- Advanced Extrauterine Pregnancy at 33 Weeks with a Healthy Newborn
- What Is an Abdominal Pregnancy?
- Abdominal Pregnancy Dangers
- Abdominal Pregnancy Symptoms
- Abdominal Pregnancy Diagnosis
- Abdominal Pregnancy Treatment
- A live term intra-abdominal pregnancy in a Field Hospital: a case report
- CASE REPORT
- CONFLICT OF INTEREST STATEMENT
- 3. Comment
- Advanced abdominal pregnancy, with live fetus and severe preeclampsia, case report
Advanced Extrauterine Pregnancy at 33 Weeks with a Healthy Newborn
Abdominal pregnancy is a very rare form of ectopic pregnancy, associated with high morbidity and mortality for both fetus and mother. It is, and often, seen in poor resource nations, where early diagnosis is often a major challenge due to poor prenatal care and lack of medical resources. An advanced abdominal pregnancy with a good fetal and maternal outcome is therefore a more extraordinary occurrence in the modern developed world. We present a case of an abdominal pregnancy at 33.4 weeks in an individual with no documented prenatal care, who arrived in a hospital in the Bronx, in June 25th 2014, with symptoms of generalized, severe lower abdominal pain. Upon examination it was found that due to category III fetal tracing an emergent cesarean section was performed. At the time of laparotomy the fetus was located in the pelvis covered by the uterine serosa, with distortion of the entire right adnexa and invasion to the right parametrium. The placenta invaded the pouch of Douglas and the lower part of the sigmoid colon. A massive hemorrhage followed, followed by a supracervical hysterectomy. A viable infant was delivered and mother discharged on postoperative day 4.
Symptoms of an abdominal pregnancy are very nonspecific and often include abdominal pain, nausea, vomiting, palpable fetal parts, fetal mal presentation, pain on fetal movement, and displacement of the cervix.
With remarkable advances in radiographic technology an early discovery of an extrauterine pregnancy should be a practicable endeavor. This is particularly important in a community where there are an increased number of immigrants from low resource nations .
The prevalence of ectopic pregnancy is 1-2% with 95% occurring in the fallopian tube. The incidence of abdominal pregnancy ranges from 1 : 1000 to 1 : 30,000 depending on the community but is most commonly seen in developing nations of the world , which represent approximately 1–1.4% of all ectopic pregnancies alone . The first documented case of abdominal pregnancy was reported in the year 1708, followed by numerous case reports particularly from middle and low income regions of the world . Frequently, the diagnosis was made based on complications such as hemorrhage and abdominal pain at the time of laparotomy. Most often, the pregnancy did not survive and often resulted in extraction of the dead fetus with increased maternal mortality.
In the developed world, abdominal pregnancy is extremely rare and very few of such cases have been published in the last 10 years. It is unclear if abdominal pregnancy is a result of secondary implantation from an aborted tubal pregnancy or result of primary implantation from intra-abdominal fertilization. Associated risks for developing abdominal pregnancy are endometriosis, pelvic inflammatory disease, assisted reproductive techniques, tubal occlusion, and multiparity .
In view of rarity and lack of management guidelines of advanced abdominal pregnancy, we expose this case of abdominal pregnancy in order to present the symptoms associated that could lead to an early recognition and the successful management that resulted in a good maternal and fetal outcome.
2. Case Report
A 27-year-old G2P0010 at 33 weeks and 4 days by last menstrual period was brought in by Emergency System to the hospital on June 25th 2014, with complaints of severe abdominal pain of 1 hour duration. Patient was without medical or surgical history and had a termination of pregnancy before. Abdominal pain was generalized, 10 out of 10 in severity, and associated with vomiting. She denied any diarrhea, vaginal bleeding, or leakage of amniotic fluid. She had recently migrated from the Dominican Republic in May 2014 with no record of prenatal care.
On examination, patient was in visible pain with elevated blood pressure, maternal tachycardia, and bilious emesis. An abdominal examination revealed generalized tenderness with guarding and rebound and a fundal height of 34 cm. The fetal heart rate was category III with absent variability and repetitive late decelerations. A vaginal examination revealed a bulging pouch of Douglas with the presenting part deep in the pelvis: a short, firm, and closed cervix displaced anteriorly behind the pubic symphysis.
On the way to the operating room limited bed side sonogram revealed fetus in cephalic and a questionable placental location. A tentative diagnosis of uterine rupture versus concealed placental abruption was made proceeding with immediate abdominal delivery.
