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CASE REPORT
Year : 2021  |  Volume : 19  |  Issue : 2  |  Page : 122-125

Advanced primary abdominal pregnancy – A case series based on single-center experience from a rural secondary level hospital in Northeast India


1 Department of Obstetrics and Gynaecology, Makunda Christian Leprosy and General Hospital, Karimganj, Assam, India
2 Department of General Surgery and Pediatric Surgery, Makunda Christian Leprosy and General Hospital, Karimganj, Assam, India
3 Department of Anaesthesia, Makunda Christian Leprosy and General Hospital, Karimganj, Assam, India

Date of Submission11-Dec-2020
Date of Decision11-Jan-2021
Date of Acceptance20-Jan-2021
Date of Web Publication15-Apr-2021

Correspondence Address:
Dr. V Carolin Solomi
Department of Obstetrics and Gynaecology, Makunda Christian Leprosy and General Hospital, Bazaricherra, Karimganj, Assam
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_154_20

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  Abstract 


Five patients with advanced primary abdominal pregnancy presented to our center between 2010 and 2020. The clinical profile, presentation, and management of these patients are described with a discussion on this rare but important condition. Of the five, four women survived. There was preoperative fetal demise in four of them, and one patient had a healthy live term baby. Advanced primary abdominal pregnancy, although very rare, is a life-threatening variation of ectopic gestation. Correct diagnosis is often a serious obstetric dilemma and the condition is associated with a 90-fold increase in maternal mortality rate and fetal survival is exceedingly rare. The clinical symptoms by which patients present are similar to other ectopic pregnancies like tubal ectopics. However, in our subset of patients, all were in their third trimester and four out of five presented in shock. Hence, a high degree of clinical suspicion for abdominal pregnancy is required to clinch a correct diagnosis. Often, the diagnosis of abdominal pregnancy is made only during laparotomy. Preoperative ultrasound has 50% accuracy in diagnosing this condition. Magnetic resonance imaging is considered gold standard for the diagnosis of abdominal pregnancies. Medical management with methotrexate is opted when the site of abdominal pregnancy is in the liver and spleen where life-threatening hemorrhage is expected. Surgical management is considered in patients with severe intraperitoneal hemorrhage and in second- and third-trimester abdominal pregnancies. Early diagnosis and proper surgical management irrespective of the stage of gestation is important for achieving good outcome.

Keywords: Advanced primary abdominal pregnancy, ectopic gestation, ectopic pregnanc, pregnancy


How to cite this article:
Solomi V C, Ismavel VA, Miriam A. Advanced primary abdominal pregnancy – A case series based on single-center experience from a rural secondary level hospital in Northeast India. Curr Med Issues 2021;19:122-5

How to cite this URL:
Solomi V C, Ismavel VA, Miriam A. Advanced primary abdominal pregnancy – A case series based on single-center experience from a rural secondary level hospital in Northeast India. Curr Med Issues [serial online] 2021 [cited 2021 Jun 19];19:122-5. Available from: https://www.cmijournal.org/text.asp?2021/19/2/122/313815




  Introduction Top


About 1.4% of ectopic pregnancies are abdominal (1 in 3000–10,000 deliveries).[1] Abdominal pregnancy is a rare form of extrauterine pregnancy where the implantation of fertilized ovum occurs inside the peritoneal cavity but outside the uterus, fallopian tubes, and broad ligament. In abdominal pregnancies, the key factor is that the pregnancy will not be supported by endometrium; instead, the placenta gets attached to peritoneum, bowel, omentum, or uterine serosa and nourishes the fetus. The reported implantation sites of abdominal pregnancies include uterine serosa, pouch of Douglas, liver, spleen, omentum, mesentery, peritoneum of pelvic and abdominal wall, and Gerota's fascia of kidney.

