Simultaneous Tubal and Intrahepatic Ectopic Pregnancy Managed by Feticide and Conservative Observation

Simultaneous Tubal and Intrahepatic Ectopic Pregnancy Managed by Feticide and Conservative Observation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Simultaneous Tubal and Intrahepatic Ectopic Pregnancy Managed by Feticide and Conservative Observation Walid E Abdelrahim, Mohamed Daffalla-Awadalla Gismalla, Samir Gorashi Abdelrhman Dafalla, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7890810/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 25 You are reading this latest preprint version Abstract Background Hepatic ectopic pregnancy (HEP) is a rare and life-threatening condition, with only approximately 40 cases previously reported worldwide. We present the first documented case of a patient presenting with an acutely ruptured tubal ectopic pregnancy who was subsequently diagnosed with a separate, viable intrahepatic pregnancy. Case Presentation A 38-year-old woman (Para 6) presented in hypovolemic shock (BP 90/40 mmHg) due to a ruptured right tubal ectopic pregnancy, requiring emergency laparotomy and salpingectomy. Eleven days later, she returned with epigastric pain. A subsequent liver scan surprisingly revealed a separate, viable intrahepatic pregnancy located in liver segment 7. Given the extremely high risk of catastrophic hemorrhage associated with a solid organ gestation, a Multidisciplinary Team (MDT) recommended termination. Ultrasound-guided feticide was performed using an intracardiac injection of 20% sodium chloride solution, which successfully achieved fetal asystole. The patient remains stable and is under conservative, antibiotic-supported expectant management. Conclusions This case highlights the critical need to maintain a high index of suspicion for secondary or persistent abdominal gestation in patients presenting with new or unresolved pain shortly after initial ectopic pregnancy management. For deeply embedded, high-risk solid-organ ectopics, local feticide followed by conservative observation offers a safer definitive treatment pathway compared to potentially high-mortality surgical excision. Hepatic ectopic pregnancy Gestational sac embryonic pole Methotrexate Figures Figure 1 Figure 2 Background Hepatic ectopic pregnancy is a rare condition that occurs after implantation of the fertilized ovum in the liver tissue [ 1 ]. Beck et al.'s systematic review identified 40 reported worldwide cases of ectopic pregnancy located in the liver. The majority of these patients presented with non-specific, moderate, or severe right upper quadrant pain. [ 2 ]. It was reported that it can be presented with haemodynamically instability [ 2 ]. Open surgical excision was performed for most of the cases, while some were treated by laparoscopic intervention and excision of the pregnancy sac [ 2 ]. Conservative treatment was done for minor cases. This manuscript presents the first documented case of intrahepatic pregnancy in Sudan. A patient presented with simultaneous tubal and intrahepatic ectopic pregnancy. The tubal ectopic was treated surgically, and the intrahepatic was treated conservatively. Case presentation A 38-year-old woman (Para 6) presented to the hospital with a 6-week history of amenorrhea and vaginal bleeding, accompanied by abdominal pain and drowsiness. Upon examination, the patient showed signs of shock; Initial vital signs were: Blood Pressure (BP) 90/40 mmHg, pulse 120 beats/minute, and a high respiratory rate of 34 breaths per minute. She appeared pale and had a tender abdomen. Laboratory and imaging results confirmed the suspicion of an acute obstetric emergency. Her complete Blood count revealed low hemoglobin, and Urine analysis was positive for pregnancy. Ultrasound (US) showed an empty uterus and a right fallopian tube ectopic pregnancy. She was immediately taken for an emergency laparotomy via a midline infraumbilical incision. Upon surgical entry, the abdomen was full of blood. The primary finding was a ruptured right fallopian tube, which was the source of the initial hemorrhage. A right salpingectomy was performed, with removal of the fallopian gestational sac, and the bleeding from the tube was secured (hemostasis achieved). Unexpectedly, active bleeding was then noted from the liver area. A large clot was found attached to the lower border of the liver, and upon its removal, a small gestational sac was identified. The bleeding from the liver was managed by covering the area with Syrgisel, achieving hemostasis. A drain was placed, and the abdominal incision was closed. The patient was discharged in stable condition on postoperative day three. Eleven days following her discharge, the patient returned complaining of epigastric pain. She was stable and not pale upon examination. Her abdomen was soft. A pelvic ultrasound was free (clear of pathology). A subsequent liver scan, surprisingly, revealed a viable intra-abdominal pregnancy located in liver segment 7. The US showed an active gestational sac with associated