At the time of laparotomy, meconium stained amniotic fluid was seen upon entry to the peritoneal cavity. A fetus was located outside of the endometrial cavity covered only by the uterine serosa on the right side with a placenta attachment to the serosa of the uterus. The left ovary was unremarkable in appearance and an anatomical distortion of the right adnexa was appreciated. A large opening was noted on the posterior aspect of the serosa where the amniotic fluid was leaking.
An incision was made on the protruding serosa and a viable female infant was delivered via cephalic presentation with Apgar score of 9/9 at 1 and 5 minutes with weight of 2362 g. The uterus and placenta were exteriorized after delivery due to massive bleeding and distortion of the anatomy (Figure 1). On further inspection of the placenta, it was noted to invade the pouch of Douglas and lower part of the sigmoid colon and the right uterine serosa.
Figure 1 Representing placenta location and uterus after delivery of the baby, to note the size and the integrity of the uterus with a large placenta in the abdominal cavity.
A massive hemorrhage protocol was initiated and an emergency back-up team was called. A general surgical consult was requested due to involvement of bowel. The decision was made to proceed on hysterectomy and removal of the placenta tissue due to continuous bleeding. The patient underwent supracervical hysterectomy and excision of the placenta tissue occupying the right side of the pelvic floor. Adhesiolysis from the sigmoid colon was performed by surgery with minimal damage to the serosa.
Intraoperatively, the patient received 6 units of packed red blood cells, 4 units of fresh frozen plasma, and one unit of platelets. Estimated blood loss was 3000 mL. The patient was then transferred to the ICU for further observation and extubated the following morning.
She was discharged home with the baby on day 4 after surgery. There was no evidence of anomaly documented in the baby. Mother and baby are doing well and currently being followed up closely.
A pathology report revealed that placenta with a segment of trivessel umbilical cord marked old infarct at fetal and maternal surfaces. Attached to the maternal surfaces are fibrous tissues with smooth muscle and dilated vessels. Focal endovasculopathy with luminal occlusion, focal amnion with squamous metaplasia with an attached stretched ovary and fragment of mostly chorionic villi.
The uterus was described as intact and weighed 300 g measuring 9.5 cm in length, 11 cm from cornua to cornua and 6 cm anterior posterior diameter with thick endometrial, decidual changes and focal autolysis, no chorionic villi or trophoblast are seen in the endometrium.
Primary abdominal pregnancy refers to an extrauterine pregnancy where implantation of fertilized ovum occurs directly in the abdominal cavity while the secondary abdominal pregnancy is a tubal pregnancy that ruptures with reimplantation within the abdominal cavity usually resulting in tubal or ovarian damage .
In this report, the findings of recurrent pain throughout pregnancy especially during fetal movement, signs of peritonitis on day of presentation with free fluid in the abdomen, and findings of intraoperative distortion of the right ovary and fallopian tube are more indicative of a ruptured tubal pregnancy with a secondary implantation on the serosa and the right broad ligament. Nunyaluendo and Einterz , in a recent review of 163 cases of abdominal pregnancy, revealed that identification of this condition is often missed with only 45% cases diagnosed during the prenatal period. In this case, patient did not have any prenatal care and had history of intermittent pain throughout the pregnancy. Another factor to consider is the fact that she had a previous termination of pregnancy in the first trimester via suction curettage previously to this pregnancy in 2012 that could cause a defect in the uterus.
Interestingly, the most common symptoms in abdominal pregnancy are abdominal pain 100%, nausea and vomiting 70%, and general malaise 40% . Our patient had sudden severe abdominal pain with vomiting one hour prior to presentation to the hospital. A high index of suspicion for possible rupture of uterus versus abdominal pregnancy should be always considered when the fetal parts are easily palpated on abdominal examination and signs and symptoms of an acute abdomen. However a vaginal examination revealed fetal head bulging through the pouch of Douglas displacing the cervix into the retropubic space as described before is a concerning finding.
An abdominal pregnancy is often associated with fetal deformities , such as facial and cranial asymmetry, joint abnormalities and limb deformity, and central nervous deformities in about 21% of cases. In our case, there was no evidence of deformity or abnormalities as per the team of pediatricians.
Bleeding from placental implantation site could be massive and life threatening and is often the most common cause of maternal mortality which can reach as high as 20–30%. The decision to remove or leave the placenta should depend on extent of the placentation particularly with the bowel and omental involvement as well as on the expertise of the surgeon. Because of increased postoperative morbidity and mortality, it is not advisable to leave the placenta in situ . In this case, because of the involvement of the broad ligament on the right side with distortion of the ovary and tube on the same side and extension of part of the placenta to small portion of the sigmoid colon posteriorly the decision was made intraoperatively for a supracervical hysterectomy to obtain adequate hemostasis. In our case massive transfusion protocol was applied as per hospital protocol .