Abdominal pregnancy can be primary or secondary based on the site of implantation. A primary abdominal pregnancy develops “de novo” in the peritoneal cavity. These are very rare, and 38 cases of primary advanced abdominal pregnancies with live babies have been reported till 2017.[2],[3] Secondary abdominal pregnancies are relatively common and usually follow uterine surgeries, dilation and curettage, a history of tubal or uterine horn pregnancies, or after artificial insemination. The global incidence of abdominal pregnancy is 1/10,000 deliveries, although there is increased incidence in some areas (1/2256 in sub-Saharan Africa).[4] This higher incidence in low-resource settings is attributed to increased incidence of pelvic inflammatory disease. Abdominal pregnancy has a high incidence of perinatal morbidity and mortality, the reported maternal mortality being 0.5%–18% and perinatal mortality rate 45%.[5]


  Materials and Methods Top


This case series is from a secondary level charitable hospital located in rural Northeast India. This 190-bedded hospital which is focused on poor patients saw 126,382 outpatients, admitted 15,297 inpatients, performed 8710 surgeries, and conducted 6750 deliveries in 2019–2020. Since it is the only reliable referral center for a large area, many rare conditions are seen.[6],[7] All deliveries between 2010 and 2020 were included. The details of patients with advanced primary abdominal pregnancies were taken from their hospital records after getting informed written consent, and the data are anonymized.


  Results Top


We had five patients with advanced primary abdominal pregnancy, with an inhospital incidence of 0.09/1000 pregnancies in our study population. The total number of deliveries during the study period was 54,013. All patients were multigravidae with gestational age at presentation ranging from 28 to 40 weeks. The mean gestational age at presentation was 31+2 weeks, while the mean age was 28 years. None of them had any risk factors for abdominal pregnancy except one patient who had tubal ligation. The most common presentation among our patients was acute abdomen in shock.[8] One patient was admitted for safe confinement at 40 weeks. The clinical details, management, and outcome are described in [Table 1].
Table 1: Clinical, investigational, operative, and recovery data of study patients

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All the five patients had signs of peritonitis and were severely anemic. Four patients were diagnosed preoperatively as probable abdominal pregnancy by ultrasound. None of them had any uterine stimulation methods. All five patients had emergency total abdominal hysterectomy with unilateral/bilateral salphingoopherectomy. One patient underwent partial cystectomy, ileal resection, and anastomosis as the bowel loops and bladder were attached to the sac, as shown in [Figure 1]. All patients required blood transfusion. [Figure 2] shows Intra-operative picture showing the delivery of a term live baby from the extra-uterine gestational sac. None of them had major postoperative complications. Of the five patients, four women survived while one woman succumbed due to nonavailability of adequate Rh-negative blood. One mother had a healthy term baby while the other four had fetal demise.
Figure 1: Sac on the left above uterus. Bowel loops attached to the top of the sac. Artery forceps in the uterine cavity.

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Figure 2: Intraoperative picture showing the delivery of a term live baby from the extrauterine gestational sac.

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  Discussion Top


Abdominal pregnancies can be classified as early (<20 weeks' gestation) and advanced (beyond 20 weeks' gestation). Abdominal pregnancies that survive beyond 20 weeks are rare and are referred as “miracle babies.”[9]

Studdiford's criteria remain the standard definition in diagnosing primary abdominal pregnancy:[10]

  1. Normal tubes and ovaries
  2. Absence of uteroplacental fistula
  3. Pregnancy attached exclusively to peritoneal surface in the early gestation itself so that the possibility of secondary implantation after a primary nidation elsewhere can be eliminated.


Women with abdominal pregnancies usually present with GI symptoms, painful fetal movements, abnormal presentations, vaginal bleeding, and syncope. In our series, most of them presented in shock. Another important clinical presentation is the lack of myometrial response to oxytocin stimulation. The absence of uterine contractions after parenteral oxytocin or prostaglandin suggests the possibility of abdominal pregnancy. None of the patients in our series had termination attempted via oxytocin or prostaglandins.

Abdominal pregnancies are diagnosed by ultrasound. Most cases of abdominal pregnancies are missed during routine ultrasound scan unless there is a high index of suspicion. The classical finding in abdominal pregnancy is the absence of myometrial tissue between the maternal bladder and the pregnancy and an empty separate uterine cavity. When there are fetal malpresentations, careful study of the spatial relationship of the fetus with the placenta and uterus should be done to confirm whether the pregnancy is intrauterine or intra-abdominal. In our series, probable diagnosis of abdominal pregnancy was made preoperatively by ultrasound in four and one patient was diagnosed as rupture uterus with free fluid in the abdomen.

Another diagnostic tool is grossly elevated maternal serum alpha-fetoprotein (MSAFP). It is said that amniotic fluid AFP will be transferred into maternal circulation in patients with abdominal pregnancy because of the increased transfer of AFP into the peritoneal cavity through the part of amnion covering the abdominal placenta. None of our patients had MSAFP measurement because all of them presented in emergent situation.

