doi:10.1111/jog.14131 J. Obstet. Gynaecol. Res.

2019

Successful management of diaphragmatic ectopic

pregnancy using ultrasound-guided percutaneous
microwave ablation

Hongrong Qian1, Guo Tian2,3, Haizhen Zheng4, Weifeng Liang5,6 and Tian’an Jiang2,3
1
Department of Ultrasound, 4Department of Gynecology, 6Shengzhou People’s Hospital, Shengzhou Branch of the First Affiliated
Hospital of Zhejiang University, Shengzhou, 2Department of Ultrasound, and 5State Key Laboratory for Diagnosis and Treatment
of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated
Hospital, College of Medicine, Zhejiang University and 3Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary
and Pancreatic Tumor of Zhejiang Province, Hangzhou, China

Abstract
Diaphragmatic ectopic pregnancy is a rare status during the perinatal period. We reported that a 24-year-old
woman with diaphragmatic ectopic pregnancy successfully received ultrasound-guided percutaneous micro-
wave ablation. It found that beta-human chorionic gonadotropin level decreased showing 1067, 311.3 and
118.4 mIU/mL within five postoperative days, and P level reduced from 3.64 to 1.59 nmol/L. Contrast-
enhanced ultrasonography image on the third day after ablation indicated that there was no enhancement in
the lesion. This case indicated that ultrasound-guided percutaneous microwave ablation could be critical for
a good outcome in diaphragmatic ectopic pregnancy.
Key words: contrast-enhanced ultrasonography, diaphragmatic ectopic pregnancy, microwave ablation,
ultrasound, β-HCG level.

Introduction complicated monochorionic multiple pregnancies.3,4

Abdominal pregnancy outside the fallopian tube,
ovary and ligament is a special type of ectopic preg-
nancy (about 1%),1 of which the ratio of live births
is approximately 1:8000–10 000.2 The treatment eas-
ily caused hemorrhage during surgery. Interven-
tional treatments became attractive due to their
safety and effectiveness in recent years. Microwave
ablation was useful for selective feticide in
There were not serious maternal complications
(coagulation dysfunction, hemorrhage, placental
abruption or chorioamnionitis) occurred after
microwave ablation (MWA).3 These suggested
microwave ablations could be also applied into
other lesions besides solid tumors. Here we
reported that one case of confirmed diaphragmatic
pregnancy admitted with different initial diagnoses,

Abbreviations: CEUS, contrast-enhanced ultrasonography; CT, computed tomography; MRI, magnetic resonance imaging.; MWA,
microwave ablation; P, progesterone; US, ultrasonography; β-HCG, beta-human chorionic gonadotropin
Received: March 11 2019.
Accepted: September 6 2019.
Correspondence: Tian’an Jiang PhD, Department of Ultrasound, The First Affiliated Hospital, College of Medicine, Zhejiang
University, Hangzhou 310003, China; Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of
Zhejiang Province, Hangzhou 310003, China. Email: tiananjiang@zju.edu.cn.
Weifeng Liang PhD, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for
Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou,
China; Shengzhou People’s Hospital, Shengzhou Branch of the First Affiliated Hospital of Zhejiang University, Shengzhou, China.
Email: 11518295@zju.edu.cn