A high index of suspicion and recognition of signs and symptoms are therefore detrimental to diagnosis and guide to a prompt surgical emergency. In patients with acute symptoms and lack of prenatal care, abdominal pregnancy should always be a differential.
Prompt delivery of the fetus, followed by and control of hemorrhage and decision of placenta removal are the greatest challenges. Adequate personnel including anesthesia, pediatricians, and general surgeons may be necessary for a successful management.
Conflict of Interests
The authors declare that there is no conflict of interests regarding the publication of this paper.
What Is an Abdominal Pregnancy?
Abdominal pregnancy is extremely rare, but poses significant health risks when it occurs.
An abdominal pregnancy occurs when a fertilized egg implants on an organ or tissues in a woman’s abdomen.
In the United States, one to two percent of pregnancies are ectopic pregnancies, caused when the fertilized egg implants somewhere other than the uterus.
Of those, about 1.4 percent are abdominal pregnancies. (In most other ectopic pregnancies, the fertilized egg implants in a fallopian tube.)
Abdominal Pregnancy Dangers
Abdominal pregnancies are dangerous for both the mother and the fetus.
For the mother, the danger is heavy internal bleeding if the placenta detaches from the abdominal organ or tissue to which it is attached.
For the fetus, the dangers include not receiving adequate blood and nutrients to support healthy growth, and not being protected by the amniotic sac and fluid (as would normally happen in the uterus).
Those fetuses that do survive an abdominal pregnancy often have malformations.
Abdominal Pregnancy Symptoms
A woman with an abdominal pregnancy may initially have the same signs and symptoms as those of a normal pregnancy:
- Missed period
- Nausea and occasional vomiting
- Breast tenderness
However, she may also have abdominal pain and/or vaginal bleeding, which should be checked out by a doctor.
Abdominal Pregnancy Diagnosis
Many abdominal pregnancies are missed or go undiagnosed until a late stage.
A doctor may suspect an abdominal pregnancy if a woman reports abdominal pain or pain with the fetus’s movements, or if the growing fetus does not seem to be in the right place in the mother’s body.
Blood tests that measure human chorionic gonadotropin (hCG) levels can also indicate a problem if levels of the hormone are not rising normally as the pregnancy progresses.
Usually, ultrasound is used to diagnose abdominal pregnancy. Ultrasound uses sound waves to create images of internal structures.
Ultrasound is used to confirm the location of the gestational sac.
In some cases laparoscopy — the insertion of a very small viewing instrument into the abdomen — is used to confirm the diagnosis.
Abdominal Pregnancy Treatment
In very rare cases, an abdominal pregnancy has resulted in a live birth. Most abdominal pregnancies, however, are terminated medically or surgically.
If caught early, an abdominal pregnancy may be ended with a dose of methotrexate (Trexall), a drug that stops cells from dividing and is toxic to the placenta.
When an abdominal pregnancy is ended surgically, the surgeon must take steps to prevent heavy bleeding at the place of implantation.
In some cases, the placenta is left in the woman’s body and treated with methotrexate to prevent such bleeding and allow the body to reabsorb the placenta.
A high index of suspicion is needed to make a first time diagnosis of abdominal pregnancy3. Diagnosis is missed in one-fourth of reported cases4.
The reported incidence of abdominal pregnancy varies widely with geographical location ranging between 1: 10,000 deliveries in the USA5,6 and 1:654 deliveries in Ibadan-Nigeria2. Multiparity and poor socio-economic status are implicated as epidemiological factors7.
Clinical presentation can be variable with abdominal pain occurring at 16-17 weeks gestation8,9 as was observed in our patient. The finding of clinical jaundice and severe anaemia as part of presentation in our patient was unusual. Jaundice associated with pregnancy has been described by Holzbach10 in three disease entities which include: 1) recurrent cholestasis of pregnancy (RCP); 2) viral hepatitis coincident with pregnancy; 3) acute fatty liver of pregnancy (AFLP). Although our patient was not screened for Hepatitis B surface antigen (HBs Ag), the finding of blood elements in her urine against a background of normal liver enzymes suggested that her jaundice was due to a haemolytic crises probably caused by ingestion of herbal concoctions.
