Advanced abdominal pregnancy, with live fetus and severe preeclampsia, case report

Prolonged abdominal pregnancy incidentally discovered during cesarean section: a case report

BACKGROUND

Abdominal pregnancy is a rare medical condition that is still missed in developing countries due to inadequate medical facilities. The clinical indicators manifest in various forms and are nonspecific, making it challenging to diagnose and often leading to delayed detection. However, obstetric ultrasound serves as an essential tool in early detection. Our objective was to share our experience dealing with this condition and emphasise the importance of early ultrasound diagnosis through efficient pregnancy monitoring in our regions.

CASE PRESENTATION

35-year-old Black African woman who had ten months of amenorrhea sought consultation due to an absence of active foetal movements. Her pregnancy was of 39 weeks with fetal demise which was confirmed following clinical examination and ultrasound. She underwent cesarean section in view of transverse position of fetus. During cesarean section, the fetus was found within the abdominal cavity with the placenta attached over the left iliac fossa including surface of left ovary. The uterus and right adnexa were within normal limits. A 2600 g macerated fetus with placenta and membranes were extracted without any complications. The maternal outcome was successful.

CONCLUSIONS

Abdominal pregnancy remained an inadequately diagnosed condition in developing countries. It is imperative to increase awareness among pregnant women regarding high-quality prenatal care, including early obstetric ultrasound, from conception. Meanwhile, healthcare professionals should receive continuous training and the technical platform modernised. To ensure accurate diagnosis, the location of the gestational sac must be identified for every pregnant woman during their initial ultrasound appointment.

Challenges and perspectives of abdominal pregnancy in a resource-limited setting: A case series

INTRODUCTION AND IMPORTANCE

Abdominal pregnancies, although rare, present unique challenges in both diagnosis and management. This case series reports on four cases of abdominal pregnancies diagnosed in a remote and underserved region of the Democratic Republic of Congo, highlighting the difficulties encountered in an under-equipped environment.

CASE PRESENTATION

The cases were documented in a remote village of DRC, which lacks specialized medical personnel and relies heavily on traditional healers. We report here 4 cases of abdominal pregnancies, their clinical presentations, diagnostic modalities, and surgical approaches. The cases varied in terms of clinical symptoms, gestational age, and placental implantation sites. Delayed diagnosis and presentation were common, resulting in significant hemoperitoneum and adverse fetal outcomes. All cases required laparotomy for both diagnosis and intervention.

CLINICAL DISCUSSION

Abdominal pregnancies can go undetected until advanced gestational age, with common physical findings including abdominal tenderness, abnormal fetal lie, fetal body parts readily palpable, and a displaced cervix. Laboratory tests may raise suspicion, but treatment options depend on intraoperative findings and gestational age. Advanced abdominal pregnancies are associated with high mortality rates for both the mother and the fetus. Laparotomy is typically required for diagnosis and intervention, with variations in placental implantation sites. Management of the placenta remains a debated topic, with partial or complete removal both viable options.

CONCLUSION

Abdominal pregnancies pose significant challenges in resource-poor settings, where limited healthcare resources and a shortage of specialized medical personnel can impede early diagnosis and appropriate management. Enhancing prenatal care, improving diagnostic capabilities, and increasing awareness among healthcare providers and communities are essential for optimizing outcomes in these complex obstetric cases.

Acute generalized peritonitis revealing an ovarian pregnancy: a case report

Introduction and importance

Abdominal pregnancy is still seen in developing countries due to inadequate medical facilities. The clinical indicators manifest in various forms and are nonspecific, making it challenging to diagnose and often leading to delayed detection. The occurrence of an infectious complication that leads to the development of generalised acute peritonitis is rare. The author present a case of 34-year-old patient who presented with febril generalised acute peritonitis caused by an abdominal pregnancy. The result of the abdominal ultrasound and the serum β-human chorionic gonadotropin (β-HCG) level led to initial diagnostic confusion.