© 2019 Japan Society of Obstetrics and Gynecology 1

H. Qian et al.
was successfully performed by ultrasound-guided
percutaneous.
Case Report
A 24-year-old woman admitted to our hospital with
menopause for 62 days, vaginal bleeding for 3 days,
and lower abdominal pain for 3 days. The patient had
a sudden right upper epigastric pain prior to 12 days,
then relieved herself. The blood beta-human chorionic
gonadotropin (β-HCG) levels were examined 433.80
mIU/mL on the same day. Abdominal ultrasound
and computed tomography scan both had no obvious
abnormalities in the ureter and bladder, kidney and
uterus. Thereafter, three serial blood β-HCG level tests
were progressively elevated, indicating 977.3, 1358
and 2526 mIU/mL, respectively (Fig. 1). Two blood
progesterone (P) tests were 2.01 and 1.91 nmol/L,
respectively. On admission, β-HCG level increased to
3065 mIU/mL, and vaginal ultrasound found no
obvious gestational sac in the uterus. The size of the
left ovarian cystic mass was about 5.6 × 4.5 × 3.5 cm,
and the size of the left peri-ovarian inhomogeneous
echo was about 2.5 × 1.1 × 0.8 cm (Fig. 2a). Thus ini-
tial diagnosis was ectopic pregnancy and left ovarian
cyst. Then the patient received the laparoscopic explo-
ration under general anesthesia. It detected a left
ovarian cystic mass about 6 × 5 × 5 cm, and a right
ovarian cystic mass about 3 × 2 × 3 cm in size. The
ampulla of the left fallopian tube is thickened while
there was no obvious abnormality in the right
fallopian tube. This study was approved by the
Figure 1 Changes in beta-human chorionic gonadotro-
pin (β-HCG) level before and after admission. Red
arrow represents the time point of microwave abla-
tion (MWA) treatment.
2 © 2019 Japan Society of Obstetrics and Gynecology
institutional review board of the First Affiliated Hos-
pital of Zhejiang University. In the laparoscopic sur-
gery, the left fallopian tube ampulla thickening was
detectable, and no obvious abnormalities were found
in the abdominal cavity exploration. The fallopian
tube ampulla pregnancy was firstly considered. The
patient requested to keep the fallopian tube and
refused the oviduct incision sampling test. After the
enrolled case had written informed consent for the
procedure, the case was given a injection of metho-
trexate (MTX) 50 mg for the left fallopian tube and
bilateral ovarian cysts excision. Postoperative patho-
logical diagnosis showed bilateral ovarian corpus
luteum cysts.
However, during the postoperative second and
third follow-up, β-HCG levels were 2427 and 2838
mIU/mL, respectively. It may be that the ectopic
pregnancy embryo was still active. After the patient’s
consent, MTX chemotherapy is generally adminis-
tered 50 mg/m2 according to body surface area for
ectopic pregnancy. This patient has a body surface
area of about 1.6 square meters, thus intramuscular
injection of the MTX 80 mg was performed to kill the
embryo. During the treatment period, the patient
sometimes felt pain in the right upper abdomen. On
admission, abdomen ultrasound ever showed that a
strong echogenic nodule about 2.7 × 2.1 cm at the
right hepatic diaphragm top (Fig. 2b). After MTX
treatment, contrast-enhanced ultrasound (CEUS)
(Fig. 2c) suggested its extrahepatic mass due to its
clear boundary with liver capsule. Mixed echo mass
in diaphragm surface presented nodular enhancement
(about 1.4 × 1.1 cm), and it indicated blood flow from
the diaphragm. Magnetic resonance indicated an
abnormal enhancement of the right liver capsule
about 1.7 × 1.3 cm in size (Fig. 2d). Enhanced CT also
found nodular abnormal lesions in this region
(Fig. 2e). Comparing to previous CT plain scan
(Fig. 2f), it did not find that there was obviously
abnormal density at the top of the right diaphragm.
Based on the above results, experts from general hos-
pital discussed that ectopic pregnancy may be located
in the diaphragm.
On the fourth day of chemotherapy, β-HCG level
was still 2444 mIU/mL and P level was
4.31 nmol/L. Given that the effect of chemotherapy
may be poor and side effects were serious. The patient
felt a pain in the right liver area and refused to take
conservative medication. She also refused laparotomy
because the lesion was located at the top of the dia-
phragm at high risk of hemorrhage and the surgical
 MWA for diaphragmatic ectopic pregnancy

Figure 2 (a) A 24-year-old man with diaphragmatic pregnancy. The left peri-ovarian inhomogeneous echo (white arrows)
was about 2.5 × 1.1 × 0.8 cm. (b) Ultrasound (US) indicated that a strong echogenic nodule (white arrows) about
2.7 × 2.1 cm at the right hepatic diaphragm top. (c) Magnetic resonance (MR) showed an abnormal enhancement of the
right liver capsule about 1.7 × 1.3 cm in size (white arrows). (d) Contrast-enhanced ultrasonography (CEUS) suggested
mixed echo mass (white arrows) in diaphragm surface presented nodular enhancement (about 1.4 × 1.1 cm).
(e) Enhanced computed tomography (CT) found nodular abnormal lesions (white arrows) at the right hepatic dia-
phragm top. (f) Previous CT plain scan did not find that there was significant abnormal density at the top of the right
diaphragm. (g) The microwave antenna was percutaneously delivered through the liver into the center of targeting
lesion (white arrows). (h) The ablation showed hyperechoic area (white arrows) covering the entire lesions and periph-
eral tissue. (i) CEUS image on the third day after ablation indicated that there was no enhancement in the lesion (white
arrows). (j) CT plain scan indicated the lesion had a complete response.