The diagnosis of early abdominal pregnancy is by β-hCG estimation and Ultrasonography. In the case of our patient, Ultrasonography was the single stand-alone test used to diagnose abdominal pregnancy.
Allibone GW et al 11 described major criteria for sonographic diagnosis of intra-abdominal pregnancy. These include:
1) demonstration of foetus in a gestational sac outside the uterus, or the depiction of an abdominal or pelvic mass identifiable as the uterus separate from the foetus; 2) failure to see a uterine wall between the foetus and the urinary bladder; 3) recognition of a close approximation of the foetus to the maternal abdominal wall; and 4) localization of the placenta outside the confines of the uterine cavity. All of these features were recognized in our patient. More recent literature listed other additional criteria such as oligohydramnios, abnormal foetal lie, placenta previa appearance and maternal bowel gas impeding foetal visualization4. Magnetic resonance imaging (MRI T2-WI), or colour Doppler Ultrasound could be used to localize the placenta8,12. Where resources abound placental localization by Magnetic resonance imaging offers the best method of diagnosis. In our case, colour Doppler Ultrasound was used with accuracy. Evaluation of gross foetal morphology can be further assisted by use of 3-D Ultrasonography where this is available. The outlook for the foetus in abdominal pregnancy is poor13. The perinatal mortality varies from 85 to 95%14, and the rate of foetal deformation is reported to range from 20 to 90%15,16. The most common deformations and malformations were observed in the exposed areas of the foetus such as the head and the extremities16. The intraoperative finding of a missing left lower limb from the foetus in this case was not suggested by earlier ultrasound images where cine-recordings depicted active movement of both lower extremities. The final Ultrasound scan at 20 weeks gestational age when foetal demise was detected revealed only one lower limb in extended fixed position. Cathy A. Stevens15 proposed two etiological mechanisms for the foetal limb defects in abdominal pregnancy. These mechanisms which are extrinsic compression and vascular disruption may have resulted in foetal auto-amputation in this case.
Current concepts on management of abdominal pregnancy support immediate active surgical intervention with termination of the pregnancy if diagnosed before 24 weeks gestation5,17,18. In patients who present after 24 weeks, the appropriateness of conservative management5 is debatable. There is need to assess each individual case and adopt the most appropriate method with a view to limiting materno-foetal morbidity and mortality. A conservative approach requires close surveillance of the patient and regular monitoring using Ultrasonography. The patient should be admitted into hospital where blood bank facilities and resources needed for rapid surgical intervention are obtainable. Intra-operative management of the placenta poses another dilemma for the clinician. Although removal of the placenta offers a better prognosis2, this should not be attempted if there is any risk of massive haemorrhage with a fatal outcome. Placentas left in-situ usually regress gradually and are monitored with serial serum β-hCG estimation and Ultrasonography. The prophylactic use of methotrexate in placenta management is no longer advocated by some clinicians19. In their view, the necrosed placental tissue is a potent culture medium with increased risk of serious intraperitoneal infection.
A pregnant woman with a stomach ache turned out to have a serious pregnancy complication that was missed during her previous ultrasound exams: The woman’s 32-week-old fetus was growing within her abdomen, outside her uterus, according to a new report of her case.
When doctors examined the woman further and discovered the abdominal pregnancy, they quickly operated on the woman’s abdomen and found her live fetus floating in her abdominal cavity, without its nourishing amniotic sac. The healthy baby girl was delivered and sent home with her 22-year-old mother in good condition, researchers in Tanzania said.
Abdominal pregnancies are rare, and when they do happen, they can go unnoticed even if ultrasounds are used, because the pregnancy can appear normal in an ultrasound examination, the researchers wrote in the report, published Feb. 25 in the journal BioMed Central. An abdominal pregnancy that goes unnoticed can threaten the mother’s life and cause massive bleeding.
“I’ve seen maybe four or five abdominal pregnancies over the course of 25 years,” said Dr. Jill Rabin, chief of ambulatory care, obstetrics and gynecology at Long Island Jewish Medical Center in New Hyde Park, N.Y., who wasn’t involved with the case.
“Many times, these pregnancies are not diagnosed until the labor,” Rabin said. “The woman is going through labor, the cervix is dilated and you are wondering, ‘Why is the patient having contractions and nothing is happening?'”
Abdominal pregnancy is a rare form of ectopic pregnancy, occurring in about 1 out of every 10,000 pregnancies, according to some estimates. In an abdominal pregnancy, an embryo usually first implants in one of the fallopian tubes (instead of the uterus), and then moves backward within the body, toward the ovaries. From there, it implants for the second time — this time, in the abdomen.
