|Year : 2013 | Volume
| Issue : 1 | Page : 25-28
Late presentation of advanced abdominal pregnancy with live baby: A case report and literature review
Hauwa Musa Abdullahi, Ibrahim Adamu Yakasai, Muhammed Zakari, Samaila Danjuma Shuaibu
Department of Obstetrics and Gynaecology, Bayero University Kano/Aminu Kano Teaching Hospital, Kano, Nigeria
|Date of Web Publication||29-Aug-2013|
Ibrahim Adamu Yakasai
Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, Kano PMB 3452 Kano
Source of Support: None, Conflict of Interest: None
Abdominal pregnancy is a rare form of ectopic pregnancy. It is associated with an increase in maternal morbidity and mortality, as well as perinatal mortality rate of up to 85%-95%. A case of abdominal pregnancy in an unbooked primigravida who presented in the third trimester and was successfully managed is hereby described. She came with weight loss and jaundice. The fetus was alive and she was managed conservatively till a laparotomy was eventually performed. The outcome was good for mother and baby.
Keywords: Abdominal pregnancy, laparotomy, live baby
|How to cite this article:|
Abdullahi HM, Yakasai IA, Zakari M, Shuaibu SD. Late presentation of advanced abdominal pregnancy with live baby: A case report and literature review. Niger J Basic Clin Sci 2013;10:25-8
|How to cite this URL:|
Abdullahi HM, Yakasai IA, Zakari M, Shuaibu SD. Late presentation of advanced abdominal pregnancy with live baby: A case report and literature review. Niger J Basic Clin Sci [serial online] 2013 [cited 2020 Oct 24];10:25-8. Available from: https://www.njbcs.net/text.asp?2013/10/1/25/117242
| Introduction|| |
Abdominal pregnancy is an advanced form of ectopic pregnancy where the pregnancy is implanted within the peritoneal cavity. , It can be either primary or secondary.  Primary abdominal pregnancy is rare. It occurs when a fertilized ovum implants itself initially on some abdominal organ. This is diagnosed using Studdiford's criteria, viz. tubes and ovaries should be normal, there is no abnormal connection (fistula) between the uterus and the abdominal cavity, and the pregnancy is related solely to the peritoneal surface without signs that there was a tubal pregnancy first. 
Most of the cases of abdominal pregnancy are secondary. This means that the ovum first implants in the Fallopian tube More Details, ovary, or uterus, and subsequently gets to the peritoneal cavity.  About 10 out of every 100,000 pregnancies in the United States are ectopic.  However, a report from Nigeria places the frequency of abdominal pregnancy at 34 per 100,000 deliveries.  Risk factors are similar to those of tubal pregnancy, with sexually transmitted disease playing a major role.  The maternal mortality rate from abdominal pregnancy is estimated to be about 5 per 1000 cases, 7 times the rate for ectopic in general and about 90 times the rate for a normal delivery.  The overall fetal survival rate remains low with a perinatal mortality rate of 40-95%. 
| Case Report|| |
Mrs. MD, a 20-year-old primigravida, whose last menstrual period was on 20/08/11, with an expected date of delivery of 27/05/12, and was estimated to be at gestational age of 31 weeks and 1 day, presented to the labor ward with a 6-month history of abdominal pain and weight loss and a week history of yellowish discoloration of the eyes. General examination revealed a chronically ill looking, moderately pale and jaundiced lady. Her blood pressure was 90/60 mmHg. The abdomen was uniformly enlarged and fetal movements were seen, but there was tenderness and the fetal parts were easily palpable. The liver, spleen, and kidneys were not palpably enlarged. The cervical os was closed on pelvic examination.
An impression of acute viral hepatitis in a patient with suspected abdominal pregnancy was made. She was admitted into the ward, counseled on the diagnosis and plan of management, and co-managed with the physicians. Her packed cell volume was 26.6%; urea, creatinine, and electrolytes were within normal limits. The liver function tests showed elevated alanine transaminase (75 U/L) and aspartate transaminase (93 U/L). Both direct (42 U/L) and total bilirubin (58 U/L) levels were elevated. Serum proteins were normal. Her HbsAg was negative. An ultrasound scan revealed a single live intra-abdominal fetus lying obliquely with the head in the left iliac fossa and fetal limbs in contact with the left lobe of the liver. The placenta extended from the uterine fundus to the mid portion of the right kidney. There were no obvious fetal deformities seen. The estimated gestational age was 28 weeks. A diagnosis of extrauterine pregnancy with a live baby was made, and the plan was to admit her, optimize her clinical condition and do a laparotomy.
