# A rare case report of successful surgical treatment of diaphragmatic pregnancy after chemotherapy

## TL;DR

A rare case of diaphragmatic pregnancy was successfully treated with a combination of chemotherapy and surgery after initial misdiagnosis.

## Contribution

This case report presents a successful treatment strategy combining chemotherapy and surgery for a rare diaphragmatic pregnancy.

## Key findings

- Kehr's sign was a key diagnostic clue for upper abdominal ectopic pregnancy.
- Combining chemotherapy with laparoscopic resection minimized surgical risk and improved outcomes.
- Complete removal of the pregnancy tissue from the diaphragm was achieved with minimal bleeding.

## Abstract

Diaphragmatic pregnancy is a rare type of ectopic pregnancy, and its clinical manifestations are complicated and easy to misdiagnose, which presents great challenges for clinical diagnosis and treatment. We report a case of diaphragmatic pregnancy and describe its difficult but successful diagnosis and treatment in detail.

A 34-year-old woman from northern China was admitted to the hospital with delayed menstruation and right upper abdominal pain with right shoulder pain (Kehr's sign). An initial emergency laparoscopy for suspected ruptured ectopic pregnancy revealed hemoperitoneum but failed to identify the ectopic pregnancy tissue, likely due to an incomplete surgical survey. Subsequent serial β-hCG monitoring showed a persistent rise, and MRI localized the ectopic pregnancy tissue at the outer edge of the right lobe of the liver. Conservative treatment with methotrexate and 5-fluorouracil chemotherapy was given in time, which induced a significant biochemical response. However, due to the worsening of abdominal pain despite declining β-hCG levels, indicating a persistent risk of rupture, definitive laparoscopic resection was performed. Intraoperatively, the pregnancy tissue was found to be implanted on the surface of the diaphragm, and the pregnancy tissue was successfully removed completely from the diaphragm with little intraoperative bleeding. Postoperative pathology results confirmed the presence of pregnancy chorionic tissue. The patient recovered well without complications and was discharged 5 days after surgery.

This case highlights that Kehr's sign is a crucial diagnostic clue for upper abdominal ectopic pregnancy. A systematic survey of the entire abdomen, including the diaphragm, is mandatory during laparoscopy to avoid diagnostic omission. The sequential combination of chemotherapy and surgical treatment may represent an effective strategy to minimize surgical risk and optimize outcomes for this high-risk condition.