Introduction
Abdominal pregnancy is a rare obstetric entity accounting for 1.4% of
ectopic pregnancies and is associated with a high maternal and perinatal
morbidity and mortality (1). Defined as an implantation in the
peritoneal cavity, exclusive of tubal, ovarian or intraligamentary
pregnancy (2), the estimated incidence is 1:10,000 live births (3).
Though there are several theories about the pathophysiology, it is
broadly classified into two types, namely primary and secondary
abdominal pregnancies (4). Risk factors associated with abdominal
pregnancies include dilation and curettage, uterine surgeries, history
of tubal pregnancy and artificial insemination (5). Studdiford, as early
as 1944, proposed the diagnostic criteria of primary abdominal pregnancy
which included the following: 1-normal tubes and ovaries, 2- no evidence
of uteroperitoneal fistula, 3-pregnancy related solely to the peritoneal
surface, and 4- no evidence of secondary implantation following initial
primary tubal nidation (6). Allibone et al. defined the ultrasound
criteria necessary to diagnose an abdominal pregnancy namely: 1-fetus
outside the uterus, 2- failure to see a uterine wall between the fetus
and the urinary bladder, 3-close approximation of fetal parts and
maternal abdominal wall, 4- eccentric position/attitude of the fetus,
5-placenta outside the uterine cavity, and 6- visualisation of the
placenta immediately adjacent to the fetal chest and head with no
amniotic fluid (7). Despite defined diagnostic criteria, diagnosis maybe
hindered by factors such as an anterior uterine leiomyoma, retroflexed
uterus and bicornuate uterus (8). A high index of suspicion is required
to diagnose this condition as its clinical features and presenting
symptoms vary widely and are non-specific. The more common presenting
symptoms include persistent abdominal pain, missed periods, bloody
vaginal discharge and vague gastrointestinal symptoms like nausea and
vomiting (9). We report a case of secondary abdominal pregnancy at 13
weeks of gestation which was managed surgically.
Objective : To highlight the diagnostic and management dilemmas
in secondary abdominal pregnancies
Methods: Case report and literature review on 314 abdominal
pregnancies.
Case report:
A 32-year-old primigravida at 13 weeks 5 days of gestation, presented to
OBG emergency department, with complaints of generalised pricking
abdominal pain and mild chest pain for 5 days which was gradually
worsening and spotting per vagina for one day. Five days prior to her
presentation at our hospital, she had been admitted at a local hospital
with complaints of vomiting and mild abdominal pain. On evaluation
there, hemoglobin was 5.7 g/dl and ultrasonography reported a live
intrauterine fetus with a crown rump length of 4.57 cm corresponding to
11 weeks of gestation. Fetal heart rate was 175 bpm and maternal ascites
along with fluid in the Morrisons pouch was noted. She received two
units of packed red cells transfusion and repeat hemoglobin on
6th June 2020 was 9.4 g%. As her symptoms persisted
she was referred to our centre, Kasturba Medical College Hospital,
Manipal, a tertiary care hospital.
She had an uneventful antenatal course prior to 13 weeks of gestation
and no risk factors were identified. On examination she was alert and
cooperative, heart rate 92 bpm and blood pressure 110/70 mmHg.
Cardiovascular and respiratory system examination were normal. Per
abdominal examination revealed abdominal distension, minimal tenderness,
no guarding or rigidity and uterus was not palpable. Per speculum
examination showed a posterior, long, closed cervix and no evidence of
bleeding or clots. Laboratory investigations showed hemoglobin of 8.9
g/dl and the coagulation profile, liver and renal function tests were
within normal limits. Admission β-HCG level was 60,614 mIU/ml.
Transvaginal sonography revealed an empty uterus measuring 7x4 cm, a
left adnexal mass of 7x7 cm and a collection in the Pouch of Douglas
measuring approximately 4x3x3 cm. There was evidence of hemoperitoneum
with fluid collections in the hepatorenal and splenorenal pouches. An
extrauterine live fetus was noted above the uterine fundus, more towards
the left side, corresponding to 11 weeks of gestation. There was no
communication demonstrable between the fetus/placenta and uterine
contour. The couple was counselled in detail about the abdominal
pregnancy, the need for surgical removal of the pregnancy and possible
complications. A multidisciplinary team including urologist, general and
vascular surgeons were on standby and adequate blood products were
arranged. After obtaining high risk consent, emergency laparotomy was
performed. Intraoperatively, hemoperitoneum was confirmed and a live
fetus was lying in the abdominal cavity above the uterine fundus towards
the left, just below the abdominal wall. A 500g clot was evacuated. The
umbilical cord was ligated and a fetus measuring 6.5x2x2 cm, weighing
approximately 20 g was removed (Figure 1). There was evidence of sealed
rupture on the left fallopian tube and left uterine cornu; and part of
placental tissue was attached to the site. Following a left
salpingectomy and uterine cornual repair the bleeding was controlled. On
further exploration, bulk of the placental tissue was found attached to
the small bowel mesentery and partly to the omentum. With intra
operative assistance from surgeons, bulk of the placental tissue was
separated. An on-table decision was taken to leave a very minimal amount
of placental tissue in situ (<1cm), which was firmly attached
to the vascular mesentery in order to avoid massive hemorrhage. Both
ovaries and the right fallopian tube appeared normal. Two
intra-abdominal drains were left in situ. The total intra operative
blood loss was 1370 ml. Intraoperatively she received 3 units of packed
red blood cells and 2 units of fresh frozen plasma. Immediate
post-operative period was uneventful. Fibrinogen levels and
thromboelastography evaluation were normal. She received broad spectrum
intravenous antibiotics. Postoperative Hb was 8 g/dl. Both
intraabdominal drainage tubes were removed on the 2ndpost- operative day. She recovered well and was discharged after
counselling regarding birth spacing and future pregnancies.
Review of literature on 314 abdominal pregnancies:
We performed a literature review of 314 abdominal pregnancies from
1930-2021 using electronic searches in MEDLINE, EMBASE, PubMed, Web of
Science and bibliographies of relevant articles. The review was limited
to human studies in English. Case reports, case series and systematic
reviews were included. Data recorded included site of the ectopic,
gestational age at diagnosis, surgical and/or medical management, blood
loss and transfusions, maternal morbidity and mortality and fetal
outcomes. Descriptive statistics are provided.