She was managed conservatively for 2 weeks in conjunction with the neonatologists. She was on dietary advice, analgesia and hematinics. Intramuscular injection of 12 mg dexamethasone was also given 12 hourly for 24 h, and the special care baby unit informed. Six pints of blood were grouped and cross-matched and kept for her use. The baby was regularly monitored twice weekly with ultrasonography, and fetal heart activity was monitored daily with handheld Doppler. Laparotomy was performed at 33 weeks gestation due to increasing severe abdominal pain and vomiting. The surgery was performed together with the surgeons, in the presence of the pediatricians. The findings were those of moderate adhesions involving the anterior abdominal wall and the amniotic sac [Figure 1] and [Figure 2]. A 1.4 kg female baby was delivered through the amniotic sac with Apgar scores of 8 at 1 min and 9 at 5 min [Figure 3]. There were severe adhesions involving the posterior uterine wall, bowels, and also the placenta. The placenta was mostly adherent to the fundus of the uterus [Figure 4]. There were no obvious fetal deformities seen. The placenta was gently separated and completely removed from the fundus of the uterus and the bowels. Estimated blood loss was 2.2 L. She was transfused with 4 pints of whole blood. The fallopian tubes and ovaries were grossly normal. The baby was reviewed by the pediatrician and found to be preterm but in stable condition with no obvious congenital anomalies, and was admitted to the special care baby unit. Initially the baby was fed with expressed breast milk; later, the mother was able to breastfeed him directly.
|Figure 1: Adhesions between anterior abdominal wall and the amniotic membrane|
Click here to view
|Figure 4: The placenta attached to the fundus of the uterus and part of the bowel|
Click here to view
Postoperatively she was managed with intravenous fluids, analgesics, antibiotics, and hematinics. She was discharged on the 10 th postoperative day and was given a 2 weeks appointment to postnatal clinic. Her packed cell volume at discharge was 28%. The surgical findings and risk of recurrence were discussed with the patient. Despite this, she was lost to follow-up.
| Discussion|| |
A patient with an abdominal pregnancy may just display the normal signs of pregnancy or have non-specific symptoms such as abdominal pain, vaginal bleeding, and/or gastrointestinal symptoms.  Mrs. MD presented late with abdominal pains and weight loss for 6 months with yellowish discoloration of the eyes of 1 week duration. Similar symptoms were also mentioned in one case reported by Ani et al.  The diagnosis of an abdominal pregnancy is frequently missed, with only about 45% of the cases diagnosed during the antenatal period. This is because most patients do not present with the typical symptoms of persistent abdominal pain and/or gastrointestinal symptoms during pregnancy. , Then the condition becomes dangerous as severe bleeding can occur intraperitoneally resulting in hemorrhagic shock which can be fatal. Other causes of maternal death in patients with an abdominal pregnancy include toxemia, anemia, pulmonary embolism, coagulopathy, and infection.  The jaundice that the patient manifested with could have been because of superimposed severe infection with septicemia.
Suspicion of an abdominal pregnancy is raised when the fetal parts can easily be felt or the lie is abnormal. Sonography is extremely helpful in the diagnosis as it can demonstrate that the pregnancy is outside an empty uterus, with no amniotic fluid between the placenta and the fetus, no uterine wall surrounding the fetus, fetal parts being close to the abdominal wall, and the fetus being in abnormal lie. , These were the findings in Mrs. MD. Magnetic resonance imaging may also be used to diagnose abdominal pregnancy when clinical feature and ultrasound fails to make the diagnosis.  The patient was not offered this investigation as her presenting features and abdomino-pelvic ultrasound strongly suggested her diagnosis. Elevated level of serum alpha-fetoprotein is another clue to the presence of an abdominal pregnancy. 
It is generally recommended that laparotomy should be done when the diagnosis of an abdominal pregnancy is made. However, if the pregnancy is advanced (24 weeks and above), the baby is alive, and medical support systems are in place, careful monitoring could be considered to bring the baby to viability (34-36 weeks). Laparotomy was performed at 33 weeks after administering steroids to promote lung maturity. This is similar to the report from other centers.  Babies of abdominal pregnancies often have skeletal abnormalities due to compression in the absence of the amniotic fluid buffer. The rate of malformations and deformations is estimated to be about 21%; typical deformations are facial, cranial and joint abnormalities. The most common malformations are limb defects and central nervous malformations.  None of these was seen in baby of MD.