Magnetic resonance imaging is considered as a gold standard tool to diagnose an abdominal pregnancy as it provides very clear anatomical relationships of the developing fetus to surrounding structures. It will also guide in surgical planning.

The primary goal in the management of advanced abdominal pregnancy is to save the mother and the fetus. Early abdominal pregnancies can be terminated based on the maternal condition by methotrexate, laparoscopic or open surgery, arterial embolization, and intracapsular injection of potassium chloride into the abdominal pregnancy sac. Advanced abdominal pregnancies require laparotomy. If the fetus is viable and the mother is stable, expectant treatment can be adopted with watchful waiting to ensure a live birth.

The secondary goal in the management is to treat the abnormally located placenta. Management of the placenta still remains inconclusive. When the placenta is located in a blood vessel-rich area, forcible removal of the placenta surgically can cause serious bleeding. Several approaches are suggested for handling the placenta:

  1. Ligating the umbilical cord close to placenta and leaving it undisturbed inside the abdomen without further treatment
  2. Ligating the placental blood supply and removal of the pelvic organs upon which implantation has occurred such as uterus, omentum, and intestines
  3. Leaving the placenta in situ with usage of methotrexate later to absorb the placental trophoblastic tissue.


The problem associated with the usage of methotrexate for in situ placenta is the rapid rate of absorption of the abdominal placenta, which will convert it into a necrotic material which increases the risk of infection.[8]

In our series, all five of them underwent total abdominal hysterectomy with removal of the placenta surgically. One patient required bowel and bladder resection because the placenta and the gestational sac were attached to bowel and bladder. In the last patient, the gestational sac and the placenta had its feeding pedicle in the infundibulopelvic ligament. After clamping the pedicle, the gestational sac was opened and a live baby was delivered, as shown in [Figure 3].
Figure 3: Histopathology picture showing chorionic villi in the myometrium.

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  Conclusion Top


Abdominal pregnancies are a very serious diagnostic and management dilemma, especially in low-resource settings. A high index of suspicion and prompt laparotomy can be lifesaving. An obstetrician working in a remote area with active maternity services should expect to encounter cases of abdominal pregnancies in his or her lifetime.

Acknowledgments

We thank all the five patients who consented to be part of this case series.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Nandi, D, Nwobodo E, Ekele B. Abdominal pregnancy in Usmanu Dan-Fodiyyo University Teaching Hospital, Sokoto: A ten-year review. J Basic Clin Reprod Sci 2012;1:34-7.  Back to cited text no. 1
    
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Mengistu Z, Getachew A, Adefris M. Term abdominal pregnancy: A case report. J Med Case Rep 2015;9:168.  Back to cited text no. 2
    
3.
Fekade GH, Getnet TY, Ahmed AE, Walelign Kindie T. Advanced abdominal pregnancy, with live fetus and severe preeclampsia, case report. BMC Pregnancy Childb 2017;17:243.  Back to cited text no. 3
    
4.
Ojabo AO, Hembah-Hilekaan SK, Audu O, Okoh EA, Oka NO. Outcome of management of 5 cases of abdominal pregnancies. Open Access Library J 2015;2:e1643.  Back to cited text no. 4
    
5.
Osanyin GE, Okunade KS, Oye-Adeniran BA. A case report of a successfully managed advanced abdominal pregnancy with favorable feto-maternal outcomes. Trop J Obstet Gynaecol 2017;34:240-2.  Back to cited text no. 5
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6.
Flint C, Miriam A, Ismavel VA. The Makunda model: An observational study of high quality accessible healthcare in low-resource settings. Christian J Glob Health 2020;7:37-51.  Back to cited text no. 6
    
7.
Ismavel VA, Miriam A. Massive abdominal tumor – More than a medical problem. Curr Med Issues 2017;15:249-51.  Back to cited text no. 7
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8.
Meşeci E, Güzel Y, Zemheri E, Eser SK, Ozkanlı S, Kumru P. A 34-week ovarian pregnancy: Case report and review of the literature. J Turk Ger Gynecol Assoc 2013;14:246-9.  Back to cited text no. 8
    
9.
Krishna D, Damyanti S. Advanced abdominal Pregnancy. A diagnostic and management dilemma. J Gynecol Surg 2007;23:69-72.  Back to cited text no. 9
    
10.
Studdiford W. Primary peritoneal pregnancy. Am J Obstet Gynecol 1942:44;487-91.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]



 

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