field was difficult to expose. After careful consider- Discussion

ation and informed consent were available,
ultrasound-guided percutaneous MWA was per-
formed. Following locating the right diaphragmatic
lesion via CEUS, the microwave antenna was percu-
taneously delivered through the liver into the center
of targeting lesion with output power of 60 W for
6 min (Fig. 2g). The ablation was not stopped until
hyperechoic area covering the entire lesions and
peripheral tissue (Fig. 2h).
No major complications occurred during the opera-
tion. On the postoperative second day, she felt little
painful from the right abdomen to the right shoulder
and then alleviated by oneself. However, it
surprisedly found that β-HCG level decreased quickly
showing 1067, 311.3 and 118.4 mIU/mL within five
postoperative days, and P level reduced from 3.64 to
1.59 nmol/L. Two weeks after the microwave ablation
treatment, the hCG was almost normal
(3.67 mIU/mL), and following the 23rd day, hCG was
restored to normal (1.41 mIU/mL) (normal reference
value: 0–3 mIU/mL
). CEUS image on the third day after ablation indi-
cated that there was no enhancement in the lesion
(Fig. 2i). And CT plain scan showed the lesion had a
complete response (Fig.2j). And the right chest had no
effusion.
Abdominal pregnancy was a serious status at risk of
many factors such as hemorrhage during the placenta
separation, infection, toxemia, disseminated intra-
vascular coagulation and pulmonary embolism.
Its mortality risk was 7.7-fold that of tubal preg-
nancy and 90-fold that of intrauterine pregnancy.5
Abdominal pregnancy is divided into primary and
secondary abdominal pregnancy. Primary abdomi-
nal pregnancy is extremely rare, and most abdomi-
nal pregnancy occurred after abortion or rupture of
tubal pregnancy. Because abdominal pregnancy
had no specific symptom, it easily caused misdiagnosis.
In this case, laparoscopy detected the left fallopian tube
thickening with a small amount of blood in the abdomi-
nal cavity. Thus secondary intra-abdominal pregnancy
might be considered.
Surgical resection is the traditional treatment of
abdominal pregnancy with large trauma. Hepatic
ectopic pregnancies may be more complicated than
ectopic pregnancies at other regions. Previous study
showed that a 33-year-old woman with ectopic preg-
nancy on the upper surface of the right liver lobe
received exploratory laparotomy. Then the patient
was stable, and her serial β-HCG level was normal.6
Due to bleeding from the placental site of primary

© 2019 Japan Society of Obstetrics and Gynecology 3

H. Qian et al.
hepatic pregnancy, postoperative hepatic artery
embolization was also considerable after surgery as
the case was labile with uncontrollable bleeding.7
Many locoregional therapies have been developed
including US-guided injection of injection of MTX,
which could be repeated if necessary when symptoms
were worse. MTX treatment is a safe treatment option
with a reasonably high success rate, with similar
probability of a later intrauterine pregnancy as con-
ventional surgical treatment.8 However, it was also
reported that MTX failed to treat cervical pregnancy,
but resolved with hysteroscopy.9 Thus treatment
approaches need comprehensive consideration if in
trouble.
Comparing the above options, US-guided MWA
for diaphragmatic ectopic pregnancy have not been
reported. However, emerging studies have indicated
that percutaneous MWA was effective in multiple
organs. 2-year overall survival rate using US-guided
MWA for hepatocellular carcinoma attached
86.1%.10 It was reported that percutaneous MWA
was well-tolerated in stage T1 renal cell carcinoma
without major complications.11 Forty patients with
uterine fibroids underwent US-guided MWA, and
the shrinkage rate of the fibroid was 93.1% at
12 months after ablation.12 In addition, MWA was
effective both in the treatment of malignant and
benign thyroid nodules.13,14 It was an alternate
option for treating lung cancer with low risk of
adverse events.15 Furthermore, MWA was applied
in the feticide for monochorionic multiple pregnan-
cies.3,4 Ultrasound had the strength of lower cost
and lack of radiation exposure. When the micro-
wave needle was into a lesion under the US guid-
ance, polar molecules in the tissue moved at a high
speed under microwave field. They rubbed each
other to rapidly generate heat about 60 C, leading to
irreversible necrosis. US-guided MWA could real-
timely display the position of the needle tip at any
angles, which was usually used for the treatment of
large lesions. Nevertheless, there were several limi-
tations noted in this study as follows. First, it was
only useful for a few special types of ectopic preg-
nancy. Second, it needed appropriate puncture route
to avoid damage to vital organs during treatment.
In short, this preliminary study showed that US-
guided MWA could be effective in selected patients
with diaphragmatic ectopic pregnancy. In the future,
more prospective studies with larger samples will be
needed to validate this method and serve more
patients.
4 © 2019 Japan Society of Obstetrics and Gynecology
Acknowledgments
This study was supported by the Natural Science
Foundation of Zhejiang Province (No. LY16H180004),
the opening foundation of the State Key Laboratory
for Diagnosis and Treatment of Infectious Diseases,
Collaborative Innovation Center for Diagnosis and
Treatment of Infectious Diseases, The First Affiliated
Hospital of Medical College, Zhejiang University,
grant NO. 2015KF06; the Foundation of Zhejiang
Health Committee (2017KY346), the sub-topic of the
major research project integration project
(SQ2018YFC0114904 and 9163030311).
Disclosure
The authors declare that they have no conflicts of
interest.
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© 2019 Japan Society of Obstetrics and Gynecology 5