The growing placenta may be attached to several organs including the fallopian tubes and ovaries. Other sites reported are the liver and spleen,  giving rise to a hepatic pregnancy  or splenic pregnancy, respectively.  Even an early diaphragmatic pregnancy has been described in a patient where an embryo began growing on the underside of the diaphragm.  Once the baby has been delivered, placental management becomes an issue. In normal deliveries, the contraction of the uterus provides a powerful mechanism to control blood loss; however, in an abdominal pregnancy, the placenta is located over tissues that cannot contract and attempts at its removal may lead to significant blood loss. Generally, unless the placenta can be easily removed, it may be preferable to leave it in place and allow for a natural regression.  This process may take about 4 months and can be monitored by checking human chorionic gonadotropin levels. Use of methotrexate to accelerate placental regression is controversial as the large amount of necrotic tissue is a potential site for infection.  Placental vessels have also been blocked by angiographic embolization.  In the case of Mrs. MD, despite the fact that the placenta was attached to the fundus of the uterus and some parts of the bowel, it was successfully removed.
| Conclusion|| |
We presented a rare case of late presentation of advanced abdominal pregnancy. The patient had laparotomy and delivery of a live baby, and the placenta was successfully removed.
| References|| |
|1.||Etuk SJ. Abortion: Spontaneous and induced; Ectopic pregnancy. In: Ikpeze OC, editor. 1 st ed. Fundamental of Obstetrics and Gynaecology. Africa: Africana 1 st Publishers plc; 2009. p. 177-90. |
|2.||Kwawukume EY, Idrisa A. Ectopic pregnancy. In: Kwawukume E, editor. 1 st ed. Comprehensive Obstetrics in the Tropics. Ghana: Accra Asante and Hitscher Printing Press Ltd.; 2002. p. 211-8. |
|3.||Isah AY, Ahmed Y, Nwobodo EI, Ekele BA. Abdominal pregnancy with full term live fetus. a case report. Ann Afr Med 2008;7:198-9. |
|4.||Atrash HK, Friede A, Hogue CJ. Abdominal pregnancy in the United States: Frequency and mortality. Obstetr Gynecol 1987;63:333-7. |
|5.||Sunday-Adeoye I, Twomey D, Egwuatu EV, Okonta PI. A 30-year review of advanced abdominal pregnancy at the mater Misericordiae hospital, Afikpo, southeastern Nigeria (1976-2006). Arch Gynecol Obstet 2011;283:19-24. |
|6.||Kun KY, Wong PY, Ho MW, Tai CM, Ng TK. Abdominal pregnancy presenting as a missed abortion at 16 weeks' gestation. Hong Kong Med J 2000;6:425-7. |
|7.||Dahab AA, Aburass R, Shawkat W, Babgi R, Essa O, Mujallalid RH. Fulltrem extrauterine abdominal pregnancy: A case report. J Med Case Rep 2011;5:531. |
|8.||Dahiya K, Sharma D. Advanced abdominal pregnancy: A diagnostic and management dilemma. J Gynecol Surg 2007;23:69-72. |
|9.||Tromans PM, Coulson R, Lobb MO, Abdulla U. Abdominal pregnancy associated with extremely elevated serum alphafetoprotein: Case report. Br J Obstet Gynaecol 1994;91:296-8. |
|10.||Chui AK, Lo KW, Choi PC, Sung MC, Lau JW. Primary hepatic pregnancy. ANZ J Surg 2001;71:260-1. |
|11.||Yagil Y, Beck-Razi N, Amit A, Kerner H, Gaitini D. Splenic pregnancy: The role of abdominal imaging. J Ultrasound Med 2007;26:1629-32. |
|12.||Anderson PM, Opfer EK, Busch JM, Magann EF. An early abdominal wall ectopic pregnancy successfully treated with ultrasound guided intralesional methotrexate: A case report. Obstet Gynaecol Int 2009;2009:247452. |
|13.||Cardosi RJ, Nackley AC, Londono J, Hoffman MS. Embolization for advanced abdominal pregnancy with a retained placenta. A case report. J Reprod Med 2002;47:861-3. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]