Case presentation

A 34-year-old primigravida with no medical or surgical history of comorbidity prior consulted in the authors' department for generalised abdominal pain in the context of fever and amenorrhoea for more than 4 months. Physical examination revealed a painful and contracted abdomen. The biological assessment showed white blood cells at 27 100/ul, the haemoglobin level at 11.8 g/dl. The serum β-HCG level was less than 5 UI/l. The abdominal ultrasound noted a peritonitis secondary to an abscess of the appendix. Exploratory laparotmy revealed 200 ml of pus in the peritoneum and a mass in the right iliac fossa at the expense of the ovary with agglutination of the intestines loops. After adesyolysis, a single-piece excision of the mass was performed, the break-in showing a macerated foetus, a right adnexectomy and an appendectomy. The maternal outcome was good.

Clinical discussion

Abdominal pregnancy remains an inadequately diagnosed condition in developing countries. This case reminds clinicians that abdominal pregnancy remains a differential diagnosis of all abdominal pain in a woman of childbearing age including when the serum β-HCG level was less than 5 UI/l.

Conclusion

It is imperative to increase awareness among pregnant women about high-quality prenatal care, including early obstetric ultrasound, from conception. Meanwhile, healthcare professionals should receive continuous training and the technical platform modernised.

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.

A delayed spontaneous second-trimester tubo-abdominal pregnancy diagnosed and managed by laparotomy in a "self-identified" infertile woman, a case report and literature review

BACKGROUND

Abdominal pregnancy, a rare form of ectopic pregnancy, is associated with high morbidity and adverse consequences for future fertility. Early recognition and management reduce mortality and allow minimal invasive and conservative treatment. In modern medicine, primitive prevention to unexpected fatal pregnancies is crucial.

CASE PRESENTATION

A divorced 33-year-old "self-identified" infertile polycystic ovary woman diagnosed as repeated implantation failure in previous in vitro fertilization with her ex-husband ever presented in surgery department with a history of 15-day abdominal pain, nausea, and vomiting and 3-h worsening abdominal pain. The serum beta-human chorionic gonadotropin value was more than 10,000 m-international units per milliliter. Sonogram findings were significant for the absence of intrauterine gestation; a placenta and well-formed living fetus of second-trimester gestation were seen in the abdomen, accompanied by hemoperitoneum. A unique spontaneously second-trimester tubo-abdominal pregnancy was confirmed in emergent laparotomy by gynecologists, she received a removing of the living fetus, a right total salpingectomy, resection of partial omentum and blood transfusion. The patient recovered uneventfully and her serum beta-human chorionic gonadotropin returned to normal range on the 30th postoperative day, till now, she has weak fertility awareness because of her catastrophic experiences in the unexpected abdominal pregnancy.

CONCLUSIONS

This case highlights woman with a previous in vitro fertilization history may be in is a high risk to be delayed or missed in diagnosis in an intended ectopic pregnancy due to a fixed belief in infertility. Educational interventions and contraceptive care should be provided by fertility and healthcare practitioner. The possibility of abdominal pregnancy must always be suspected and dealt with promptly and appropriately by the astute clinician.

Conservative management of complete fetal expulsion into the abdominal cavity after silent uterine rupture - case report

BACKGROUND

Clinically silent uterine rupture with complete fetal expulsion into the abdominal cavity is an extremely rare complication. Diagnosis can be difficult and the risk to the mother and fetus is high. Conservative management has been described only in a few cases of partial expulsion of the fetus so far.

CASE PRESENTATION

We present a case of 43-year-old tercigravida with a history of previous laparotomic myomectomy and subsequent cesarean section. The subsequent pregnancy was complicated by uterine wall loosening and rupture at the site of the previous uterine scar after myomectomy and complete fetal expulsion into the abdominal cavity. The diagnosis was made at 24 + 6 weeks of gestation. Considering the absence of clinical symptomatology and the good condition of the fetus, a conservative approach was chosen with intensive monitoring of the maternal and fetal conditions. The pregnancy ended by elective cesarean section and hysterectomy at 28 + 0 weeks of gestation. The postpartum course was uneventful and the newborn was discharged to home care 63 days after delivery.

