doct 40(2):121–122. doi: 40/2/12110.1258/td.2009.090218 Yadav R, Raghunandan C, Agarwal S, Dhingra S, Chowdhary S (2012) Primary hepatic pregnancy. J Emerg Trauma Shock 5(4):367–369. doi:10.4103/0974-2700.102417JETS-5-367 Ma J, Zhou C, Duan Z, Jiang Y (2013) Successful management of primary hepatic pregnancy with selective hepatic artery embolization and intra-arterial methotrexate infusion. Int J Gynaecol Obstet 122(1):78–79. doi:10.1016/j.ijgo.2013.02.019 Studdiford WE (1942) Primary peritoneal pregnancy. Am J Obstet Gynecol 44:487–491 Takeda A, Imoto S, Mori M, Yamada J, Nakamura H (2012) Early abdominal pregnancy complicated by parasitic dermoid cyst: diagnosis by diffusion-weighted magnetic resonance imaging and management by laparoendoscopic single-site surgery. J Minim Invasive Gynecol 19(5):647–650. doi:10.1016/j.jmig.2012.03.024 Takahashi A, Takahama J, Marugami N, et al. (2013) Ectopic pregnancy: MRI findings and clinical utility. Abdom Imaging 38(4):844–850. doi:10.1007/s00261-012-9969-0 Tongsong T, Pongsatha S (1993) Transvaginal sonographic features in diagnosis of ectopic pregnancy. Int J Gynaecol Obstet 43(3):277–283 Parker RA 3rd, Yano M, Tai AW, et al. (2012) MR imaging findings of ectopic pregnancy: a pictorial review. Radiographics 32(5):1445–1460 ((discussion 1460–1442)). doi:10.1148/rg. 325115153

Contrast-enhanced multiphasic CT and MRI of primary hepatic pregnancy: a case report and literature review.

Primary hepatic pregnancy is extremely rare and difficult to diagnose radiologically. We present a 32-year-old woman with primary hepatic pregnancy di...
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