Diagnosing an abdominal pregnancy is difficult, Rabin said. “It’s very rare, but you have to keep it in your mind when examining a pregnant woman who has abdominal pain.”
Other symptoms include painful fetal movements, and gastrointestinal problems. Also, if it’s too easy to feel the baby, or see it with an ultrasound, that might be a sign that the baby is outside the uterus, Rabin said.
If doctors find that a fetus is growing outside the uterus, they make an incision in the pregnant woman’s abdomen, to deliver the baby. The placenta is often left to be absorbed by the body, because removing the placenta can cause severe bleeding. “The patient has to be followed very, very closely to be sure that the placenta is reabsorbed; it takes a couple of months,” Rabin said.
Most of the babies that Rabin has seen in abdominal pregnancies were healthy, she told Live Science.
“The placenta is attached to something vascular, so the baby is getting fed from the mother’s blood supply, just not in the way that we would like, so many of these babies are very small,” Rabin said.
If an abdominal pregnancy is detected in the first trimester, doctors usually remove the embryo. However, most cases are not diagnosed until later on in the pregnancy. “If it’s diagnosed in the second trimester, you watch the mother very carefully, but every case is different,” Rabin said.
Email Bahar Gholipour. Follow us @LiveScience, Facebook & Google+. Original article on Live Science.
A live term intra-abdominal pregnancy in a Field Hospital: a case report
Abdominal pregnancy is a rare form of ectopic pregnancy with high morbidity and mortality for both the mother and the fetus. Diagnosis can be challenging, especially in a resource-limited setting. We report a case of abdominal pregnancy that presented to Médecins Sans Frontières field hospital in Agok, South Sudan, with abdominal pain. Examination revealed a term pregnancy and a live fetus in transverse lie. The diagnosis of abdominal pregnancy was made intraoperatively, with successful management and delivery of a healthy baby.
Abdominal pregnancy is a rare form of ectopic pregnancy with high morbidity and mortality for both the mother and the fetus. Ectopic pregnancy represents about 1–2% of all pregnancies, with 95% of those occurring in the fallopian tubes . The incidence of abdominal pregnancy varies in different populations, ranging from 1:10 000 to 1:30 000 pregnancies, and being most prevalent in developing countries with limited resources and limited diagnostic facilities .
The diagnosis of abdominal pregnancy can be challenging, especially in a resource-limited setting. When discovered early, laparotomy is usually done due to the high risk it carries to the mother. An abdominal pregnancy that reaches term with a healthy mother and fetus, thus, is a rare occasion.
A 25-year-old G2P0, presented to the maternity department in MSF Agok hospital in South Sudan, on 14th of October 2016 with abdominal pain. She had not sought medical advice or antenatal care prior to this visit. Her pregnancy was estimated to be 34–35 weeks, as she did not know the exact date of her last menstrual cycle. She had been having progressive abdominal pain for 2 days. The pain was generalized and increased with movement. She had a previous miscarriage, and was concerned about this pregnancy.
On examination, the abdomen was mildly tender, and the fetal head could be easily palpated at the right upper quadrant. The patient had a normal blood pressure, with mild tachycardia at 100 bpm. Her haemoglobin level was 10 g/dl. Ultrasound scan was performed, which confirmed a live term fetus, in transverse lie, with no indication of extra-uterine pregnancy. Caesarean section was planned in view of the transverse lie.
A Pfannenstiel (transverse lower abdominal) incision was used. A normal non-pregnant uterus was found, with the placenta attached to the fundus. The incision was extended to an inverted-T incision. A full term, live female fetus was delivered. There was active bleeding from the placenta, which was attached to the fundus and left cornual region of the uterus, the small bowel mesentery and the left lateral abdominal wall. Partial removal of the placenta was carried out to control the bleeding. Further inspection of the uterus revealed no evidence of perforation. Left ovary was found to be normal, but the left Fallopian tube could not be discerned. The right side ovary and tube were normal.
Postoperatively, the patient had to be transfused due to intraoperative blood loss. She was started on antibiotic therapy. The baby was well, weighing 2.5 kg, and showing no obvious external congenital abnormalities. Both the mother and the baby were kept in the hospital for 2 weeks postoperatively, during which the mother recovered well from surgery, with no signs of infection or bleeding. They were discharged home, with a follow-up appointment in one month. The mother and child have been on regular follow up. The child has shown normal developmental milestones till date (6 weeks after birth).