perigestational fluid, raising serious concern for potential rupture (Fig. 1 , and Fig. 2 ). It was separate from the ruptured tubal ectopic pregnancy. The case was referred to WAD Medaani Obstetric and Gynaecology Hospital, a tertiary referral center, for specialized management. A Multidisciplinary Team (MDT), comprising specialists from Obstetrics, Hepatobiliary (HPB) Surgery, and Interventional Radiology, reviewed the case. Given the high risk of hemorrhage associated with a hepatic pregnancy, the MDT unanimously recommended termination. Under ultrasound guidance, a feticide procedure was performed. An intracardiac injection of 1 cc of 20% sodium chloride solution was administered using a 25-gauge spinal needle. Follow-up imaging confirmed fetal asystole (cessation of heartbeat). The patient is currently being managed conservatively with antibiotics to prevent infection and Methotrexate. She remains in stable condition under close observation for resolution of the ectopic tissue. Discussion This patient was presented initially with a typical case of a ruptured tubal ectopic pregnancy, characterized by hypovolemic shock necessitating emergent salpingo-oophorectomy and significant blood transfusion. Then, she re-presented, merely 12 days post-discharge, with right upper quadrant (RUQ) pain, signaling the presence of the secondary ectopic located in liver segment 7. The development of a hepatic gestation following treatment for a tubal ectopic raises critical questions regarding its origin. While the tight timeframe suggests the possibility of two separate, near-simultaneous implantations (heterotopic implantation outside the uterus), the most plausible mechanism is a secondary abdominal pregnancy. This occurs when the conceptus, originally expelled from the fallopian tube (or occasionally the fimbriae), survives and successfully reimplants onto a peritoneal surface, such as the liver capsule. Intra-hepatic ectopic pregnancy is a rare condition; only less than 40 cases have been reported [ 2 ]. This is the first case in Sudan. The clinical presentations were dependent mainly on amenorrhea, empty uterus, and mimic in abdominal pregnancy [ 3 ]. This case was presented with a feature of internal hemorrhage, which necessitates emergency laparotomy. This case is unique because the patient had a separate sac and ectopic pregnancy, the first at the fallopian and the other intrahepatic. The diagnosis was dependent entirely on high-quality ultrasound imaging, which confirmed a viable gestational sac within the liver parenchyma [ 3 ]. The location in liver segment 7, given its deep vascularity, confers an extremely high risk of catastrophic hemorrhage, differentiating it from more accessible peritoneal or omental implantations. This danger necessitated the involvement of a Multidisciplinary Team (MDT), including Obstetric, Hepatobiliary (HPB) Surgical, and Interventional Radiology specialists, underscoring the complexity of managing a pregnancy attached to a solid organ. Management options for stable abdominal pregnancies include laparoscopic surgical excision [ 4 ], [ 5 ] or open excision [ 6 ]. Methotrexate administration, or local feticide followed by expectant management, is commonly used when the sections are not feasible [ 7 , 8 ]. Due to the high risk of attempting surgical excision from the liver parenchyma, the MDT opted for ultrasound-guided feticide. The successful administration of 1 cc of 20% sodium chloride solution intracardially achieved fetal asystole, thereby arresting trophoblastic activity and minimizing the immediate risk of rupture and massive hemorrhage. Conclusion and Clinical Implications This case underscores the necessity of maintaining a high index of suspicion for persistent or secondary abdominal gestation in women who present with unusual or persistent abdominal pain shortly after initial ectopic pregnancy management. While surgical or systemic medical treatment may be considered for deeply embedded solid organ ectopics, local feticide followed by conservative, antibiotic-supported expectant management, as implemented here, offers a potentially safer definitive treatment pathway. Close observation remains paramount until complete resolution of the ectopic tissue is confirmed. Declarations Acknolwegment We thank the patient and her family for their trust and cooperation throughout the management and publication process. Authors’ contributions WEA, MDAG, and SAG conceived the idea, collected the data, manuscript, and literature review. SMS and MYMA designed the study. All authors wrote the manuscript, read the article, and approved the final version. Funding The authors declare that they had no funds Data availability Data is collected with the corresponding author and is available upon request. Ethics approval and consent to participate This case report was approved by the Ethical Review Committee–Health Sector of the University of Sinnar, with ethical committee reference number 2-10/2025 . Consent for publication Written informed consent was obtained from the patient for the publication of this case report and any accompanying images. Competing interests Authors declare no competing interests. References Zhang N, Yang L, Wang Y, Li X, Zhang C, Xu J. Primary hepatic ectopic pregnancy in a patient with polycystic ovary syndrome: a case report. Medicine. 