choriocarcinoma is a highly vascular and metastatic malignant gestational trophoblastic neoplasm usually metastasized through the haematogenous route . the incidence of gestational choriocarcinoma is approximately 1 in 20,00040,000 pregnancies ; approximately 50% of the cases occur following term pregnancy , 25% after hydatidiform mole , and the remaining 25% related to other gestational conditions . metastasis spreads commonly to the lung ( 80% ) , vagina ( 30% ) , and pelvis ( 20% ) , and less commonly to the liver and brain ( 10% each ) . pancreatic metastasis of choriocarcinoma is rarely encountered in the literature , with very few reported cases of secondary pancreatic metastasis of choriocarcinoma . patients with a history of gestational trophoblastic disease ( gtd ) or molar pregnancy are usually kept under strict regular follow - up ; however , the prognosis may be unfavourable for those who present with an acute condition , disseminated metastasis , haemorrhagic complications , and a delayed diagnosis . we share our experience of pancreatic and hepatic metastasis of an undiagnosed case of choriocarcinoma that presented with a short history of vomiting and pain in the right hypochondrium , with findings of hypovolaemic shock due to intraperitoneal haemorrhage . unfortunately , we lost the patient despite 2 emergency laparotomies for intractable profuse intraperitoneal haemorrhage due to ruptured hepatic metastasis of the choriocarcinoma . a young , 30-year - old woman ( para 1 ) was escorted from a health centre to our obstetric triage unit with acute onset of lower abdominal pain and hypovolaemic shock preceded by 3 days of fever and right hypochondriac pain . there was no history of vaginal bleeding . on arrival , she was conscious but haemodynamically unstable . she looked pale with cold and clammy skin ; her pulse was 134 beats / min and blood pressure was 90/30 mm hg . she had a history of an uncomplicated term spontaneous vaginal delivery 10 months earlier in our hospital . after delivery , she had had regular periods at 2-week intervals with no excessive bleeding and was not using any contraceptive methods . the laboratory investigations revealed the following : blood group o rh positive ; positive urine pregnancy test ; -human chorionic gonadotropin ( hcg ) 49,200 miu / ml ; haemoglobin 5.95 g / dl ; and platelet count 125  10/l . however , she had a deranged coagulation profile and liver function tests : the serum bilirubin level was 12.5 the ovaries appeared normal with no adnexal mass , but there was a significant quantity of free fluid in the pouch of douglas and morrison 's pouch . the patient 's presentation and clinical signs were strongly suggestive of ruptured ectopic pregnancy warranting urgent exploratory laparotomy . on opening the abdominal cavity with a pfannenstiel incision , more than 1 litre of blood with clots was aspirated from the peritoneal cavity . on examination , the uterus and ovaries were normal ; however , the right fallopian tube was mildly congested and inflamed but not ruptured . we noted profuse fresh bleeding pouring from the left hypochondriac region and requested a general surgery consultation to rule out a surgical cause . the surgeon explored the abdominal viscera by extending the incision and removed another litre of blood clots from the left hypochondriac area . after removing the blood clots , multiple variably sized nodular foci were noted on both lobes of the liver , the largest one measuring around 4  5 cm ( fig 1 ) . tissue for histopathology was carefully captured from a fragile nodule . on further exploration of the abdominal cavity , the bowels were found normal , but the body of the pancreas had nodular foci similar to those of the liver , measuring approximately 2  1.5 cm ( fig 2 ) . haemostasis was secured after suturing the ruptured nodules of the liver , and empirical right - sided salpingectomy was carried out . intraoperatively , the patient lost around 3 litres of blood , which was replaced by 6 units of whole blood and 7 units of fresh frozen plasma . the patient was transferred to the intensive care unit after surgery ; however , 12 h following the laparotomy , she again had severe intra - abdominal haemorrhage , and consequently a second exploratory laparotomy was performed to control the haemorrhage . haemostasis could not be completely achieved , and therefore it was decided to transfer the patient to a tertiary care hospital for hepatic artery embolization after haemodynamic stabilization . she stayed in the intensive care unit under ventilator support , and since she remained critical , she could not be transferred to tertiary care . despite all resuscitative measures , the patient expired 11 h after the second exploratory laparotomy due to haemorrhagic shock . histopathology of the liver confirmed neoplastic cells compatible with choriocarcinoma , but the fallopian tube was normal with no evidence of chorionic villi . a pancreatic tissue biopsy was not taken during surgery due to the high clinical suspicion of haemangioma . hepatic metastasis of choriocarcinoma occurs in only 10% of gtd cases , and pancreatic metastasis is extremely rare . alvarez et al .   report a case of pancreatic and hepatic metastasis that was saved by pancreatic resection and chemotherapy . in 1989 , erb and gibler   reported a similar case of ruptured hepatic metastasis of choriocarcinoma , who survived after hepatic lobectomy and chemotherapy . .   