Primary abdominal pregnancy refers to an extra-uterine pregnancy where implantation of a fertilized ovum occurs directly in the abdominal cavity while the secondary abdominal pregnancy is a tubal pregnancy that ruptures with reimplantation within the abdominal cavity usually resulting in tubal or ovarian damage . Our patient most likely had a secondary abdominal pregnancy, as the left sided Fallopian tube could not be identified intraoperatively.
A patient usually presents with signs of intra-abdominal bleeding due to separation of the placenta. Abdominal pain, painful fetal movements, abnormal presentation and uneffaced cervix should arouse suspicion of ectopic pregnancy, especially abdominal pregnancy.
Ultrasonography findings of intra-abdominal, extra-uterine fetus and placenta confirms the diagnosis. But even with routine ultrasonography examination, the diagnosis can be missed, especially in the later stages of pregnancy . In a limited-resource setting, such as a field hospital in South Sudan, the diagnosis can be made intraoperatively.
Optimal management requires careful evaluation and planning. Generally speaking, for previable abdominal pregnancies, i.e. prior to 24 week of gestation, immediate operative intervention is indicated, but for viable pregnancies presenting after 24 weeks of gestation, a more conservative approach is advocated, provided the patient can be under strict observation, preferably in a hospital .
Bleeding from the placental implantation site is the most serious and life-threatening complication of abdominal pregnancy. Usually complete removal of the placenta is not advised, and partial removal is only advised to control bleeding. Otherwise, it should be left in situ and is removed by involution and resorption. This is usually monitored by measuring the serum human chorionic gonadotropin levels on follow up . In this case, clinical examination and monitoring of the haemoglobin level were the only means available for monitoring the patient.
For the newborn, congenital malformations are common, with reports of fetal malformations as high as 40%, with only 50% of these babies surviving the first week of life . No investigations were possible in our case. The baby showed normal morphological appearance and reflexes on examination.
The authors would like to acknowledge the effort and support provided by MSF, both in the field and elsewhere.
CONFLICT OF INTEREST STATEMENT
1 Nwobodo EI . Abdominal pregnancy: a case report. Ann Afr Med 2004;3:195–6. 2 Badria L , Amarin Z , Jaradat A , Zahawi H , Gharaibeh A , Zobi A . Full-term viable abdominal pregnancy: a case report and review. Arch Gynaecol Obstet 2003;268:340–2. 3 Varma R , Mascarenhas L , James D . Successful outcome of advanced abdominal pregnancy with exclusive omental insertion. Ultrasound Obstet Gynecol 2003;21:192–4. 4 White RG . Advanced abdominal pregnancy: a review of 23 cases. Iran J Med Sci 1989;158:77–8. 5 Jianping Z , Fen L , Qiu S . Full-term abdominal pregnancy: a case report and review of the literature. Gynecol Obstet Invest 2008;65:139–41. 6 Teng H , Kumar G , Ramli N . A viable secondary intra-abdominal pregnancy resulting from rupture of uterine scar: role of MRI. Br J Radiol 2007;80:134–6. Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2017. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact [email protected]
Because the symptoms of ectopic pregnancy can be mimicked by common immediate complications after hysterectomy, such as protracted abdominal pain, pelvic hematoma formation, vaginal cuff infection, and vaginal bleeding, ectopic pregnancy is rarely expected in most cases until additional imaging or repeat operation confirms the diagnosis , , , , , . Therefore, the prevention of “early presentation” ectopic pregnancy after hysterectomy is the prevention of pregnancy before hysterectomy. As previously recommended, hysterectomy, like tubal sterilization, should be avoided in the luteal phase of the menstrual cycle in those women not previously sterilized or not using reliable contraception, unless no vaginal intercourse has occurred during the preoperative period. Women should be preoperatively counseled as such. Any woman who has undergone hysterectomy and had not previously undergone tubal sterilization or had a partner vasectomy, or was not using reliable contemporaneous contraception, should be considered at risk for this diagnosis, should otherwise unexplained postoperative pain or bleeding occurs.
Interestingly, no additional early post-hysterectomy pregnancies have been reported since this author’s 2009 report.
The usual method of vaginal cuff closure differs between vaginal hysterectomy and abdominal hysterectomy. The adnexal structures are brought into closer proximity of the vaginal cuff with vaginal hysterectomy cuff closure, and can even be incorporated into the peritoneal closure, increasing the change for a prolapsed fallopian tube into the vaginal cuff or the development of a vaginal-to-peritoneal or tubo-vaginal fistula , . “Late presentation” ectopic pregnancies after total abdominal hysterectomy have been reported, indicating that vaginal-to-peritoneal fistula can even develop after this procedure. However, the small number of such cases would suggest that it is less likely to occur, presumably because the residual fallopian tubes and ovaries are more distant from the vaginal cuff during abdominal hysterectomy cuff closure, and the commonly used technique of closure of the pelvic floor parietal peritoneum over the vaginal cuff isolates the vagina from the peritoneal cavity . These numbers of ectopic pregnancies and the hysterectomy method differences are suggestive that the risk would be greater after vaginal hysterectomy, but this is not based on any proven medical evidence.
