Abstract
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.
Keywords: Abdominal ectopic pregnancy, laparotomy, magnetic resonance imaging, ultrasound
An abdominal ectopic pregnancy is a pregnancy that occurs outside of the uterus and instead in the abdominal cavity. Common forms of placental implantation in abdominal pregnancies include attachment on reproductive organs with subsequent rupture into the peritoneal cavity, as well as direct attachment to uterine serosa, omentum, bowel, and mesentery.1,2 Abdominal ectopic pregnancies increase the risk of fatal intraperitoneal hemorrhage.2 Therefore, it is important to diagnose and effectively manage this rare type of pregnancy in order to reduce morbidity and mortality.
CASE STUDY
A 29-year-old gravida 1, para 0 woman presented to her obstetrician at 17 weeks’ gestation with abdominal pain. She was originally thought to have an intrauterine pregnancy, but a sonogram showed it was outside the uterus. Magnetic resonance imaging revealed an abdominal ectopic pregnancy with the placenta cephalad to the uterus and implanted on the uterine fundus (Figure 1). The placenta received its arterial supply from the right and left uterine arteries and appeared to invade the serosa of the sigmoid colon. The left femoral vein had a thrombus occupying approximately 30% of the lumen. The patient had a history of a seizure disorder, treated with lamotrigine, and a history of untreated multiple sclerosis. She had no history of sexually transmitted disease, pelvic inflammatory disease, or endometriosis. She had never had surgery. Bimanual exam revealed a 14-week-sized uterus. Fetal heart tones were 144 beats a minute in the left lower quadrant.
Figure 1.
Abdominal pregnancy in sagittal view. The placenta is cephalad to the uterus and appears to be implanted on the uterine fundus. The fetal spine is visible, as is a 4 cm posterior fibroid.
She was counseled on the need for surgical removal of the ectopic pregnancy to save her life. Vascular surgery, trauma surgery, urology, and gynecological oncology services were all consulted. Four units of blood were put on hold. Her starting hematocrit was 26%. The patient was taken to the operating room for an exploratory laparotomy, inferior vena cava filter placement, and bilateral ureteral stent placement.
On abdominal entry, the omentum was adhered and draped across the placenta. It did not invade pelvic vasculature or the colon. A placenta was partially adhered to the omentum (Figure 2a). A partial omentectomy was performed to free the placenta. The fetus was identified inferior to the placenta on the patient’s right (Figure 2b). The gestational sac was artificially ruptured, the cord was clamped and cut, and the fetus was removed. The placenta was noted to be attached to the left cornua and fallopian tube. The placenta and left fallopian tube were then removed using the bipolar cautery. The original intention was to leave the placenta to reduce the risk of hemorrhage, but intraoperative bleeding from the placenta necessitated its removal.
Figure 2.
(a) Placenta with clotted blood. (b) Gestational sac with fetal feet prior to rupture.
DISCUSSION
Ectopic pregnancies comprise 1% to 2% of all pregnancies, with most occurring in the fallopian tube.3 In rare cases ectopic pregnancies can be found in the abdominal cavity; these pregnancies consist of about 1% of all ectopic pregnancies.3–7 Due to the potential complication of hemorrhage from the placental implantation site, abdominal ectopic pregnancies have a high morbidity and mortality.2,3,5,6,8 As a consequence, proper diagnosis and treatment are essential.
Risk factors for abdominal pregnancy include previous ectopic pregnancy, tubal surgeries/rupture, endometriosis, and pelvic inflammatory disease.1 While abdominal pregnancy presentation is variable, findings such as severe abdominal pain and painful fetal movement should raise suspicion for abdominal pregnancy.6 Due to the variability of symptoms, abdominal pregnancies can be misdiagnosed.5 In our case, the pregnancy was initially thought to be intrauterine; however, a sonogram showed the presence of an extrauterine pregnancy. Ultrasound findings showing an empty uterus, with a gestational sac or mass outside of the uterus, fallopian tubes, and ovaries confirming the diagnosis of abdominal pregnancy.1,5 If the diagnosis of abdominal pregnancy is inconclusive with ultrasound findings, magnetic resonance imaging can be used.5 Further, beta-human chorionic gonadotropin levels early in the pregnancy >1500 mIU/mL without an intrauterine gestational sac should warrant concern for abdominal or other ectopic pregnancies.8
Abdominal pregnancy before 24 weeks is generally treated with laparotomy with removal of the ectopic pregnancy with or without placental removal (if low risk of maternal hemorrhage).3,6 A multidisciplinary surgical team including vascular surgery, trauma surgery, urology, and gynecological oncology may be warranted due to the risk for heavy bleeding, complicated pelvic surgery, and urological involvement. It is important to continue to follow the patient for risk of postoperative complications such as hemorrhage or infection.8 There have been rare instances in which abdominal ectopic pregnancies have been diagnosed later in the pregnancy and carried to term.3,4,6,8,9 As abdominal pregnancies are associated with a high risk of maternal and perinatal mortality, it is always important to encourage proper counseling and shared decision making between the patient and provider before deciding upon a treatment plan.4,6,7
References
- 1.Agarwal N, Odejinmi F.. Early abdominal ectopic pregnancy: challenges, update and review of current management. Obstet Gynecol. 2014;16(3):193–198. doi: 10.1111/tog.12109. [DOI] [Google Scholar]
- 2.Okafor I, Ude A, Aderibigbe A, et al. Abdominal pregnancy—a case report. J West Afr Coll Surg. 2011;1(1):121–130. [PMC free article] [PubMed] [Google Scholar]
- 3.Baffoe P, Fofie C, Gandau BN.. Term abdominal pregnancy with healthy newborn: a case report. Ghana Med J. 2011;45(2):81–83. doi: 10.4314/gmj.v45i2.68933. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Hailu FG, Yihunie GT, Essa AA, Tsega WK.. Advanced abdominal pregnancy, with live fetus and severe preeclampsia, case report. BMC Pregnancy Childbirth. 2017;17(1):243. doi: 10.1186/s12884-017-1437-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.AbdulJabbar NA, Saquib S, Talha WEM.. Successful management of abdominal pregnancy: two case reports. Oman Med J. 2018;33(2):171–175. doi: 10.5001/omj.2018.32. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Abdelrahman S, Deeter M, Muthusami A, Peterson TG, Wackenier L.. A live term intra-abdominal pregnancy in a field hospital: a case report. J Surg Case Rep. 2017;2017(3):rjx062. doi: 10.1093/jscr/rjx062. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Dabiri T, Marroquin GA, Bendek B, Agamasu E, Mikhail M.. Advanced extrauterine pregnancy at 33 weeks with a healthy newborn. Biomed Res Int. 2014;2014:102479. doi: 10.1155/2014/102479. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Sib SR, Ouédraogo I, Sanogo M, et al. A full term abdominal pregnancy with an isthmic tubal implantation of the placenta. BMC Pregnancy Childbirth. 2018;18(1):448. doi: 10.1186/s12884-018-2071-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Mengistu Z, Getachew A, Adefris M.. Term abdominal pregnancy: a case report. J Med Case Rep. 2015;9:168. doi: 10.1186/s13256-015-0635-3. [DOI] [PMC free article] [PubMed] [Google Scholar]