INTRODUCTION:
Abdominal pregnancy is one of the rare and life threatening type
of Ectopic pregnancy which is implanted in the peritoneal cavity outside the
uterus, fallopian tubes and ovaries.(1)The clinical symptoms of uncomplicated
abdominal pregnancy is not specific. (2)
It poses a lot of challenges both in the diagnosis and management,
hence high index of suspicion is vital in making prompt diagnosis.(2) In
addition to clinical suspicion, imaging especially ultrasound is a very
important diagnostic tool, rarely Magnetic Resonant Imaging (MRI) can also be
used. (3, 4)
Abdominal pregnancy can be classified into primary or secondary
type depending on the primary site of gestational implants.
The primary abdominal pregnancy is
the type of ectopic pregnancy in which the blastocyte
is primarily implanted inside the peritoneal cavity, while the secondary
abdominal pregnancy occurs when the blastocyte is
initially implanted either in the tube, uterus or ovary but later migrated out
due to tubal or uterus ruptures or tubal abortion, then it will be implanted
into the peritoneal cavity. Studdford in 1943
introduced criteria for the diagnosis of primary abdominal pregnancy. (5)
Though the exact aetiology of primary abdominal pregnancy is unknown. (5, 6)
however, there are different risk factors. The risk factors identified are
tubal damage, pelvic inflammatory disease, multiparty invitro-fertilization
and others.
The incidence of abdominal pregnancy differs in various publication
and ranges between 1 – 10,000 pregnancies and 1 - 30,000 pregnancies.(1,7) Abdominal
pregnancy may account for up to 1.4% of all ectopic pregnancies (1,7). The
incidence is high in women in developing nations. (2, 7) This may be due to low
socio-economic status, high rate of P.I.D, history of infertility, tubal
sterilization, tubal reconstruction surgeries and pregnancy with intra-uterine
contraceptive devices. (8)
When comparing tubal and intrauterine pregnancies, the risk of
dying from abdominal pregnancy is high. It is 7.7 times higher than the tubal
pregnancy and 90 times greater than intra-uterine pregnancy. (7,8) The maternal mortality may range from 0.5% to 18% and
the perinatal mortality is 40-95%. (9)
Congenital malformation are every common amongst baby resulting
from abdominal pregnancy. There are reports of fetal malformation as high as
40% associated with abdominal pregnancies and only 5% of these babies survive
up to one week post delivery (10,14).Also
intra-uterine growth restriction is common among babies in advanced abdominal
pregnancies. (2,13)
A review of literature from 2008-2013, showed that 38 cases of
advanced abdominal pregnancies result in a live birth were identified from 16
countries (4,10).This abdominal pregnancy with resultant healthy new born is
very rare (9,10). Therefore, we present a rare case of abdominal pregnancy with
a live baby at 33 weeks gestation.
CASE
REPORT
A 30 year old unbooked Gravida 3 Part 2+0 unsure of her date and she has had 2
successful vaginal deliveries. Her last delivery was in 2014,
however she had been amenorrhoic for 8 months. She
visited a peripheral hospital for a 2 month period to presentation on account
of dull aching abdominal pain of 4 months duration. She stated to have had
exploratory laparotomy at the peripheral hospital on account of Ectopic
pregnancy 2 months prior to presentation and she stated that Ectopic pregnancy
was not located and she was discharged, however the abdominal pain and
distention persisted and also became worst. She stated that the abdominal pain
was dull aching pain all over the abdomen with associated abdominal distention
and shortness of breath. She also experienced increased nausea and vomiting,
compared to the previous 2 pregnancies. She also stated that the abdominal pain
worsened on feeling movement in the abdomen, she reported to have had no
vaginal bleeding. She never had antenatal care or an ultrasound examination for
the index pregnancy. When the symptoms persisted and was worsening, she went
back to the peripheral hospital that now referred her to our institution for
the first time since the conception of current pregnancy.
On physical examination, she was not pale, anicteric, afebrile,
not dehydrated and there was no pedal edema. Her vital signs were pulse rate
86beats/min, Blood pressure = 110/70mmHg, Respiratory rate = 20 cycles/min,
Temperature = 36.50C. Her
respiratory and cardiovascular examinations were unremarkable.
Abdominal examination showed, mild abdominal tendencies and the
pregnancy was 34 weeks with easily palpable fetal parts, transverse lie, fetal heart rate was 150beat/min. there was no clear border
of the uterus. The pelvic examination, showed cervix that was posterior, not
effaced and closed.
After admission, the Laboratory results showed her haematocrit level of 31% Blood group is O+ve,
urine analysis was normal. Ultrasound findings indicated intra-abdominal viable
pregnancy at 33 weeks in a traverse lie, the uterus was empty. Based on the
above findings, she was diagnosed to have a preterm viable extra-abdominal
Pregnancy. She was given Dexamethasone for lungs maturation and was booked for
Elective laparotomy. Three Units of blood was provided. She was counselled on her condition and possible option of
intra-operative management and complications.