2020 Mar 1;99(13):e19649. Beck MH, Sehouli J, Leppig JA, Knitter S, Pratschke J, Krenzien F. Multimodal management of ectopic hepatic pregnancy: a systematic review of the literature. Archives of Gynecology and Obstetrics. 2024 Nov;310(5):2345-53. Cai YY, Xiao EH, Shang QL, Xiao LZ. Ectopic pregnancy in the liver incidentally diagnosed by imaging: a case report. Experimental and Therapeutic Medicine. 2017 Jul;14(1):373-6. Garzon S, Raffaelli R, Montin U, Ghezzi F. Primary hepatic pregnancy: report of a case treated with laparoscopic approach and review of the literature. Fertility and Sterility. 2018 Oct 1;1 10(5):925-31. Rajanbabu M et al (2023) Primary hepatic ectopic pregnancy: diagnosis and laparoscopic management. J Minim Invasive Gynecol 31:178–179 Nichols C, Koong D, Faulkner K, Thompson G. A hepatic ectopic pregnancy treated with direct methotrexate injection. Australian and New Zealand journal of obstetrics and gynaecology. 1995 May;35(2):221-3. Sibetcheu Tchatou A, Tchounzou R, Mbuagbaw L, Mboudou ET. Successful medical treatment of a hepatic pregnancy: a case report. Journal of Medical Case Reports. 2017 Mar 15;11(1):70. Moores KL, Keriakos RH, Anumba DO, Connor ME, Lashen H. Management challenges of a live 12‐week sub‐hepatic intra‐abdominal pregnancy. BJOG: An International Journal of Obstetrics & Gynaecology. 2010 Feb;117(3):365-8. Additional Declarations No competing interests reported. Supplementary Files Video1.mp4 Supplementary video: The video demonstrating the hepatic Ultrasound abdomen with intrahepatic ectopic pregnancy and active cardiac fetal beating. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 11 Feb, 2026 Reviews received at journal 08 Feb, 2026 Reviews received at journal 08 Dec, 2025 Reviews received at journal 07 Dec, 2025 Reviewers agreed at journal 05 Dec, 2025 Reviews received at journal 04 Dec, 2025 Reviews received at journal 03 Dec, 2025 Reviews received at journal 01 Dec, 2025 Reviews received at journal 28 Nov, 2025 Reviewers agreed at journal 28 Nov, 2025 Reviewers agreed at journal 28 Nov, 2025 Reviews received at journal 27 Nov, 2025 Reviewers agreed at journal 27 Nov, 2025 Reviewers agreed at journal 26 Nov, 2025 Reviewers agreed at journal 22 Nov, 2025 Reviewers agreed at journal 21 Nov, 2025 Reviews received at journal 21 Nov, 2025 Reviewers agreed at journal 21 Nov, 2025 Reviewers agreed at journal 19 Nov, 2025 Reviewers agreed at journal 19 Nov, 2025 Reviewers invited by journal 19 Nov, 2025 Editor invited by journal 25 Oct, 2025 Editor assigned by journal 21 Oct, 2025 Submission checks completed at journal 21 Oct, 2025 First submitted to journal 18 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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2","display":"","copyAsset":false,"role":"figure","size":71565,"visible":true,"origin":"","legend":"\u003cp\u003eColor Doppler ultrasound images showing the intrahepatic ectopic pregnancy with a fetal echo (heartbeat) and prominent peritrophoblastic flow, suggesting high vascularity.\u003c/p\u003e","description":"","filename":"Fig2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7890810/v1/59bbe207b4179e950b449e74.jpeg"},{"id":97145088,"identity":"1fdf1e3a-9f8a-4cbc-b821-750052e6db67","added_by":"auto","created_at":"2025-12-01 10:13:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":510070,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7890810/v1/8c12fb39-21ee-4732-84ed-bf7b4f1c443c.pdf"},{"id":97096076,"identity":"9a673d13-8814-4c9c-861e-545f4292c301","added_by":"auto","created_at":"2025-11-30 23:27:49","extension":"mp4","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":547910,"visible":true,"origin":"","legend":"\u003cp\u003eSupplementary video: The video demonstrating the hepatic Ultrasound abdomen with intrahepatic ectopic pregnancy and active cardiac fetal beating.\u003c/p\u003e","description":"","filename":"Video1.mp4","url":"https://assets-eu.researchsquare.com/files/rs-7890810/v1/3085bb53d3ea866633488c27.mp4"}],"financialInterests":"No competing interests reported.","formattedTitle":"Simultaneous Tubal and Intrahepatic Ectopic Pregnancy Managed by Feticide and Conservative Observation","fulltext":[{"header":"Background","content":"\u003cp\u003eHepatic ectopic pregnancy is a rare condition that occurs after implantation of the fertilized ovum in the liver tissue [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Beck et al.'s systematic review identified 40 reported worldwide cases of ectopic pregnancy located in the liver. The majority of these patients presented with non-specific, moderate, or severe right upper quadrant pain. