LAUSR

A healthy 31-year-old nulliparous female presented to the Gold Coast University Hospital in 2019 with intermittent left lower quadrant abdominal pain for several days. Her last menstrual period was 7 weeks prior and serum beta-human chorionic gonadotrophin (βHCG) was 12 725 IU/L. Examination and initial bloods were unremarkable. Transvaginal ultrasound revealed an empty uterine cavity with a 3-cm haemorrhagic cyst on her left ovary and a small volume of free fluid in the pouch of Douglas. Suspecting an ectopic pregnancy, an abdominal ultrasound was arranged to assess for uncommon sites of implantation. It revealed an 8 × 1.2 × 0.9 mm anechoic mass, located on the inferior pole of the spleen with a visualized yolk sac and cardiac activity. A laparoscopy was completed with gynaecology, colorectal and general surgery teams present. Laparoscopy revealed a small volume of free blood in the pouch of Douglas and a 3-cm haemorrhagic cyst on the left ovary. The right ovary, bilateral fallopian tubes and uterus appeared normal. Views of the spleen revealed no free blood in the left upper quadrant; however, a suspicious area with visible branching vessels were seen over an abnormally large fat pad on the inferior aspect of the spleen. It was thought that this represented this unusual implantation site for the ectopic pregnancy. No other abnormality was seen. The region over the inferior pole of the spleen was excised laparoscopically with a capsule dissection of the fat pad with the aim of splenic preservation. The colonic splenic flexure was partially mobilized to inspect the inferior pole of the spleen; however, the spleen was not fully mobilized to inspect all posterior surfaces as it was felt that this could result in splenic rupture. The left ovarian cyst was also enucleated and contents excised in case contributory to the presentation. The diaphragm and all remaining abdominal organs appeared normal upon laparoscopic inspection. Urgent histopathology however did not reveal any chorionic villi, trophoblastic tissue or implantation site reaction in the tissue sent (Fig. 1) and βHCG continued to rise post-operatively. Crosssectional imaging was urgently arranged with a high-resolution contrast-enhanced computed tomography. This revealed a persistent 14-mm intracapsular gestational sac in the posterior inferior aspect of the spleen (Fig. 2). Urgent laparoscopy was arranged with a preoperative plan for total splenectomy. This was completed using a medial to lateral approach with laparoscopic vascular stapling of the splenic vessels first. Once fully mobilized and prior to removing the specimen piecemeal via Endo Catch (Macquarie Park NSW Australia), the gestational sac could be appreciated at this difficult position posteromedially, at the inferior pole of the spleen (Fig. 3). Histopathology confirmed foetal sac and placental vessels involving the main substance of the spleen. The patient made an excellent post-operative recovery, her βHCG rapidly fell and she was discharged after 4 days. Routine post-operative vaccines were arranged in addition to regular low-dose amoxicillin. Ectopic pregnancies should be considered in all reproductive age female patients presenting to the emergency department with abdominal pain. They are due to implantation of a blastocyst outside of the normal uterine cavity. Fallopian tube ectopics are most common, accounting for 96% of all ectopic pregnancies. Abdominal ectopic pregnancies on the other hand are rare and occur in 1.4% of all ectopic pregnancies. Abdominal pregnancies have a