Subtotal hysterectomy has increased in the United States in the past decade, estimated to now make up 7.5% of all hysterectomies performed , , . Fourteen cases of “late presentation” ectopic pregnancy have followed supracervical or cesarean hysterectomy, including the current case , , , , , , , , , , , . Leaving a remnant of the cervix or the epithelialization of a much larger vaginal cuff closure area because of cervical dilation at the time of cesarean hysterectomy may increase fistulous tract formation , . With the now more commonly performed laparoscopic supracervical hysterectomy, this author and other investigators are concerned about a potential increase in the incidence of ectopic pregnancy after hysterectomy. The commonly used technique of cauterizing the residual proximal cervical canal to prevent cyclic vaginal bleeding after hysterectomy at the time of laparoscopic supracervical hysterectomy may not be adequate to prevent patency of the cervical canal. Pathologic identification of such a communication through a residual cervix has been documented . Cautery of the cervical canal and cervical stump at the time of laparoscopic supracervical hysterectomy has also failed to prevent a patent cervical canal and an ectopic pregnancy after hysterectomy .
It may not be possible to prevent all “late presentation” ectopic pregnancies after hysterectomy, but its prevention is the prevention of vaginal-to-peritoneal cavity communication. Vaginal cuff closure, regardless of operative technique, should be sure not to incorporate the fallopian tube into the vaginal cuff, and postoperative vaginal cuff granulation tissue, a very common finding, must be differentiated from a portion of prolapsed fallopian tube, with biopsy, if necessary . When the cervix is left in situ, techniques should be used to obliterate or isolate the residual cervical canal, thus preventing a patent cervical canal allowing the sperm access to the peritoneal cavity.
Ectopic pregnancy after hysterectomy is very rare. An estimated 600,000 hysterectomies are performed each year in the United States, and one-third of all US women will have had a hysterectomy by age 60 years , , . Only 72 cases of ectopic pregnancy after hysterectomy have now been reported in the world’s literature since 1895. This incidence is very small, but may be on the increase because of supracervical hysterectomy. This author recommends that any woman, even after hysterectomy but with ovaries in situ, who presents with an acute abdomen or abdominal–pelvic pain should be screened for pregnancy. A urine pregnancy test is readily available and inexpensive, and although ectopic pregnancy after hysterectomy has been very uncommon until now, only a high index of suspicion will make the diagnosis.
Advanced abdominal pregnancy, with live fetus and severe preeclampsia, case report
An abdominal pregnancy is a rare type of ectopic pregnancy, which may account for about 1% of all ectopic pregnancies . It is associated with high maternal and perinatal mortality. A review of literatures from 2008 to 2013 showed that 38 cases of an AAP resulting in a live birth were identified from 16 countries .
Abdominal pregnancy could be either primary or secondary . The latter is the commonest type. To consider abdominal pregnancy as primary, the pregnancy must meet the three criteria . The first is both tubes and ovaries must be in normal condition with no evidence of recent or remote injury . The second is no evidence of utero-peritoneal fistula should be found . The third is pregnancy must be related exclusively to the peritoneal surface and be early enough to eliminate the possibility that it is a secondary implantation following a primary implantation in the tube . In our case both the ovaries and tubes were normal in appearance and we didn’t identify any utero-peritoneal fistula. But the third criterion is not clearly met. In the case of primary abdominal pregnancy placenta sits on the intraabdominal organs generally the bowel, mesentery, or the peritoneum . So we assume that it may be a case of secondary abdominal pregnancy.
Commonly abdominal pregnancy is easily missed and diagnosed after substantial emergency bleeding. This may be caused by less vascularized placenta, a weak gestational sac, and the lack of protection of the myometrium . There are no widely accepted diagnostic criteria for abdominal pregnancies and the current diagnostic criteria for primary abdominal pregnancy are based on Studdiford standards . Patients with abdominal pregnancy typically have persistent abdominal and/or gastrointestinal symptoms during their pregnancy . This is also true in our case.
