Early primary abdominal pregnancy: Diagnosis and management. A case report

Rupture of fetal membrane in ectopic tubal pregnancy: A case report and literature review

RATIONALE

Ruptured tubal pregnancies occurring in the second trimester are rare; yet, they pose a critical risk of life-threatening hemorrhage. This study aims to highlight the importance of timely surgical intervention in such cases to prevent fatal outcomes. The case underscores the diagnostic and therapeutic challenges that arise when distinguishing between tubal and abdominal pregnancies, particularly in the presence of hemoperitoneum, which can obscure imaging results.

PATIENT CONCERNS

We present a case involving the spontaneous rupture of a tubal pregnancy at 15 weeks and 3 days of gestation. The patient exhibited elevated beta-human chorionic gonadotropin levels. Initial transabdominal ultrasound suggested an abdominal pregnancy, and computed tomography scans supported these findings.

DIAGNOSES AND INTERVENTIONS

Urgent midline laparotomy revealed the condition to be a tubal pregnancy, contrary to initial imaging. The surgical procedure included the removal of the gestational sac and the affected fallopian tube, followed by abdominal closure. Hemoperitoneum was noted to compromise the accuracy of imaging modalities, complicating the preoperative diagnosis.

OUTCOMES

Histopathological examination confirmed the diagnosis of tubal pregnancy. The patient had an uneventful recovery and was discharged 7 days post-surgery with stable hemoglobin levels.

LESSONS

This case underscores the importance of considering the differential diagnosis of abdominal versus tubal pregnancy in the presence of hemoperitoneum, due to their differing clinical management needs. It offers insights that may guide clinicians in the timely diagnosis and treatment of advanced tubal pregnancies, where prompt surgical intervention is critical.

Ectopic pregnancy located at pelvic wall and liver: Two uncommon case reports from Vietnam and mini-review literature

INTRODUCTION AND IMPORTANCE

Abdominal ectopic pregnancy (AEP) located at hepatic region and pelvic-wall ectopic pregnancy (EP) are rare entities, that provoking a potentially life-threatening condition. Due to insufficient data, a proper management of non-specific types remains a challenge for all gynecologists worldwide.

CASE PRESENTATION

Two child-bearing age women were hospitalized due to delayed menstruation and a urine pregnancy test was positive without a determination of intrauterine pregnancy. The first EP case was located at the pelvic wall which identified incidentally during laparoscopy for a presumed tubal ectopic pregnancy on ultrasonography throughout. The second EP case was found at the hepatic region due to intermittent pain rising from the right upper quadrant region and serial ultrasonic findings. In our management, both cases were successfully assessed by laparoscopy and laparotomy without requiring further intervention, respectively.

CLINICAL DISCUSSION

An accurate diagnosis of EP location at liver and pelvic wall is totally difficult since its uncommon location. An initial assessment should be based on clinical symptoms and the treatment remains controversial. The surgical management including laparotomy and laparoscopy depends on clinical evaluation, experience of surgeon, and interdisciplinary team. Thus, these abnormal sites of ectopic pregnancy ought to take into consideration for all gynecologists in an emergency condition with a major hemorrhage.

CONCLUSIONS

In reproductive age women, primary EP at liver and pelvic wall should be considered with high index of suspicion if intrauterine pregnancy is totally excluded. Timely diagnosis, rational management by surgical excision, and a multidisciplinary team can reduce substantially adverse outcomes.

Advanced abdominal ectopic pregnancy and the role of antenatal ultrasound scan in its diagnosis and management

Abdominal pregnancy is a very rare form of ectopic gestation in which implantation occurs in the peritoneal cavity. It accounts for about 1% of all ectopic pregnancies and is associated with a higher risk of morbidity and mortality due to complications such as preeclampsia, placenta abruption, and oligohydromnios, which necessitate pregnancy termination before term, and the risk of massive hemorrhage associated with abnormal placentation. We present a case of advanced abdominal ectopic pregnancy, diagnosed in the second trimester and complicated by anhydramnios. An abdominal ultrasound scan showed a nongravid uterus and a single live extrauterine fetus within the abdominal cavity, with no surrounding liquor at 23 weeks and 3 days average gestational age. Mother was consented and an emergency laparatomy performed. A premature baby was delivered but died in Neonatal Intensive Care Unit (NICU) after 4 hours due to severe acute respiratory distress syndrome. Mother had good postoperative recovery. Advanced abdominal ectopic pregnancy though very rare, is associated with complications that lead to early termination. Ultrasound scan is a reliable tool for the diagnosis of abdominal pregnancy in settings with limited access to Magnetic Resonance Imaging (MRI). It should be recommended to all mothers at their earliest antenatal care (ANC) visit to help determine the site of pregnancy and guide further intervention.