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. It was reported that it can be presented with haemodynamically instability [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Open surgical excision was performed for most of the cases, while some were treated by laparoscopic intervention and excision of the pregnancy sac [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Conservative treatment was done for minor cases. This manuscript presents the first documented case of intrahepatic pregnancy in Sudan. A patient presented with simultaneous tubal and intrahepatic ectopic pregnancy. The tubal ectopic was treated surgically, and the intrahepatic was treated conservatively.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 38-year-old woman (Para 6) presented to the hospital with a 6-week history of amenorrhea and vaginal bleeding, accompanied by abdominal pain and drowsiness. Upon examination, the patient showed signs of shock; Initial vital signs were: Blood Pressure (BP) 90/40 mmHg, pulse 120 beats/minute, and a high respiratory rate of 34 breaths per minute. She appeared pale and had a tender abdomen. Laboratory and imaging results confirmed the suspicion of an acute obstetric emergency. Her complete Blood count revealed low hemoglobin, and Urine analysis was positive for pregnancy. Ultrasound (US) showed an empty uterus and a right fallopian tube ectopic pregnancy.\u003c/p\u003e\u003cp\u003eShe was immediately taken for an emergency laparotomy via a midline infraumbilical incision. Upon surgical entry, the abdomen was full of blood. The primary finding was a ruptured right fallopian tube, which was the source of the initial hemorrhage. A right salpingectomy was performed, with removal of the fallopian gestational sac, and the bleeding from the tube was secured (hemostasis achieved).\u003c/p\u003e\u003cp\u003eUnexpectedly, active bleeding was then noted from the liver area. A large clot was found attached to the lower border of the liver, and upon its removal, a small gestational sac was identified. The bleeding from the liver was managed by covering the area with Syrgisel, achieving hemostasis.\u003c/p\u003e\u003cp\u003eA drain was placed, and the abdominal incision was closed. The patient was discharged in stable condition on postoperative day three. Eleven days following her discharge, the patient returned complaining of epigastric pain. She was stable and not pale upon examination. Her abdomen was soft. A pelvic ultrasound was free (clear of pathology).\u003c/p\u003e\u003cp\u003eA subsequent liver scan, surprisingly, revealed a viable intra-abdominal pregnancy located in liver segment 7. The US showed an active gestational sac with associated perigestational fluid, raising serious concern for potential rupture (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, and Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). It was separate from the ruptured tubal ectopic pregnancy.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe case was referred to WAD Medaani Obstetric and Gynaecology Hospital, a tertiary referral center, for specialized management. A Multidisciplinary Team (MDT), comprising specialists from Obstetrics, Hepatobiliary (HPB) Surgery, and Interventional Radiology, reviewed the case.\u003c/p\u003e\u003cp\u003eGiven the high risk of hemorrhage associated with a hepatic pregnancy, the MDT unanimously recommended termination. Under ultrasound guidance, a feticide procedure was performed. An intracardiac injection of 1 cc of 20% sodium chloride solution was administered using a 25-gauge spinal needle. Follow-up imaging confirmed fetal asystole (cessation of heartbeat). The patient is currently being managed conservatively with antibiotics to prevent infection and Methotrexate. She remains in stable condition under close observation for resolution of the ectopic tissue.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis patient was presented initially with a typical case of a ruptured tubal ectopic pregnancy, characterized by hypovolemic shock necessitating emergent salpingo-oophorectomy and significant blood transfusion. Then, she re-presented, merely 12 days post-discharge, with right upper quadrant (RUQ) pain, signaling the presence of the secondary ectopic located in liver segment 7. The development of a hepatic gestation following treatment for a tubal ectopic raises critical questions regarding its origin.\u003c/p\u003e\u003cp\u003eWhile the tight timeframe suggests the possibility of two separate, near-simultaneous implantations (heterotopic implantation outside the uterus), the most plausible mechanism is a secondary abdominal pregnancy. This occurs when the conceptus, originally expelled from the fallopian tube (or occasionally the fimbriae), survives and successfully reimplants onto a peritoneal surface, such as the liver capsule.\u003c/p\u003e\u003cp\u003eIntra-hepatic ectopic pregnancy is a rare condition; only less than 40 cases have been reported [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This is the first case in Sudan. The clinical presentations were dependent mainly on amenorrhea, empty uterus, and mimic in abdominal pregnancy [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This case was presented with a feature of internal hemorrhage, which necessitates emergency laparotomy.