Primary Hepatic Pregnancy.

Dear Editor,

While we are reading the article published by Yadav . Doi: 10.4103/0974-2700.102417, which is actually difficult and rare case with great interest, some possible management options raised in our minds and we would like to know the authors' opinion about those management options in such cases if possible.

Yadav et al. presented a 25-year-old woman with live 18-week fetus with borderline vitals and tender abdomen confirmed as a primary right lobe hepatic pregnancy with 500 cc of hemoperitoneum and bleeding from the placental site at laparotomy. After extraction of the fetus and abdominal packing, hepatic artery embolization was done followed by re-laparotomy and repacking of the abdomen again. Unfortunately, she developed disseminated intravascular coagulopathy despite adequate replacement and she passed away due to multiorgan failure.[1]

We are thinking about the following possible management options in such difficult cases and we would like to know the authors' opinion regarding those management options if possible.

Multidisciplinary team management includes senior obstetrician, anesthetist, surgeon, hepatologist, and radiologist, with blood bank and neonatal supports, which is crucial before termination of pregnancy (TOP) in such cases

Preoperative magnetic resonance imaging (MRI) defines the regional anatomy and is crucial in identification of placental implantation; therefore, it can help in the decision of whether or not to remove the placenta during laparotomy

Preoperative intragestational ultrasound-guided methotrexate (MTX) to destroy active trophoblastic tissue, to facilitates placental involution and decreases the bleeding risks, which has been reported in some cases of cesarean section scar pregnancies, interstitial ectopic pregnancies, and morbidly adherent placenta (MAP)[23]

The preoperative insertion of arterial catheters for intraoperative embolization if needed. The arterial embolization has been reported in cases of MAP successfully[4]

Intraoperatively, the placenta should be kept in place without any attempt of removal unless was separated spontaneously, because any attempt to remove the placenta will precipitate uncontrollable massive bleeding[5]

The intraoperative massive bleeding from the placenta site can be controlled by interlocking sutures and/or packing which removed 48 h or removal of the placenta with its attached structure, if this structure is removable and less vascular (omentum or adnexa)[56]

The packing or the placenta if left in situ associated with risks of ileus, peritonitis, and abscess formation necessitating a second laparotomy[6]

Postoperatively, MTX systemic alternating with leucovorin (active folic acid) can be used to help placental involution.[2]

In general, multidisciplinary team management is crucial before TOP in such rare and difficult cases. Conservative management of hepatic pregnancy could be feasible with follow-up using the newer imaging techniques (MRI and/or three-dimensional ultrasound) to localize the placenta accurately before TOP. The placenta should be left in situ if possible, and any bleeding from the membrane edges can be controlled by interlocking sutures and packing. Preoperative intragestational ultrasound-guided MTX facilitates placental involution and preoperative insertion of arterial catheters for intraoperative embolization if needed.

Patient consent

This article does not contain any studies with human or animal subjects.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.