Primary omental ectopic pregnancy: A rare case report

Primary abdominal pregnancy is the rarest form of ectopic pregnancy in which the fertilized ovum is directly implanted into peritoneal cavity. This condition poses significantly high risk of maternal morbidity and mortality. Here, we present a case of 5 weeks of primary omental pregnancy managed by laparotomy.

Right abdominal pregnancy with hemorrhagic shock after previous left tubal pregnancy: A case report

Abdominal pregnancy is the rarest ectopic pregnancies, with an incidence of 1 per 10,000 live births, and life-threatening because the symptoms are not specific and diagnosis is made after abdominal pain, amenorrhea and vaginal bleeding occur. We present a rare case of abdominal pregnancy in a 31-year-old Indonesian woman with severe abdominal pain within 24 hours before hospital admission, accompanied by nausea, vomiting, dizziness and weakness. She felt the pain increasing since the last 2 weeks and limiting her movement. She has a history of a left tubal pregnancy 5 years ago. Ultrasonography examination revealed an ectopic pregnancy, and she was rushed to the operation room for emergency exploratory laparotomy. An abdominal pregnancy was found, located in the right adnexa with excessive fluid in cavum Douglass and a foetus in around 11-12 weeks of gestation accompanied by free fluid in the subdiaphragmatic, subhepatic and pelvic cavity. The surgery was a successful, four units of whole blood were transfused, and the patient was safely discharged from the hospital. The current concept on management of abdominal pregnancy supports immediate surgical intervention with pregnancy termination, as found in this case, because the patient's condition is hemodynamically unstable indicating hemorrhagic shock correlated with massive hemoperitoneum. A prompt diagnosis and good teamwork in treatment plays an important role for such a life-threatening condition to avoid maternal morbidity and mortality in a case of abdominal pregnancy.

Abdominal pregnancy with a live newborn in a low-resource setting: A case report

Abdominal pregnancy is defined as pregnancy anywhere within the peritoneal cavity, exclusive of tubal, ovarian, or broad ligament locations. It is a rare form of ectopic pregnancy with high morbidity and mortality for both the mother and the fetus. Diagnosis can be frequently missed in low-resource settings because of poor antenatal healthcare provision, low socioeconomic patient status as well as lack of adequate medical resources. Clinical diagnosis can be difficult and ultrasound scan is helpful during the early stages of gestation but can be disappointing thereafter. A case of abdominal pregnancy in a 25-year-old woman, who presented at 26 weeks of gestation with severe abdominal pain not relieved by any medication, is reported. An emergency laparotomy was undertaken as her vital signs deteriorated. An abdominal pregnancy was found and a live neonate delivered. Ministries of health in developing countries should ensure routine access to ultrasound in early pregnancy. Obstetricians should bear in mind that abdominal pregnancy can present late in gestation.

Abdominal pregnancy: a case report and review of 17 cases

PURPOSE

To analyze the clinical characteristics of abdominal pregnancy, and to explore the diagnosis and prognosis of different treatment methods.

METHODS

The cases of patients with abdominal pregnancy admitted to Peking Union Medical College Hospital between January 1, 1989 and January 1, 2021, were analyzed retrospectively.

RESULTS

The median age of 17 patients was 34 years (22-42 years); the median gestational duration was 57 days (from 41 days to 32 weeks). Among all 17 patients, 15 (88.24%) presented with abdominal pain. The implantation sites of the gestational sac included the bladder peritoneal reflection, anterior wall of the rectum, omentum, serous membrane of the uterus, and inside or on the surface of uterosacral ligament. In all, only 29.41% cases (5/17) were diagnosed before surgery. All 17 patients were treated via surgery. Further, 58.82% (10/17) patients recovered without complications, 29.41% (5/17) developed fever, 5.88% (1/17) underwent reoperation because of intra-abdominal bleeding, and 5.88% (1/17) developed double lower limb venous thrombosis. All 17 patients survived.

CONCLUSION

The preoperative diagnosis rate of abdominal pregnancy is low. Planting sites in the pelvic peritoneum and pelvic organs are more common than the others. Laparoscopic surgery in the first trimester of pregnancy can achieve better therapeutic effects. However, the blood supply of the placenta should be fully evaluated before surgery. When it is expected that attempts to remove the placenta will cause fatal bleeding, the placenta can be left in place, but long-term close follow-up should be paid attention to.