\u003c/p\u003e\u003cp\u003eThis case is unique because the patient had a separate sac and ectopic pregnancy, the first at the fallopian and the other intrahepatic. The diagnosis was dependent entirely on high-quality ultrasound imaging, which confirmed a viable gestational sac within the liver parenchyma [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe location in liver segment 7, given its deep vascularity, confers an extremely high risk of catastrophic hemorrhage, differentiating it from more accessible peritoneal or omental implantations. This danger necessitated the involvement of a Multidisciplinary Team (MDT), including Obstetric, Hepatobiliary (HPB) Surgical, and Interventional Radiology specialists, underscoring the complexity of managing a pregnancy attached to a solid organ.\u003c/p\u003e\u003cp\u003eManagement options for stable abdominal pregnancies include laparoscopic surgical excision [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] or open excision [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Methotrexate administration, or local feticide followed by expectant management, is commonly used when the sections are not feasible [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Due to the high risk of attempting surgical excision from the liver parenchyma, the MDT opted for ultrasound-guided feticide. The successful administration of 1 cc of 20% sodium chloride solution intracardially achieved fetal asystole, thereby arresting trophoblastic activity and minimizing the immediate risk of rupture and massive hemorrhage.\u003c/p\u003e"},{"header":"Conclusion and Clinical Implications","content":"\u003cp\u003eThis case underscores the necessity of maintaining a high index of suspicion for persistent or secondary abdominal gestation in women who present with unusual or persistent abdominal pain shortly after initial ectopic pregnancy management. While surgical or systemic medical treatment may be considered for deeply embedded solid organ ectopics, local feticide followed by conservative, antibiotic-supported expectant management, as implemented here, offers a potentially safer definitive treatment pathway. Close observation remains paramount until complete resolution of the ectopic tissue is confirmed.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknolwegment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the patient and her family for their trust and cooperation throughout the management and publication process.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWEA, MDAG, and SAG conceived the idea, collected the data, manuscript, and literature review. SMS and MYMA designed the study. All authors wrote the manuscript, read the article, and approved the final version.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they had no funds\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData is collected with the corresponding author and is available upon request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case report was approved by the Ethical Review Committee\u0026ndash;Health Sector of the University of Sinnar, with ethical committee reference number 2-10/2025\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for the publication of this case report and any accompanying images.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors declare no competing interests.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eZhang N, Yang L, Wang Y, Li X, Zhang C, Xu J. Primary hepatic ectopic pregnancy in a patient with polycystic ovary syndrome: a case report. Medicine. 2020 Mar 1;99(13):e19649.\u003c/li\u003e\n \u003cli\u003eBeck MH, Sehouli J, Leppig JA, Knitter S, Pratschke J, Krenzien F. Multimodal management of ectopic hepatic pregnancy: a systematic review of the literature. Archives of Gynecology and Obstetrics. 2024 Nov;310(5):2345-53.\u003c/li\u003e\n \u003cli\u003eCai YY, Xiao EH, Shang QL, Xiao LZ. Ectopic pregnancy in the liver incidentally diagnosed by imaging: a case report. Experimental and Therapeutic Medicine. 2017 Jul;14(1):373-6.\u003c/li\u003e\n \u003cli\u003eGarzon S, Raffaelli R, Montin U, Ghezzi F. Primary hepatic pregnancy: report of a case treated with laparoscopic approach and review of the literature. Fertility and Sterility. 2018 Oct 1;1 10(5):925-31.\u003c/li\u003e\n \u003cli\u003eRajanbabu M et al (2023) Primary hepatic ectopic pregnancy: diagnosis and laparoscopic management. J Minim Invasive Gynecol 31:178\u0026ndash;179\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eNichols C, Koong D, Faulkner K, Thompson G. A hepatic ectopic pregnancy treated with direct methotrexate injection. Australian and New Zealand journal of obstetrics and gynaecology. 1995 May;35(2):221-3.\u003c/li\u003e\n \u003cli\u003eSibetcheu Tchatou A, Tchounzou R, Mbuagbaw L, Mboudou ET. Successful medical treatment of a hepatic pregnancy: a case report. Journal of Medical Case Reports. 