Abdominal pregnancy often leads to early spontaneous separation of the placenta from implantation site, causing abdominal bleeding. In rare cases, the pregnancy can develop to late stages like in our case . Ultrasonography remains the main method for the diagnosis of extra uterine pregnancy. It usually shows no uterine wall surrounding the fetus, fetal parts close to the abdominal wall, abnormal lie and/or no amniotic fluid between the placenta and the fetus . In our case, bicornuate uterus with intrauterine pregnancy was considered on ultrasound examination. This may be due to the implantation of the placenta on the posterior aspect of the empty uterus and recognized as sharing the myometrium.
Intrauterine growth restriction is common in advanced abdominal pregnancies in our case; the newborn was only 1.8 kg at 37 weeks of gestation and the FL to AC ratio was 24.2. These two evidences showed us the newborn had intrauterine growth restriction . Intrauterine growth restriction may also be caused by the severe preeclampsia.
Advanced abdominal pregnancy with sever preeclampsia is reported rarely . This may be due to under reporting or due to the rare nature of advanced abdominal pregnancy by itself . Various theories have been forwarded to explain pre-eclampsia/eclampsia but basic to its occurrence is the presence of placental tissue in the maternal body and it is postulated that poor placentation resulting from inappropriate uterine spiral artery invasion may be the primary pathology . This may explain the occurrence of severe pre-eclampsia in our case. It is very difficult to find causal relationship between the two conditions but from this case we can clearly understand the role of the endometrial cavity in development of preeclampsia may be not significant .
The most important issue in managing advanced abdominal pregnancy is the placental management. The massive hemorrhage that often occurs with surgery is related to the lack of constriction of the blood vessels after placental separation . The parietal peritoneum, mesentery and bowel are the usual sites where the placenta attached firmly, and there is no bleeding if it is left untouched . In such cases the umbilical cord should be ligated close to the placenta, excess membranes trimmed off and the abdomen closed with drainage . Sometimes, the placenta may separate spontaneously simulating an abruption, but the conditions in which hemorrhage becomes uncontrollable is more likely to arise from failed attempts at placental removal . Placental separation is not always straightforward and it may fail in up to 40% of cases . The hemorrhage from the placental separation may be torrential and rapid surgical action is necessary to salvage the woman’s life . Various local techniques can be used to stop bleeding in such cases. This may include, compression of the bleeding site, ligating the vascular pedicles, lavage with cold saline and local and/or systemic coagulation promoting agents (tranexamic acid, plasminogen derivatives, absorbable gelatin sponge, etc.) . Repair of placental lacerations may need to be performed . The removal of the organ to which the placenta is adherent (hysterectomy and/or salpingoophrectomy, resection of the bowel and/or bladder) maybe justified to control the hemorrhage . Abdominal packing has been used effectively for uncontrolled hemorrhage following caesarean hysterectomy for morbidly adherent placenta, massive hemorrhage during gynecological cancer surgery and for post-partum hemorrhage . However, we found only a single case report wherein it has been used to control hemorrhage in secondary abdominal pregnancy. As a last resort, the abdomen may be packed tight with abdominal packs and closed partially. The packs can be removed after 48 h or sooner if directed by hemodynamic instability . Alternative options for placental management includes methotrexate therapy and uterine artery embolization. Arterial embolization performed pre-operatively minimizes blood loss . Placental vascular embolization facilitates resorption of a placenta that is left in situ .
The only two options that can be performed in our case were either to leave the placenta in place and use methotrexate or remove it and control the hemorrhage. we preferred to remove the placenta considering its favorable location (the posterior aspect of the uterus and right broad ligament, no attachments to bowel or momentum). By removing the placenta we also can avoid the potential risks of infection and spontaneous separation . After we removed the placenta hemostatic sutures were taken to control bleeding from posterior surface of the broad ligament. However, bleeding from the posterior aspect of uterine serosa continued and we decided to pack the area. We used membrane remnants and broad ligament to keep the pack in place. We controlled the bleeding with the above technique and the patient left operation room with stable condition.
After 24 h we removed the packs. There were no surface bleeders or heamoperitoneum. The membrane remnants trimmed off and abdomen closed. The decision whether to remove the placenta or leave it in situ should therefore be individualized following careful assessment of the implantation site . Our case showed that abdominal packing is effective in selected cases.
Abdominal pregnancy with live fetus is an extremely rare condition and requires a high index of suspicion. The life-threatening complication of AAP is bleeding from the detached placental site. Endometrial cavity may not be required for development of sever preeclampsia and packing is effective in controlling bleeding in selected cases.