CONCLUSIONS

Fetal expulsion into the abdominal cavity after silent uterine rupture of the scarred uterus may be accompanied by minimal symptomatology making early diagnosis difficult. This rare complication must be considered in the differential diagnosis in women after major uterine surgery. In selected cases and under conditions of intensive maternal and fetal monitoring, conservative management may be chosen to reduce the risks associated with prematurity.

Abdominal pregnancy secondary to uterine horn pregnancy: a case report

BACKGROUND

Pregnancy begins with a fertilized ovum that normally attaches to the uterine endometrium. However, an ectopic pregnancy can occur when a fertilized egg implants and grows outside the uterine cavity. Tubal ectopic pregnancy is the most common type (over 95%), with ovarian, abdominal, cervical, broad ligament, and uterine cornual pregnancy being less common. As more cases of ectopic pregnancy are diagnosed and treated in the early stages, the survival rate and fertility retention significantly improve. However, complications of abdominal pregnancy can sometimes be life-threatening and have severe consequences.

CASE PRESENTATION

We present a case of intraperitoneal ectopic pregnancy with fetal survival. Ultrasound and magnetic resonance imaging showed a right cornual pregnancy with a secondary abdominal pregnancy. In September 2021, we performed an emergency laparotomy, along with additional procedures such as transurethral ureteroscopy, double J-stent placement, abdominal fetal removal, placentectomy, repair of the right uterine horn, and pelvic adhesiolysis, in the 29th week of pregnancy. During laparotomy, we diagnosed abdominal pregnancy secondary to a rudimentary uterine horn. The mother and her baby were discharged eight days and 41 days, respectively, after surgery.

CONCLUSIONS

Abdominal pregnancy is a rare condition. The variable nature of ectopic pregnancy can cause delays in timely diagnosis, resulting in increased morbidity and mortality, especially in areas with inadequate medical and social services. A high index of suspicion, coupled with appropriate imaging studies, can help facilitate its diagnosis in any suspected case.

Asymptomatic 39 Weeks Abdominal Pregnancy - Video Report of a Case Occurred in Ivory Coast Resulting in a Live Birth

BACKGROUND

Despite the current advances in antenatal care and imaging methodologies in obstetrics, cases of advanced abdominal pregnancies are still reported, mostly in low- and middle-income countries where frequently only a few perinatal checks are performed and where these methodologies are sometimes not adopted in obstetrical outpatient settings.

CASE PRESENTATION

We report the video of a case of a 20-year-old I gravida Ivorian patient, sent to CHU de T reichville in Abidjan, Ivory Coast, for management of abdominal 39 weeks pregnancy after routine antenatal care. She was asymptomatic with a live foetus in transverse lie position. The anamnesis revealed four prenatal checks without ultrasound evaluation, the first one at 24 weeks of pregnancy. Emergency median longitudinal sub-umbilical laparotomy incision was performed. Foetal extraction was realized by transplacental incision due to omental placental implantation. A live female baby weighting 3350 grams was delivered, presenting bilateral clubfeet and an enlarged neck. The release of the adherent placenta required a partial omentectomy and left adnexectomy and was carefully removed following active bleeding from its detached margins. The newborn died of respiratory distress on the first day after birth. No autopsy was performed. Postoperative morbidity for the woman was minimal and she was discharged on the seventh post-operative day in good general condition.

CONCLUSION

Abdominal pregnancies with a normal live foetus at such an advanced gestational age are extremely rare, and there are no available videos in the extant literature of the surgical procedure performed. Standardization of treatment principles, pre-operative preparation with imaging techniques (MRI, embolization of placental vessels) and adequately equipped and staffed neonatal units are necessary to optimize the foetus-maternal outcomes.

Advanced tubal pregnancy at 34 weeks with eclampsia and HELLP syndrome: a case report and literature re

BACKGROUND

Tubal ectopic pregnancies in the late stages of pregnancy are uncommon, and reports on their complications are scarce. We present the case of a woman who had a tubal ectopic pregnancy at around 34 weeks and developed severe pre-eclampsia complications.