Pregnancy in a rudimentary horn: multicenter's MRI features of a rare condition

PURPOSE

To describe the MRI features of rudimentary horn pregnancy (RHP) with surgical correlations.

METHODS

Nine women with a RHP underwent preoperative pelvic MRI. MRI protocol included T2- (n = 9), T1- (n = 7), and fat-suppressed contrast-enhanced T1-weighted sequences (n = 4). Two pelvic radiologists retrospectively analyzed MR images to assess the following MRI features: presence of a myometrium around the gestational sac (GS) and characteristics of its wall, GS surrounded by myometrium in contact with the round ligament, communication of the GS with the endometrial cavity of the main horn, continuity of the GS with the cervix, fibrous or muscular GS attachment to the main horn, lateral deviation, and endometrial thickness of the main horn. Ovaries and tubes were also assessed. MRI features were correlated with surgical findings.

RESULTS

Seven of the nine women [29 ± 6 SD years (range 16-37 years)] underwent surgical management. The first US diagnosed RHP in only 1/9 patients. All pregnancies were diagnosed using MRI. RHP was all located in the rudimentary horn of a unicornuate uterus. All the GS was surrounded by myometrium in contact with the round ligament. None of the RHP displayed communication with the endometrial cavity of the main horn nor with the cervix. An attachment between the RHP and the main horn was seen in 3/9 patients. All the main horns were lateralized and empty.

CONCLUSION

MRI diagnosed RHP in all patients by identifying the GS surrounded by myometrium in contact with the round ligament and the absence of continuity between the GS and the cervix.

LEVEL OF EVIDENCE

IV-retrospective study.

Biopsychosocial Approach for Conservative Management of Abdominal Pregnancy in Previously Infertile Mother

Background

Abdominal pregnancy is a rare condition in which early termination is generally recommended. However, there are cases of abdominal pregnancies treated using expectant management with satisfactory outcomes. This management may be considered in special cases, such as previously infertile couples.

Case

A case of a 27-year-old woman with infertility history complaining of vaginal bleeding was presented. Physical and ultrasound examination revealed an abdominal pregnancy with 18 weeks of gestation. Although she was ready to abort the pregnancy, she insisted to try expectant management for her pregnancy. Her baby was finally born at 25 weeks via laparotomy.

Conclusion

Abdominal pregnancy is a rare and highly morbid form of ectopic pregnancy. It demands a skilled approach in management. A comprehensive and holistic approach is required to deliver the best outcome for the patient and her family.

Massive hemoperitoneum without peritoneal signs: An unusual presentation of omental ectopic rupture. A case report

Background

Extrauterine ectopic pregnancy is a rare form of ectopic pregnancy, accounting for roughly 1:10,000–30,000 of all pregnancies. Primary omental pregnancy is the least common form of abdominal ectopic pregnancies, making it extremely rare. Typical presentation includes pelvic pain, secondary amenorrhea, with or without vaginal bleeding. Atypical presentations range from nonspecific pain to asymptomatic.

Case

A 19-year-old woman presented to the emergency department after several syncopal episodes. She had a positive urine pregnancy test (serum hCG 446 IU/L). Her hemoglobin level was 10.6 g/dL. Due to lack of pain or bleeding, abdominal imaging was not indicated. A head CT scan rendered negative results. She was subsequently diagnosed with idiopathic headaches and anemia and was discharged. She returned to hospital 48 h later with vaginal bleeding and additional syncopal episodes. She was not experiencing any abdominal pain or discomfort. Her anemia worsened (hemoglobin 7.5 g/dL). For this reason, imaging was performed. It was significant for massive hemoperitoneum. Due to the imaging findings and worsening anemia, diagnostic exploratory laparoscopy was recommended to evaluate for ruptured ectopic pregnancy. Laparoscopic findings revealed large hemoperitoneum and a 10-week gestational sac attached to the greater omentum near the transverse colon. This exceedingly rare presentation of extrauterine ectopic pregnancy offered few clinical clues other than worsening anemia until imaging later revealed the abnormality. Ruptured ectopic pregnancy, a potentially fatal complication of pregnancy, should be included into the differential diagnosis of any gravid patient with syncope and anemia unexplained by extensive diagnostic workup.

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Primary omental ectopic pregnancy is exceedingly rare.

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Ectopic pregnancy with massive hemoperitoneum can present as painless, occult bleeding.

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Hemodynamic instability is often overlooked in early pregnancy due to expectation of low blood pressure.