British Journal of Obstetrics and Gynaecology April 1978. Vol 85. pp 311-313
PRIMARY HEPATIC PREGNANCY CASE REPORT BY
J. M. M. LUWULIZA-KIRUNDA* Department of Obstetrics and Gynaecology, Makerere Medical School, Kampala, Uganda Summary A case of primary hepatic pregnancy presenting as a lithopedion in the right hypochondrium is presented. The lithopedion was removed and the patient recovered uneventfully. The diagnosis of primary hepatic pregnancy is briefly discussed.
hypochondrium. On vaginal examination the uterus was firm, anteverted, mobile and about the size of a 12 week pregnancy. The adnexae were not palpable and the cervix was firm. A pregnancy test was negative on three occasions, the haemoglobin concentration was 12.1 g/dl and there was no evidence of coagulation disorder or abnormal liver function. A straight X-ray of the abdomen showed a rolled-up fetus in a partially calcified capsule in the right hypochondrium (Fig. 1). A hysterosalpingogram showed a bulky uterus but the oviducts were not visualized. The mass in the right hypochondrium was widely separated from the uterus and was not affected by moving the uterus with the intrauterine cannula. Two weeks after admission the patient had a laparotomy through a right upper paramedian incision. On opening the abdomen, there was an oval mass, almost the size of a rugby football, attached to the inferior surface of the right lobe of the liver. A few flimsy adhesions between the mass and the surrounding bowel were divided (Fig. 2). The mass was easily and bloodlessly excised by cutting through the capsule 4 cm from the edge of the liver. The capsule was fibrotic and partly calcified. The placenta was not seen and was thought to have undergone autolysis. The free edges of the capsule remained attached to the liver and were approximated with
IN only few extrauterine pregnancies is the placental attachment site in the upper abdomen. Billington and Goodchild (1948), Serebryakova and Kanshin (1952), Van de Loo (1952), Murley (1956) and Kirby (1969) described the liver as a placental site. However, a lithopedion developing from a hepatic pregnancy has not been described previously. The following is an example of this rare condition. CASEREPORT A Ugandan woman, aged about 40, was seen in the gynaecological clinic and complained of a mass in the right hypochondrium for four years. The mass had appeared immediately after the delivery of her second baby at home. Since that confinement the patient had had three abortions at home. In the two previous months her menstrual losses had been scanty though regular. The patient denied dyspeptic symptoms. On clinical examination she was in a good condition with no clinical evidence of anaemia or jaundice. The breasts were inactive. The cardiovascular and respiratory systems were normal and the blood pressure was 100/60 mm Hg. On abdominal examination, a hard mobile non-tender mass was found in the right
* Present
address: Department of Obstetrics and Gynaecology, University of Nairobi, Nairobi, Kenya.
311
FIG.1 Straight X-ray of the abdomen showing a rolled-up fetus in a partially calcified capsule in the right hypochondrium.
FIG.2 Exposure of the encapsulated lithopedion (marked by arrow) at laparotomy; it is still attached to the liver.
c.r N
w
PRIMARY HEPATIC PREGNANCY
No. 2 catgut mounted on an atraumatic needle. The right paramedian incision was extended downwards to reveal a uterus the size of a 12 week pregnancy. The oviducts were entirely normal and hydrotubation with normal saline showed that they were patent. The ovaries looked normal and the left contained a corpus luteum. The excised mass showed a mummified female fetus with a crown to rump length of 35 cm. The patient made an uneventful recovery and went home 12 days after operation. She has not been seen since.
COMMENT It appears that this was a case of twin pregnancy, with one fetus in the uterus and the other implanted on the liver, both fetuses reaching viability. In all cases of hepatic pregnancy placental attachment appears to have been to the inferior surface of the right lobe of the liver. Some patients present with dyspeptic symptoms due to pressure on the gall bladder or duodenum. Studdiford (1942) suggested four criteria for a diagnosis of primary abdominal pregnancy:
3 13
(i) both tubes and ovaries should be normal with no evidence of recent or remote injury; (ii) no utero-peritoneal fistula should be demonstrable ; (iii) the pregnancy should be related exclusively to the peritoneum: and (iv) the pregnancy should be recent enough to exclude the possibility of secondary implantation following primary nidation in the oviduct. The patient I have described satisfied the first three criteria.
ACKNOWLEDGEMENTS I thank the Departments of Medicat Illustration and Radiology for producing the photographs and X-ray films. REFERENCES Billington, W. R.,and Goodchild, R. T. S. (1948): British Medical Journal, 2, 789. Kirby, N. (1969): Brifish Medical Journal, 1, 296. Murley, A. H. G. (1956): Lancer, 1, 994. Serebryakova, A. G., and Kanshin, N. N. (1952): Akusherstovo i ginekologiya, 5, 590. Studdiford, W. E. (1942): American Journal of Obstetrics and Gynecology, 44,487. Van de Loo, J. W. (1952): Nederlandsch tcschrvt voor verloskunde en gynaecologie, 52, 25.