CASE

A 27-year-old woman presented to our hospital several times with vomiting and convulsions. A physical exam revealed hypertension, scattered ecchymosis, and a large abdominal mass. A computed tomography (CT) scan performed in an emergency revealed an empty uterus, a stillbirth baby in the abdominal cavity, and a crescent-shaped placenta. Blood tests revealed that the patient had a low platelet count and clotting dysfunction. Laparotomy confirmed advanced right fallopian tube pregnancy without rupture, and salpingectomy was performed. Pathological examination revealed a significantly thickened tubal wall, adhesion of the placenta, and poor placental perfusion.

CONCLUSION

The unusually thickened muscular layer of the tube may be one of the reasons for tubal pregnancy progressing to an advanced stage. Placenta adhesion and the special site to which it is attached reduce the risk of rupture. The detection of a crescent-shaped placenta on imaging may aid in the accurate diagnosis, distinguishing between abdominal and tubal pregnancy. Women with advanced ectopic pregnancy are more likely to develop pre-eclampsia and have poorer maternal-fetal outcomes. These negative outcomes may be influenced by abnormal artery remodeling, villous dysplasia, and placental infarction.

Undiagnosed Term Abdominal Pregnancy in a District-Level Hospital of a Developing Country: A Miracle Baby

Term abdominal pregnancy is a sporadic ectopic pregnancy associated with high maternal and perinatal morbidity and mortality. As symptoms are non-specific and resemble those of other ectopic pregnancies, early diagnosis is the major challenge in poor health setups. A 24-year-old primigravida at 38 weeks gestation was planned to undergo a cesarean section for the transverse lie. Abdominal pregnancy was accidentally discovered during the cesarean section, and a healthy, normal baby boy was delivered. The placenta was attached to the greater omentum, so its removal required omentectomy without compromising the blood supply to the bowels. Both patient and her baby boy were discharged on the seventh day without complications. No congenital anomalies were detected in the baby. In a term abdominal pregnancy, the most significant challenges are the control of bleeding and the decision on placenta removal, followed by prompt delivery of the fetus. Therefore, along with the gynecologist, the availability of trained personnel, such as anesthetists, pediatricians, and general surgeons, is necessary for a successful management outcome.

Surviving Fetus from a Full Term Abdominal Pregnancy

Background

Abdominal pregnancy refers to a rare form of ectopic pregnancy that has been implanted in the peritoneal cavity. Clinical suspicion combined with ultrasound is important for early diagnosis. A surviving fetus from an abdominal pregnancy is extremely rare.

Case Presentation

Herein we report on a case of advanced abdominal pregnancy in a Gravida-III Abortion-II mother who presented with worsening abdominal pain of 1 week duration associated with fetal movement and managed successfully with an outcome of a live neonate and no maternal complication.

Conclusion

A live neonate from term abdominal pregnancy is a rare occurrence. Early diagnosis of abdominal pregnancy is crucial to avoid potentially catastrophic maternal complications even though our patient, fortunately, has a smooth postoperative course. A high level of suspicion combined with ultrasound is helpful in reaching a diagnosis. Skill advancement for radiologists and non-radiology professionals involved in obstetric ultrasound is recommended to avoid misdiagnosis, as in our case. Careful post-operative evaluation is important to look for maternal and fetal complications.

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.

Neuropilin-1 is uniquely expressed on small syncytiotrophoblast extracellular vesicles but not on medium/large vesicles from preeclampsia and normal placentae

Preeclampsia (PE) is a multisystem progressive hypertensive disorder unique to human pregnancy. The placenta is fundamental to its pathogenesis and releases placental factors as well as extracellular vesicles (small and medium/large syncytiotrophoblast extracellular vesicles (STB-EVs)) as a response to syncytiotrophoblast stress such as tissue factor and plasminogen activator inhibitors 1. Neuropilin 1 (NRP-1) is an anti-angiogenic factor involved in development, angiogenesis, arteriogenesis, and vascular permeability. NRP-1 acts as a co-receptor for growth factors such as vascular endothelial growth factor (VEGF), placenta growth factor (PLGF), and epidermal growth factor (EGF). Given the documented pro and anti-angiogenic roles of STB-EVs, we hypothesized that 1) STB-EVs might express NRP-1; and 2) the expression of NRP-1 might differ between normal and preeclampsia STB-EVs.

