Conservative Management and Planned Surgery for Periviable Advanced Extrauterine Abdominal Pregnancy with Favorable Outcome: Report of Two Cases

Early abdominal pregnancy in a spontaneous heterotopic pregnancy: Case report

INTRODUCTION AND SIGNIFICANCE

Spontaneous heterotopic pregnancies, concurrently occurring intrauterine and ectopic pregnancies, pose a substantial risk to maternal health and are often misdiagnosed. This case report details the challenges in identifying and managing an exceptionally rare case of abdominal pregnancy without assisted reproduction. The patient's initial misdiagnosis underscores the complexities in diagnosis, emphasizing the importance of comprehensive imaging techniques.

CASE PRESENTATION

We present the case of a 36-year-old gravida 5, para 3, with a history of dilation and curettage, experiencing a heterotopic pregnancy involving delayed miscarriage in both uterine and abdominal cavities. Despite presenting symptoms of pelvic pain and abnormal vaginal bleeding, the abdominal pregnancy was initially overlooked in ultrasound examinations. The accurate diagnosis was only achieved post-miscarriage, leading to a timely intervention through laparotomy.

CLINICAL DISCUSSION

The absence of identifiable risk factors, except for the patient's history of dilation and curettage, highlights the spontaneous nature of this non-assisted reproduction-related pregnancy. This case emphasizes the challenges in diagnosing and managing spontaneous heterotopic pregnancies, particularly when an abdominal pregnancy is involved. Vigilance and advanced imaging techniques are crucial for early recognition and appropriate intervention.

CONCLUSION

This unique case underscores the difficulties in diagnosing and managing spontaneous heterotopic pregnancies, especially when an abdominal pregnancy is present. Vigilance and advanced imaging are essential to identify rare occurrences like abdominal pregnancies that may go unnoticed in conventional ultrasound examinations. Early recognition and intervention are critical in averting potential life-threatening consequences associated with this uncommon condition.

Foley catheter tourniquet for uncontrollable extra-uterine placental hemorrhage: description of a novel surgical technique

Introduction Hemorrhage from a partially or fully detached placenta with an advanced abdominal pregnancy can be profuse and catastrophic. The general approach to placenta management is removal of "all or nothing''. In the event of acute hemorrhage, every attempt to achieve hemostasis quickly is critical. The Foley catheter has shown utility when used to control placental hemorrhage or as a temporary tourniquet applied around structures surrounding the implantation site to aid placental removal with minimal hemorrhage. We report use of the technique on four occasions with good surgical outcomes. Case Presentation We report a case of a 33 year-old primigravida admitted at term with an ultrasound diagnosis of breech presentation and placenta previa grade four. Her pre-operative clinical assessment however, raised suspicion of an abdominal pregnancy. At laparotomy, a live female infant was delivered from the extra-uterine gestation sac, weighing 3640g and with an Apgar score of 7 and 6 at one and 5 minutes respectively. Following delivery, there was profuse bleeding from the partially detached distal portion of the placenta that derived rich blood supply from the poorly accessible posterior pelvic wall. We applied a novel, simple and effective surgical technique for minimizing blood loss from the partially detached placenta using a Foley's catheter tourniquet that was applied between the detached and still attached parts of the placenta. The tourniquet was left in situ and removed at laparotomy 4 days later. The placenta was not removed. The mother and baby did well postoperatively and were discharged after 10 and 21 days respectively in good condition. The surgical technique was similarly used in 3 additional cases with good clinical outcomes. Discussion Use of a Foley catheter as an intraoperative tourniquet has become accepted as a useful technique in obstetric and gynecological surgery. We describe a simple life saving technique of applying a Foley tourniquet across a partially detached placenta following an advanced extra-uterine pregnancy to control acute hemorrhage. Conclusion We recommend that surgeons keep in mind the option of intraoperative tourniquets when faced with uncontrollable bleeding as a short-term or medium-term temporizing measure.

Hemoperitoneum during removal of the placenta in advanced abdominal pregnancy with live fetus delivered at 37 weeks of gestation. A case report in a low-resource setting and literature review

INTRODUCTION AND IMPORTANCE

Advanced abdominal pregnancy (> 20 weeks gestation) is a rare condition life-threatening for mother and fetus.

CASE PRESENTATION

A 31-years-old African woman presented from a rural district to Mutoyi Hospital for first gynecological evaluation after 37 weeks of amenorrhea, abdominal pain and vaginal bleeding. An ultrasound revealed an extra-uterine fetus. Laparotomy was done and a live fetus weighing 1980 g was delivered. Removal of the placenta, triggered massive bleeding (5000 mL) with shock. After re-laparotomy for post-operative ileus and hemoperitoneum, the mother and infant were discharged in good health.

CLINICAL DISCUSSION

Viable fetus can be delivered after an advanced abdominal pregnancy. Removal of the placenta is controversial. We review currently medical literature on advanced abdominal pregnancy and propose a management of the placenta in these patients.

CONCLUSION

We recommended to leave the placenta in situ, to avoid intraoperative bleeding. Placenta involution during follow-up can be revealed by ultrasound, colordoppler and β-hCG serum level decrease.

Advanced abdominal pregnancy in a spontaneous heterotopic pregnancy

Spontaneous heterotopic pregnancy is a potentially life-threatening condition rarely considered when a patient with an intrauterine pregnancy is asymptomatic or presents with complaints such as abdominal pain. An advanced abdominal pregnancy as the form of the ectopic component, outside the context of assisted reproduction, is an even more unusual and perilous diagnosis with very few cases reported in the literature. We report such a case in a 34-year-old multipara, with no known risk factors for ectopic pregnancy. The pregnancy was initially misdiagnosed and managed as a dichorionic gestation, complicated with fetal demise of one of the twins. The correct diagnosis was only made after term delivery of the intrauterine pregnancy. The abdominal pregnancy was subsequently managed via laparotomy with no complications.