Written consent for the surgery was obtained from her, the general
surgeon and the new neonatologist were invited to be present in the theatre.
Under spinal anesthesia, she had laparotomy. The baby was found
floating in the peritoneal cavity, part of the baby covered consented by gut.
No amniotic sac noted. The placenta was attached on the anterior wall of the
uterus involving the right fallopian tube and ovary; and omentum.
There was tubo-ovarian mass on the right. The left
ovary was essentially normal and the left tube was adherent on the ovary. The
uterine is normal size.
A live male preterm baby Apgar score 8 in the first minute and 9
at the fifth minute, Birth weight was 1.7kg.Part of the fetal membrane was seen
on the baby’s head. Estimated blood loss was 600mls.
OPERATIVE
PROCEDURE
The abdomen was opened through a middle subumbilical
incision, the peritoneal was opened carefully to avoid
rupture of the amniotic sac. The baby was found lying freely in the peritoneal
cavity. The umbilical cord was double clamped and cut in between baby was
delivered and handed over to the neonatologist.
The Apgar score at birth was 8 in one minute, 9 in five minute,
Birth weight was 1.7kg.
The placenta was attached to the Omentum
and the anterior all of the uterus getting blood supply from birth.
Clamping, cutting and transfixing of the omentum
attached to the placenta was carried out. The placenta
was separated from the anterior wall of the uterus and delivered embloc. Haemotasis was secured.
The abdomen was cleared and closed in layers. The estimated blood lost was
600mls.
The patient was taken to the PACU for monitoring and thereafter
taking to the lying inward for other post-operative care.
The baby was admitted at the SCBU, and was reported to have had
repeated episode of apnoea and he died after 24hrs in
the SCBU. The patient was discharged after one week and she is currently doing
well.
DISCUSSION
Ectopic pregnancy is a type of pregnancy and defined as the
implantation of the blastocytes outside the
endometrial Lining. Based on the location of the blastocytes,
Ectopic pregnancy can be tubal ectopic. When the implantation is inside the
tube, ovarian when implanted on the ovary, the implantation of the balstocytes inside the abdomen is called abdominal
pregnancy. Implantation of the blastocytes can also
occur inside the cervix (Cervical pregnancy) and also inside the caesarian
section scar (1, 2).
The prevalence of ectopic pregnancy is 1-2%, amongst all the
different types of ectopic pregnancies 95-98% occur inside the uterine tubes
(3, 8).An abdominal pregnancy is extremely rare but life threatening type of
pregnancy which is implanted outside the uterus cavity and fallopian tubes. (5,10) It accounts for 1 per 10,000 birth and accounts for 1.4%
of ectopic pregnancy, (5,11)
Abdominal pregnancy is usually misdiagnosed as an intra-uterine
pregnancy during antenatal care. In the first trimester, it is missed as tubal
pregnancy and late trimester, it is missed as intra-uterine pregnancy.
Abdominal pregnancy can be classified into primary and secondary
type depending on the primary site of the gestational implantation.
The primary type of abdominal pregnancy is the type of ectopic
pregnancy in which the blastocytes. Primarily
implanted inside the peritoneal cavity while the secondary type of abdominal
pregnancy is initially implanted either in the tube, uterus or ovary but later
migrated out due to tubal or uterine rupture or tubal abortion, then it will be
implanted into the peritoneal cavity.
Studdiford in 1942, introduced the following three diagnostic criteria for
primary abdominal pregnancy. (2,5, 8, 10) There are:
1. Both tubes and ovaries
must be in normal condition with no evident of recent or remote injury.
2. No evidence of
utero-peritoneal fistular should be found.
3. The pregnancy must be
related exclusively to the peritoneal surface and be diagnosed early enough. In
our index case, there were tubo ovarian mass on the
right tube and the left tube is adherent to the left ovary, though both
structures looked apparently normal grossly. Hence for this reason, our patient
is said to have a secondary type of abdominal pregnancy.
The etiology of primary abdominal pregnancy is not exactly known,
however strong risk factors have been identified. The risk factors are tubal
damage, pelvic inflammatory disease, multiparty, invitro-fertilization
and others. In our index patient, the risk factors identified are multiparty
and pelvic inflammatory disease.
The Diagnoses of extra-uterine pregnancy is very challenging (14)
in our index patient, the diagnosis was missed at the peripheral hospital and
even at exploratory laporatory that was done at the
peripheral hospital, they still missed the diagnosis. But when she presented in
our institution with the persistent abdominal pains and distention, following 8
months of amenorrhoea, abdominal pregnancy was
suspected. Our suspicious was confirmed by imaging especially ultrasound.
The ultrasound features of abdominal pregnancy include:
1. The absence of myometrial tissue between the maternal bladder and their
pregnancy.