METHODS

We isolated STB-EVs (both small and medium/large) from PE and NP placentae using the physiologic ex vivo dual lobe perfusion model. The enriched STB-EVs were characterized by Western blot, transmission electron microscopy (TEM), and nanoparticle tracking analysis (NTA) according to the international society of extracellular vesicles (ISEV) guidelines. We assessed for NRP-1 expression with Western blot (placenta and STB-EVs) and immunohistochemistry (placenta). We performed co-expression analysis for placenta alkaline phosphatase (PLAP - a known STB-EV marker) and NRP-1 with immunoprecipitation followed by Western blot.

RESULTS

We confirmed NRP-1 expression in NP and PE placenta. We showed that NRP-1 Expression was limited to small syncytiotrophoblast membrane extracellular vesicles (S STB-EVs) but not medium/large STB-EVs and that NRP-1 is co-expressed with PLAP.

CONCLUSION

Neuropilin-1 is uniquely expressed on small syncytiotrophoblast extracellular vesicles but not on medium/large vesicles from preeclampsia and normal placentae.

A unique case of coexisting intrauterine and abdominal pregnancy which progress to term with a positive birth outcome

BACKGROUND

The term heterotopic pregnancy is defined as a uterine pregnancy coexisting with a second pregnancy in an extrauterine location. Spontaneous, full-term heterotopic pregnancy with alive birth is very rare. The diagnosis and management of such exceptionally unique case is difficult. When the patient presented with an advanced labor with no antenatal care follow up and with no risk factors is even more challenging for poorly equipped facilities like ours.

CASE PRESENTATION

A 25 years old gravida 3, para 2 (both are alive) mother presented to the labor and delivery ward of Bele Primary Hospital, Southern Ethiopia with the complaint of pushing down pain of 18 h duration. Immediately after arrival, she gave birth to a 3300gm female neonate spontaneously. After delivery, an abdominal mass was recognized and manual exploration of the uterus was done to look for the presence of after coming second twin but the uterus was empty. On ultrasound examination, there was an alive fetus in transverse lie outside the uterus. With the impression of 2nd twin in a separate horn of bicornuate uterus and to rule out abdominal pregnancy, laparotomy was done. On laparotomy, there was abdominal pregnancy in the Pouch of Douglas with an intact amniotic sac. The sac was attached with the left broad ligament, left ovary, small bowel mesentery, and posterior wall of the uterus. The sac opened, a 1600gm alive female neonate with features of fetal growth restriction and left club foot was delivered. The placenta was detached spontaneously and removed without any complication.

CONCLUSIONS

The coexistence of spontaneous full-term intrauterine with advanced abdominal ectopic pregnancy is one of the rarest forms of heterotopic pregnancy. Every health professional should bear in mind that intrauterine and extrauterine pregnancy may happen simultaneously and it can progress to term without any symptoms. Ultrasound is the diagnostic method of choice but the existence of an intra-uterine pregnancy cannot rule out ectopic pregnancy. The life-threatening complication of abdominal ectopic pregnancy is bleeding from the detached placental site. Therefore, the decision to remove the placenta should be individualized.

The Use of Contrast-Enhanced Multidetector Computed Tomography Imaging in Advanced Abdominal Pregnancy

An advanced abdominal pregnancy is defined as an extrauterine pregnancy over twenty weeks gestation with a fetus living, or showing evidence of having once lived, in the mother’s abdominopelvic cavity. Our case is a 35-year-old patient with a 23-week extrauterine pregnancy, with a congenital head defect (scaphocephaly and hydrocephalus), located in the left side of the maternal abdomen with a period of gestation of 23 weeks, who underwent preoperative imaging with contrast-enhanced multidetector computed tomography (CE-MDCT). CT imaging provided significant information on the placenta and its arterial supply/venous drainage and confirmed the presence of an arteriovenous malformation of the right uterine artery. CT imaging also allowed planning of preoperative uterine artery coil embolization.