PRIMARY HEPATIC PREGNANCY CASE REPORT BY
J. M. M. LUWULIZA-KIRUNDA* Department of Obstetrics and Gynaecology, Makerere Medical School, Kampala, Uganda Summary A case of primary hepatic pregnancy presenting as a lithopedion in the right hypochondrium is presented. The lithopedion was removed and the patient recovered uneventfully. The diagnosis of primary hepatic pregnancy is briefly discussed.
hypochondrium. On vaginal examination the uterus was firm, anteverted, mobile and about the size of a 12 week pregnancy. The adnexae were not palpable and the cervix was firm. A pregnancy test was negative on three occasions, the haemoglobin concentration was 12.1 g/dl and there was no evidence of coagulation disorder or abnormal liver function. A straight X-ray of the abdomen showed a rolled-up fetus in a partially calcified capsule in the right hypochondrium (Fig. 1). A hysterosalpingogram showed a bulky uterus but the oviducts were not visualized. The mass in the right hypochondrium was widely separated from the uterus and was not affected by moving the uterus with the intrauterine cannula. Two weeks after admission the patient had a laparotomy through a right upper paramedian incision. On opening the abdomen, there was an oval mass, almost the size of a rugby football, attached to the inferior surface of the right lobe of the liver. A few flimsy adhesions between the mass and the surrounding bowel were divided (Fig. 2). The mass was easily and bloodlessly excised by cutting through the capsule 4 cm from the edge of the liver. The capsule was fibrotic and partly calcified. The placenta was not seen and was thought to have undergone autolysis. The free edges of the capsule remained attached to the liver and were approximated with
IN only few extrauterine pregnancies is the placental attachment site in the upper abdomen. Billington and Goodchild (1948), Serebryakova and Kanshin (1952), Van de Loo (1952), Murley (1956) and Kirby (1969) described the liver as a placental site. However, a lithopedion developing from a hepatic pregnancy has not been described previously. The following is an example of this rare condition. CASEREPORT A Ugandan woman, aged about 40, was seen in the gynaecological clinic and complained of a mass in the right hypochondrium for four years. The mass had appeared immediately after the delivery of her second baby at home. Since that confinement the patient had had three abortions at home. In the two previous months her menstrual losses had been scanty though regular. The patient denied dyspeptic symptoms. On clinical examination she was in a good condition with no clinical evidence of anaemia or jaundice. The breasts were inactive. The cardiovascular and respiratory systems were normal and the blood pressure was 100/60 mm Hg. On abdominal examination, a hard mobile non-tender mass was found in the right
* Present
address: Department of Obstetrics and Gynaecology, University of Nairobi, Nairobi, Kenya.
311
FIG.1 Straight X-ray of the abdomen showing a rolled-up fetus in a partially calcified capsule in the right hypochondrium.
FIG.2 Exposure of the encapsulated lithopedion (marked by arrow) at laparotomy; it is still attached to the liver.
c.r N
w
PRIMARY HEPATIC PREGNANCY
No. 2 catgut mounted on an atraumatic needle. The right paramedian incision was extended downwards to reveal a uterus the size of a 12 week pregnancy. The oviducts were entirely normal and hydrotubation with normal saline showed that they were patent. The ovaries looked normal and the left contained a corpus luteum. The excised mass showed a mummified female fetus with a crown to rump length of 35 cm. The patient made an uneventful recovery and went home 12 days after operation. She has not been seen since.
COMMENT It appears that this was a case of twin pregnancy, with one fetus in the uterus and the other implanted on the liver, both fetuses reaching viability. In all cases of hepatic pregnancy placental attachment appears to have been to the inferior surface of the right lobe of the liver. Some patients present with dyspeptic symptoms due to pressure on the gall bladder or duodenum. Studdiford (1942) suggested four criteria for a diagnosis of primary abdominal pregnancy:
3 13
(i) both tubes and ovaries should be normal with no evidence of recent or remote injury; (ii) no utero-peritoneal fistula should be demonstrable ; (iii) the pregnancy should be related exclusively to the peritoneum: and (iv) the pregnancy should be recent enough to exclude the possibility of secondary implantation following primary nidation in the oviduct. The patient I have described satisfied the first three criteria.
ACKNOWLEDGEMENTS I thank the Departments of Medicat Illustration and Radiology for producing the photographs and X-ray films. REFERENCES Billington, W. R.,and Goodchild, R. T. S. (1948): British Medical Journal, 2, 789. Kirby, N. (1969): Brifish Medical Journal, 1, 296. Murley, A. H. G. (1956): Lancer, 1, 994. Serebryakova, A. G., and Kanshin, N. N. (1952): Akusherstovo i ginekologiya, 5, 590. Studdiford, W. E. (1942): American Journal of Obstetrics and Gynecology, 44,487. Van de Loo, J. W. (1952): Nederlandsch tcschrvt voor verloskunde en gynaecologie, 52, 25.