2. An empty uterus.
3. Poor definition of
the placenta
4. Oligohydraminous
5. Unusual fetal lie
(1, 14)
In our case, the ultrasound findings are similar to the one
aforementioned. Abdominal pregnancy could be diagnosed using magnetic resonant
imaging (MRI), though it is rare (12).
Tubal pregnancy is the commonest type of ectopic
pregnancy, usually rupture or aborts in early trimester and they are
diagnosed early. However, abdominal pregnancy is the only ectopic pregnancy can
advance beyond 20 weeks gestation.
Abdominal pregnancy is associated with life threatening
complications both for the fetus and the mother, it
may lead to fetal and maternal death especially if there is intra-peritoneal
bleeding due to vascular rupture. (13, 16)
Once diagnosis is made, management depends on gestational age, haemodynamic stability and location of placental
implantation (13, 14). In early trimester, laparoscopy, vascular embolization
and Fetocide are possible management options (5,10). In late pregnancy, the main stay of management is laporatory. The fetus can be delivered easily but the
decision about the management of the placenta should be made cautiously since
removal of the placenta may cause torrential bleeding and maternal death. (14,
15)
The removal of the placenta should only be tried if attachment is
simple and easy to remove. In our patient, the placenta was attached to the omentum which was easily separated. The placenta also was
attached to the anterior wall of the uterus and it was easy to separate. The
uterus was grossly normal and there were no bleeding points on the uterus after
the separation.
When the placenta is attached to
major vessels or pelvic side walls. It is recommended to leave the
placenta in-situ and commence the patient on methotrexate when the placenta is
left in-situ, it undergoes necrosis and super-infection may set in, thus
increasing the risk of abscess formation and sepsis. Therefore, post-operative
follow-up is very important.
Fetal malformation has been reported to be as high as 40% in
abdominal pregnancy. The baby delivered in index patient was grossly normal.
Reports have also shown that only 5% of the babies survive up to one week post-delivery.
(7,10,14) The baby in this index patient died after 24
hours as a result of repeated apneic attacks.
CONCLUSION:
Abdominal pregnancy is a rare but life threatening type of ectopic
pregnancy. Abdominal pregnancy with resultant heartily new born was also very
rare.
The Diagnosis and management of abdominal pregnancy imposes a lot
of challenges.
High index of suspicion for diagnosis, a good plan and adequate
preparation for surgery is very vital to prevent maternal and perinatal death.
REFERENCES:
1. Huang K, Song L, Nang
C, Gao Z, Mens Y. Advanced
abdominal pregnancy on increasing challenging
- Clinical concern for obstetrics Int. J. Clinic, Exp
Pathol 2014, 7, 546.
2. Igwemadu
G, Tunde-Olatunya C, Akumeziri
U, Enang E. – Advanced abdominal pregnancy challenge
of management Niger J. Med. 2020, 29(3), 514.
3. Reshman
G, Edward P, Robert G. Abdominal ectopic pregnancy Baylor Univ
Med. Centre Proc 2021, 34 (4) 530-531.
4. Km Mj,
Bal Ty, Seung
WJ, Lee Ys. Sonographic
diagnoses with planned delivery after lung maturation Clin
2013, 41(9); 563-655.
5. Hiwort
Fanc. Term abdominal pregnancy with
live baby. Specialized University hospital Eastern
Ethiopia.
Tederre G, Semi Sulli
and Set Y sepr IMC. Internal medical case report
journal.
6. Mengistu
2, Getachen A., Adeu. M.
Term abdominal pregnancy case report. J. Med. Case report
2015; 9(1), 168.
7. Adesiyum
Ag, Audul A.L.Term extrauterine pregnancy in Nigeria Mother, A complication of
uterine dehiscenes. Arch Gynaecol
obstet 2009, 279 (1) 75-77.
8. Masukume
G. Live birth resulting from advanced extra-uterine pregnancy to review of care
reports from 2008 to 2013. Wed Med. Centre Obstet Gynaecol 2014, 15(1) 2-13.
9. Arga
M, Nalinishama VJ. Case report, Can fam physician 2001, 47 (10)
788-789.
10. Abdul Jabber NAK, Sagius S., Yalha Wem. Successful management of abdominal pregnancy, Two case
reports Oman Med. J. 2018, 33 (2) 171-175.
11. Krisha
D, Danyanti S, Advanced abdominal pregnancy a
diagnostic and managerial ditenme, J. Gynaecol Surg, 2007, 23; 69-72.
12. Yeng
H, Kumer G, Ranili N. A
viable secondary Intra-abdominal pregnancy resulting from ruptured uterine
Scar, role of MRI. Br. J. Radiol 2007, 80; 134-136 Pub Med.
13. Ekele
et al; Eclampsia in advanced abdominal pregnancy. Niger J. Clin pract.
December 2007, Vol. 4, 343-345.
14. Nwobodo E.l. Abdominal pregnancy. A case
report Afr. Med. J. 2004 43(4) 195-196