described 2 patients with hepatic metastasis of choriocarcinoma , one of whom died 17 days after admission despite hepatic artery embolization . the other patient , who had a history of hydatidiform mole 5 years earlier , also expired due to uncontrolled bleeding from ruptured hepatic metastasis . even though our patient had no history of gtd , it has to be stated that due to the highly vascular characteristics and haemorrhagic tendency of the primary or metastatic site of the tumour , surgical intervention is a concern , since a patient 's condition may deteriorate rapidly and the patient may even collapse [ 3 , 4 ] . besides baseline laboratory investigations , imaging techniques such as ultrasound and computed tomography ( ct ) angiograms of the abdomen can help with the diagnosis . the typical ct angiographic findings of hepatic metastasis of choriocarcinoma include peripheral hepatic artery aneurysmal dilatation at the arterial phase and persistent vascular lakes at the venous phase , which can differentiate the condition from other hypervascular hepatic lesions . once the diagnosis is confirmed by ct angiogram and serum -hcg levels , chest x - ray and brain imaging should be performed to exclude lung and brain metastases . in our case , the patient presented in an acute condition with hypovolaemic shock and haemoperitoneum ; therefore we could not wait for further investigations to confirm the diagnosis . if a patient were haemodynamically stable and had a history of molar pregnancy or gtd , a diagnosis of choriocarcinoma could be predicted . according to the world health organization 's clinical classification of gtd , patients whose -hcg level exceeds 40,000 miu / ml and who have liver metastases are regarded as a high - risk group with poor - prognosis metastatic gtd . our patient 's -hcg level was 49,200 miu / ml , and she had disseminated hepatic metastasis . a previous review reported that the overall 5-year survival rate with liver metastasis is less than 30% , and another review reported that the most common cause of death in hepatic metastasis patients is haemorrhage [ 5 , 6 ] . in gtd , the presence of hepatic metastasis is an adverse prognostic factor despite haemorrhagic complications . to date , transcatheter angiographic embolization of the hepatic arteries is the accepted treatment modality to control haemorrhage . the bleeding vessel can be selectively embolized using this technique , with immediate visualization of its effect , and it can be carried out under local anaesthesia and mild sedation . the use of embolization is advantageous in unstable patients , as it is less invasive and time - consuming than open surgery and can be repeated if necessary , with a lower chance of complications such as failure to stop bleeding , rebleeding , and postembolization syndrome . in stable patients , unfortunately , we did not have an angiographic embolization facility at our institute at that time and failed to transfer the patient to a tertiary centre , as she was haemodynamically unstable . in women with a high - risk gtd on the basis of 17 cases of hepatic metastasis , barber et al .   reported that the survival of patients with gtd increased from 17% before 1986 to 55% after 1986 , when ema / co chemotherapy was introduced . ema / co chemotherapy includes etoposide , methotrexate , actinomycin d , cyclophosphamide , and vincristine with folinic acid rescue . the prognosis of patients with gtd with liver metastasis is poor in all staging systems , though they do respond to chemotherapy [ 7 , 10 ] . further research needs to be carried out to investigate whether a more definitive scoring system to identify groups of patients at high risk will help in disease management . although 20% of these patients subsequently fail to respond to treatment and die , the rest may be cured by further chemotherapy . the follow - up protocol used in the individual institute can be applied , as there are currently no specific guidelines on an appropriate schedule for follow - up . monitoring is life - long for this group of patients , since it is not clear when it is safe to stop surveillance . although pancreatic and hepatic metastasis of choriocarcinoma is a rare cause of haemoperitoneum in women of childbearing age , clinicians should maintain vigilance about differential diagnoses of haemoperitoneum in this group of patients to avoid the potentially fatal outcome of haemorrhagic complications . ethics approval was provided by the research and studies committee ( dghs ) , al dhahirah governorate ( ref .
haemoperitoneum in women of reproductive age usually suggests either ruptured ectopic pregnancy or ruptured ovarian cysts . 
 metastatic choriocarcinoma is considered the least common cause of haemoperitoneum in women of childbearing age . 
 we report a rare case of pancreatic and hepatic metastasis of choriocarcinoma in a young , 30-year - old female who had delivered 10 months prior at term gestation with no previous history of gestational trophoblastic disease or molar pregnancy . 
 she had a short history of fever and pain in the right hypochondrium , with findings of hypovolaemic shock due to intraperitoneal haemorrhage . 
 unfortunately , the patient expired with massive uncontrolled bleeding from liver metastasis despite 2 emergency laparotomies within 12 h. this case report is an apt reminder to clinicians to include metastatic choriocarcinoma on the list of differential diagnoses for haemoperitoneum with a positive pregnancy test in women of reproductive age to diagnose early and to avoid life - threatening consequences .