2017 Mar 15;11(1):70.\u003c/li\u003e\n \u003cli\u003eMoores KL, Keriakos RH, Anumba DO, Connor ME, Lashen H. Management challenges of a live 12‐week sub‐hepatic intra‐abdominal pregnancy. BJOG: An International Journal of Obstetrics \u0026amp; Gynaecology. 2010 Feb;117(3):365-8.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Hepatic ectopic pregnancy, Gestational sac, embryonic pole, Methotrexate ","lastPublishedDoi":"10.21203/rs.3.rs-7890810/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7890810/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHepatic ectopic pregnancy (HEP) is a rare and life-threatening condition, with only approximately 40 cases previously reported worldwide. We present the first documented case of a patient presenting with an acutely ruptured tubal ectopic pregnancy who was subsequently diagnosed with a separate, viable intrahepatic pregnancy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 38-year-old woman (Para 6) presented in hypovolemic shock (BP 90/40 mmHg) due to a ruptured right tubal ectopic pregnancy, requiring emergency laparotomy and salpingectomy. Eleven days later, she returned with epigastric pain. A subsequent liver scan surprisingly revealed a separate, viable intrahepatic pregnancy located in liver segment 7. Given the extremely high risk of catastrophic hemorrhage associated with a solid organ gestation, a Multidisciplinary Team (MDT) recommended termination. Ultrasound-guided feticide was performed using an intracardiac injection of 20% sodium chloride solution, which successfully achieved fetal asystole. The patient remains stable and is under conservative, antibiotic-supported expectant management.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case highlights the critical need to maintain a high index of suspicion for secondary or persistent abdominal gestation in patients presenting with new or unresolved pain shortly after initial ectopic pregnancy management. For deeply embedded, high-risk solid-organ ectopics, local feticide followed by conservative observation offers a safer definitive treatment pathway compared to potentially high-mortality surgical excision.\u003c/p\u003e","manuscriptTitle":"Simultaneous Tubal and Intrahepatic Ectopic Pregnancy Managed by Feticide and Conservative Observation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-30 23:27:45","doi":"10.21203/rs.3.rs-7890810/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-11T17:35:05+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-08T19:52:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-08T19:15:23+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-07T07:30:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"252888002220245245787057262293177993355","date":"2025-12-05T10:55:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-04T08:16:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-03T22:43:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-01T17:48:13+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-28T18:53:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"271280279898916579561957961379642369446","date":"2025-11-28T11:53:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"187001467195259204373150469677247517048","date":"2025-11-28T11:50:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-27T14:37:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"255949571663259737092462686882857966264","date":"2025-11-27T07:51:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"109321599979826478305557177792072016047","date":"2025-11-26T11:58:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"231458571664055354447523498758293508103","date":"2025-11-22T07:06:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"237894870093868502285122482639921796992","date":"2025-11-21T16:38:50+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-21T07:14:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"222528381121914758590974480331251704447","date":"2025-11-21T06:20:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"50567426082882119895057286893896277295","date":"2025-11-19T17:36:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"153510254584684436358392709725219369455","date":"2025-11-19T16:37:26+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-19T16:31:36+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-25T15:12:36+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-21T23:26:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-21T23:24:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2025-10-18T04:23:52+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b3cefad7-1b49-462b-890a-42da7d02fd12","owner":[],"postedDate":"November 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-12T19:54:54+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-30 23:27:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7890810","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7890810","identity":"rs-7890810","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}