Ectopic pregnancy: a resident's guide to imaging findings and diagnostic pitfalls

Ectopic pregnancy (EP) is a term used to describe any pregnancy which does not implant into the uterine cavity. There are several types of EPs: tubal, interstitial, ovarian, abdominal, heterotopic, cervical, and cesarean scar. Ectopic pregnancies can acutely rupture and are the number one cause of maternal death in the first trimester of pregnancy. Therefore, prompt recognition and accurate localization have significant clinical implications on patient outcome. Unfortunately, EPs have many mimickers, which can make the diagnosis challenging in certain cases. In this review, we aim to describe and illustrate sonographic findings of each type of EP, as well as present mimickers and various imaging pitfalls. We will clarify how to avoid potential misdiagnoses that could adversely affect patient outcomes. Lastly, we will briefly address management of each type of EP and discuss potential complications.

Abdominal ectopic pregnancy

Abdominal pregnancy is a rare form of ectopic pregnancy with high morbidity and mortality. There are a limited number of case reports of abdominal ectopic pregnancies. We present a case of a 29-year-old woman who presented to her obstetrician at 17 weeks' gestation with abdominal pain. A sonogram and confirmatory magnetic resonance imaging demonstrated an abdominal ectopic pregnancy. The patient underwent exploratory laparotomy with removal of the ectopic pregnancy. Our case presents an opportunity to discuss a rare form of ectopic pregnancy and the importance of proper diagnosis and treatment to reduce morbidity and mortality.

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.

Two uterine scars and a vaginal birth

Uterine scarring increases the risk of uterine rupture during labour, which can result in significant maternal and fetal morbidity and mortality. There is insufficient evidence for a clear recommendation on the safety of vaginal delivery in the context of a patient with both a uterine perforation and a previous lower uterine segment caesarean section. We present the case of a woman with a history of one previous caesarean section and uterine perforation with a uterine manipulator, who subsequently had an uncomplicated normal vaginal delivery.

Case of Ruptured Ectopic Pregnancy in the Uterosacral Ligament and Review of the Literature

Pregnancies that implant on the uterosacral ligament are rare. Here, we describe a case of ruptured ectopic pregnancy in the left uterosacral ligament in a patient with potential risk factors including possible endometriosis and recent hysteroscopic procedure. A 29-year-old female, para 0, presented to the emergency department with generalized abdominal pain. Pelvic examination was significant for fullness in the posterior cul-de-sac. Laboratory values were significant for beta-human chorionic gonadotropin (hCG) level of 6311 mIU/mL. Sonogram findings were significant for no intrauterine gestation, a 6.9 × 4.6 × 4.7 cm³ complex left adnexal mass, and moderate free fluid within the posterior cul-de-sac. The patient underwent laparoscopy, which revealed hemoperitoneum and unremarkable bilateral fallopian tubes and ovaries. An abnormal area was noted in the left uterosacral ligament. Tissue was bluntly removed and pathologically confirmed as chorionic villi within the left uterosacral ligament. After one week, her beta-hCG decreased to 784 mIU/mL. After two weeks, she was seen as an outpatient and was doing well without any symptoms. More information is required regarding these unique pregnancies to help understand the pathophysiology and determine the management.

Rare Ectopic Pregnancies - A Literature Review for the Period 2007 - 2019 on Locations Outside the Uterus and Fallopian Tubes

The majority of ectopic pregnancies (EP) are tubal pregnancies, but other implantation sites outside the uterus and tubes are also found. These rare EP locations present a particular diagnostic and therapeutic challenge. We present an overview of potential very rare locations of ectopic pregnancies, their symptoms, diagnosis and treatment, based on a systematic analysis of case reports. A literature review of the databases PubMed, Livivo and Google Scholar for the period 2007 to 2019 was carried out. A total of 113 publications were included in our review. These studies describe EP implantations in the posterior cul-de-sac, on the uterine serosa and uterine ligaments, in the vicinity of almost all intraperitoneal organs, on the abdominal wall as well as in retroperitoneal sites. The most common presenting symptom was abdominal pain occurring in different locations. The diagnostic procedures included various imaging procedures and/or explorative surgery at different advanced stages of pregnancy. The most common and preferred option was laparotomy for surgical treatment. The placenta was successfully resected in the majority of cases. A rare EP location should be considered when making a differential diagnosis in patients of child-bearing age with abdominal pain.

