Abdominal pregnancy with a full term live fetus: case report

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.

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.

Induction of Labour in Advanced Abdominal Pregnancy with Fetal Demise due to Cord Round Neck: A Case Report of a Missed Diagnosis

BACKGROUND

There are increasing reports of term live abdominal pregnancies even though the diagnosis of abdominal pregnancy is made preoperatively only in 45% of cases which partly explains the high maternal and perinatal morbidity and mortality associated with abdominal pregnancy.

CASE REPORT

We report a rare case of misdiagnosed term abdominal pregnancy complicated by fetal demise due to cord round neck in a 29-year-old G3P2002 at 39-week and 1-day gestation. She noticed reduced fetal movements for which upon examination fetal death was diagnosed. Cervical ripening was started which eventually failed, and surgery was indicated. Findings were an abdominal pregnancy with a third-degree macerated fetus with cord round neck. She was discharged on day 8 postoperation to continue follow-up as an outpatient with regular βHCG and ultrasound checks.

CONCLUSION

This case illustrates the need to effectively confirm an intrauterine location of a pregnancy even in a case of fetal demise and the need to monitor for cord abnormalities in advanced abdominal pregnancy being managed expectantly.

Treatment of an Ectopic Pregnancy: An Ethical Reanalysis

There is considerable lack of clarity on the medical facts surrounding management of ectopic pregnancy. In particular, it is not widely appreciated that by the time an ectopic pregnancy is diagnosed, in most cases, there is no viable fetus (i.e., the fetus has already died). Moreover, there is very little ethical guidance from the medical profession regarding the emotionally difficult decision to terminate a wanted pregnancy when the life of the mother is at risk. The best articulated positions on this topic come from religious groups, based on the principle of double effect. Yet the application of this reasoning to termination of an ectopic pregnancy is inconsistent with the medical facts in many cases. To resolve these inconsistencies, while still providing a robust ethical context for resolving such difficult situations, we propose clear guidelines for determining when a viable fetus is present in ectopic pregnancy and clarify the moral object in ectopic pregnancy management. Summary: This paper explores the ethical framework for clinical decision making in the case of ectopic pregnancies. Focusing on the disordered union of mother and unborn child clarifies the object and purpose of the actions used to separate the mother and fetus in order to save the life of both, or at least one. Since over 90% of tubal ectopic pregnancies present as embryos who have already died, these cases present no ethical dilemma. This paper proposes a modification of currently used criteria for determining the viability of ectopic pregnancies and calls for further research.

Secondary Advanced Abdominal Pregnancy after Suspected Ruptured Cornual Pregnancy with Good Maternal Outcome: A Case with Unusual Gangrenous Fetal Toes and Ultrasound Diagnoses Managed by Hysterectomy

Incidence of abdominal pregnancy is accounting for 1.4% of all ectopic pregnancies. This is a rare case report of a 35-year-old multigravida who was presented to our hospital at 24 weeks of gestation with advanced live intraabdominal pregnancy diagnosed by ultrasound. The patient was followed up till 28 weeks in hospital for medicolegal viability in Egypt. Midline laparotomy was done, a live baby was delivered, and hysterectomy was done for attached placenta. Mother was discharged in good health, and baby was admitted in neonatal intensive care unit with no congenital anomalies and died after three weeks of sepsis. The management of advanced abdominal pregnancy remains controversial. Diagnosis and management of advanced abdominal pregnancy is still a challenge to today's medical world. But high index of suspicion aided with imaging studies can help in timely diagnosis, thereby preventing the associated life-threatening complications.

A pre-operatively diagnosed advanced abdominal pregnancy with a surviving neonate: a case report

Introduction

Abdominal pregnancy is a rare form of ectopic pregnancy with a high rate of maternal and fetal complications. Most of the reported cases are diagnosed in early trimesters, usually after presenting with complications. Advanced abdominal pregnancy poses a huge diagnostic and management challenge, particularly in low-income countries. A term abdominal pregnancy diagnosed pre-operatively and resulting in a surviving neonate is quite rare.

Case presentation

A 35-year-old, para 2, unbooked, Ethiopian Somali woman presented with amenorrhea of 9 months’ duration, abdominal pain, and painful fetal movements of 4 months’ duration. Her physical examination revealed a uterus sized 36 weeks’ gestation with easily palpable fetal parts. Her laboratory test results were unremarkable except for mild anemia. Her ultrasound findings were suggestive of abdominal pregnancy. Laparotomy was done to salvage an alive healthy neonate from the peritoneum with removal of placenta implanted on the right broad ligament. The mother had a smooth post-operative course.

Conclusions

An advanced abdominal pregnancy diagnosed pre-operatively with delivery of a surviving neonate is rare. A high index of suspicion and thorough clinical and ultrasound evaluation are crucial to making an early diagnosis. This is particularly important in areas where advanced imaging technologies are not readily available. Timely surgical intervention is imperative to avert maternal and fetal complications.

Electronic supplementary material

The online version of this article (doi:10.1186/s13256-015-0712-7) contains supplementary material, which is available to authorized users.

Late Abdominal Pregnancies (≥20 Weeks Gestation): A Review from 1965 to 2012

BACKGROUND

Information about the diagnosis and management of late abdominal pregnancies (≥20 weeks gestation) is limited to case reports and small case series.

METHODS

We performed a literature review of abdominal pregnancies ≥20 weeks gestation from 1965 to November 2012. Excluded were abdominal ectopic pregnancies that did not primarily implant in the peritoneal cavity, including tubal, ovarian, and intraligamentary pregnancies, and those prior to 20 weeks gestation.

RESULTS

The 31 cases identified were at 30.4 ± 7.4 weeks at diagnosis and 33 ± 8.3 weeks at delivery. The most common sites of placental implantation were uterus or adnexa (47.8%), bowel (30%), and the potential spaces surrounding the uterus (8.7%). There were 5 cases of an intra-abdominal abscess in the 14 patients in whom the placenta had been left in situ. Maternal outcomes were documented in 26 cases with 7 deaths; 27 fetal outcomes were documented in 22 cases with 3 fetal deaths (13.6%).

CONCLUSION

An abdominal ectopic pregnancy is an uncommon but serious event and should be considered in all patients until intrauterine gestation is confirmed. Management should be undertaken by an experienced surgical team in a tertiary care facility.

A multicentre study of advanced abdominal pregnancy: a review of six cases in low resource settings

Abdominal pregnancy has remained a big challenge worldwide especially in developing countries where there are limitations in diagnostic resources. The most important approach is to be vigilant for the unexpected as most patients present with no specific symptoms or clinical signs. It also poses great challenges in diagnosis and management, and is associated with a lot of morbidity and mortality. This series of six cases, each presenting in a peculiar way, typically illustrates these issues. The cases were managed in three different hospitals in the last 15 years. These series is aimed at highlighting the atypical presenting features of advanced abdominal pregnancy and the need for vigilance when there is suspicion of a case. It is also aimed at showing the difficulty of diagnosis and management of advanced abdominal pregnancy in low resource environment.

Sudden death in advanced abdominal pregnancy: a case report and discussion of the related medicolegal issues

We report sudden unexpected death in a 35-year-old woman with pregnancy of seven months duration. There was an allegation by the parents of the woman that she was subjected to an assault prior to death. Autopsy examination showed an abdominal pregnancy with a dead fetus, ruptured gestational sac, massive haemorrhage and secondary placental attachment. During her antenatal check-ups, she had persistently complained of abdominal pain and loose stools, but the diagnosis of abdominal pregnancy was missed clinically and on ultrasound scan. In this paper we discuss the diagnostic difficulties and medicolegal issues in such cases.