Abdominal pregnancy during the COVID-19 pandemic

Description of the emergency approach used for management of an abdominal pregnancy during the COVID‐19 pandemic.

Ruptured Right Broad Ligament Ectopic Pregnancy in a Patient With Prior Right Salpingo-Oophorectomy: A Case Report

Ectopic pregnancy can be a life-threatening cause of acute abdomen. Broad ligament pregnancy accounts for 1% of ectopic abdominal pregnancies and complications can be calamitous. This case report highlights a 27-year-old G2P0010 female who presented with amenorrhea and acute right lower quadrant and pelvic pain. By last menstrual period (LMP), she was at seven weeks and two days gestation. Her past surgical history was significant for a prior right salpingo-oophorectomy. The physical examination was significant for severe right lower quadrant tenderness with guarding. The urine pregnancy test was positive with the serum quantitative beta-human chorionic gonadotrophin (Beta hCG) of 28011 MIU/ML (normal range <5 MIU/ML). The transvaginal ultrasonography demonstrated an empty uterus and a gestational sac containing a fetal pole in the right adnexal area. The crown-rump length was 7.2 mm, consistent with six weeks and four days, with a positive fetal heart rate and moderate free fluid in the cul-de-sac. The patient was taken for immediate diagnostic laparoscopy, which was converted to open laparotomy due to active bleeding from the right broad ligament and pelvic wall close to large pelvic vessels. In addition to the hemoperitoneum, intraoperative findings revealed a normal left fallopian tube and ovary and absent right fallopian tube and ovary. Right ureterolysis was done and hemostasis of the bleeding broad ligament and right pelvic sidewall was established. An adherent tissue was dissected from the right broad ligament and sent to pathology. The patient did well postoperatively. The final pathology showed an ectopic pregnancy with immature chorionic villi in the broad ligament. The diagnosis of ectopic pregnancy in the broad ligament is challenging. The location could be close to the major pelvic vessels and anatomic structures like the ureter and bowel, hence, it can cause massive hemorrhage with maternal morbidity and mortality. Diagnosis is often missed preoperatively and made intraoperatively. Hence, we emphasize that this differential be considered in reproductive-aged women who present with atypical presentations of acute abdomen and amenorrhea.

Late abdominal pregnancy in a post-conflict context: case of a mistaken acute abdomen - a case report

Background

Abdominal pregnancies have been reported in both high-income countries as well as low- and middle-income countries. They are frequently missed in routine antenatal care in resource-limited settings and delayed diagnosis is usually associated with poor fetal and maternal outcomes including death. This case report is among the first from eastern Democratic Republic of Congo (DRC), a post-conflict region.

Case presentation

In this case study, we present a 25 year-old primigravida patient referred to HEAL Africa hospital for management of an acute abdomen at 33-weeks gestation. Her chief complaint was severe abdominal pain associated with each fetal movement for a period of 1 week prior to admission. A diagnosis of peritonitis was made. Emergency laparotomy revealed a normal live 2 kg baby with placental implantation on the greater omentum and small intestine mesentery. The placenta was not removed. Both maternal and fetal outcomes were good.

Conclusion

Abdominal pregnancy with a normal live fetus at such an advanced gestational age is rare. This case reminds clinicians that abdominal pregnancy remains a differential diagnosis for painful fetal movements.

Laparoscopic Removal of an Abdominal Pregnancy in the Pelvic Sidewall

STUDY OBJECTIVE

To describe the presentation, diagnosis, and management of a patient with abdominal pregnancy and to illustrate the laparoscopic technique used to manage this patient.

DESIGN

A descriptive study approved by our local Institutional Review Board. Consent was given from the patient.

SETTING

A university hospital in Ashdod, Israel.

PATIENT

On May 15th 2018, a gravida 3, para 2, 37-year-old asymptomatic patient was referred to our hospital's gynecologic emergency department due to a suspected ectopic pregnancy. The patient had no relevant medical or surgical history. Her obstetric history consisted of 2 spontaneous vaginal deliveries with no other significant gynecologic history. Her menses were regular every month. Her last menstrual period was 6 weeks before presentation. Her β-human chorionic gonadotropin (hCG) level measured on the day before presentation was 24,856 IU/L. Physical examination was unremarkable except for a small amount of brownish vaginal discharge. A transvaginal ultrasound (TVUS) exam on presentation did not demonstrate an intrauterine gestational sac, but revealed a gestational sac and a fetus next to the right adnexa, with a crown-rump length of 1.3 cm, consistent with 7+3 gestational weeks. There was a minimal amount of fluid in the pouch of Douglas.

INTERVENTION

Owing to an extrauterine pregnancy with high β-hCG value, laparoscopic operative management was chosen. On entrance to the abdominal cavity, a normal uterus and 2 ovaries and fallopian tubes were observed. A small to moderate amount of blood was present in the pouch of Douglas. a 3- to 4-cm distension was noted over the right uterosacral ligament. Following delicate probing of the area, moderate to severe bleeding commenced, which was initially controlled with local pressure and oxidized regenerated cellulose. An intraoperative TVUS identified an abdominal pregnancy in the right pelvic sidewall. The gestational sac was completely dissected and removed following ureterolysis and separation of the right ureter from the specimen. Local injection of vasopressin was also used. The β-hCG level before surgery of 19,008 IU/L decreased to 6339 IU/L on postoperative day 1. The patient was discharged in good condition on postoperative day 2. A final histopathological report confirmed a gestational sac.

MEASUREMENT AND MAIN RESULTS

This patient referred for a tubal ectopic pregnancy was eventually diagnosed with an abdominal pregnancy and was treated operatively with complete excision of the abdominal pregnancy, which was located at the right pelvic sidewall.

CONCLUSION

Abdominal pregnancy is a rare type of ectopic pregnancy with a reported incidence of 1:10,000 to 1:30,000 pregnancies, and accounts for approximately 1% of ectopic pregnancies [1]. It carries a high risk for maternal morbidity and mortality. Many different locations at different gestational ages have been reported in the literature, including the pouch of Douglas, pelvic sidewall, bowel, broad ligament, omentum, and spleen [2-4]. These varied locations and the rarity of this type of pregnancy make diagnosis and treatment challenging. The location of the growing fetal tissue may endanger the patient's life if it impinges on vital anatomic structures. In the present case, the gestational sac was very close to the right ureter, and we opted to surgically excise the gestational sac in its entirety.

Diagnosis of abdominal pregnancy still a challenge in low resource settings: a case report on advanced abdominal pregnancy at a tertiary facility in Western Kenya

Abdominal pregnancy is a rare form of ectopic pregnancy, occurring in 1: 10,000 to 1: 30,000 pregnancies and accounting for up to 1.4% of all ectopic pregnancies. It is classified as primary or secondary depending on the site of fertilization. However, when it does happen, it may remain unnoticed until term because the pregnancy can appear normal during clinical examination. Advanced abdominal pregnancy is associated with high mortality rate for both the mother and the baby at 1-20% and 40-95% respectively. We report a case of a 30-year-old female para 2+0, gravida 3 at 35⁺¹ who presented at a Tertiary facility in Eldoret Kenya with one-day history of per vaginal bleeding and 2 weeks' history of no fetal movements. The importance of this case report is to highlight the challenges associated with diagnosis of advanced abdominal pregnancy in low resource settings. Ultrasound alone cannot be relied on to make the diagnosis. Whenever an induction is not working, abdominal pregnancy should be considered.