Resident presentation

1. College of Medicine and Health Sciences
Department of Obstetrics and Gynecology
Abdominal pregnancy
Prepared by Dr MUTABAZI Viateur, PGY III Resident
Supervisor: Dr FIKREMELEKOT, MFM Specialist

2.  Name : U.S.C
 ID number : 677912
 Age : 34Y.O
 Admission date : 03/10/2023
 Diagnosis : Retained placenta post laparotomy
for abdominal pregnancy
 Discharge date : 16/10/2023
IDENTIFICATION

3. CC: Severe abdominal pain
HPI
 She presented to DH for severe
abdominal pain on 16/09/2023
with abdominal pain on pregnancy
of 32wks and found with anemia
 transfused.
 Returned after 2 weeks and on
01/10/2023 (next day), she
underwent laparotomy after
diagnosis live abd.pregnancy.
 Placenta left in place then sent for
F/U.
 ROS: No bleeding, no dizziness
OBSTETRIC HISTORY
 G1P0101 GA was 34weeks by
LMP
 3 ANCs at DH
 D2 post Laparotomy for
abdominal pregnancy BW=2kg
 Transfused with 4Us of PRBCs
 No NCDs, HIV neg, BG=O+

4. Physical examination
 V/S: BP:113/64, HR: 94, RR: 20 T:36.1, SPO2: 98%
 GCS: Fully alert
 RS: Bilateral air entry, clear lungs.
 CVS: S1&S2 are audible, no added sounds
 ABD: Distended, intact low midline incision wound, soft, no
rebound tenderness, no guarding
 GUS: No bleeding
 MSK: No edema

5. Lab investigations
03/10/2023 05/10/2023 09/10/2023 15/10/2023
Hb 8.4 10.5
Hct 24.5
MCV 85.9
MCH 29.4
Plt 109 139
Urea 2.4
Creat 48.6
BG O+
Bhcg 16947.4 5102.42 4619.0

6. Imaging
• U/S: Empty uterus, mixed echogenic image in abdomen, minimal free
fluid in Morrisson and Douglas pouches.

7. • ASS:
Retained intra-abdominal placenta post laparotomy for
live abdominal pregnancy
• MANAGEMENT
 Patient was admitted
 Painkillers: Paracetamol + Diclofenac
 Expectant management by staff decision
 Transfused with 2Us of PRBCs
 ATBs: Ceftriaxone + Flagyl
 V/S monitoring

8. Progress
• Has been stable with normal V/S and decreasing abdominal girth and
b-hcg
• Discharged on 16/10/2023 with weekly follow up of her B-hcg levels

9. 2 weeks later (02/11/2023): She consulted RMH for sero-sanguinous
secretions through the wound
 Ass: Fascia dehiscence with umbilical cord protrusion
 Management:
• E-laparotomy (On 3/11/2013): Cord reduction, washout and
fasciorrhaphy.
• ATBs/Painkillers/VS
• Wound care 2x/d

10. On 10/11/2023:
 2nd Laparotomy for another burst abdomen:
• Findings: Placenta covering big part of small bowels with adherence to
the omentum and some areas of the anterior abdominal wall.
• Done: Wound closure after placenta removal attempt failure.
EBL=1500mls. Transfused

11. In patient follow up:
 Daily compressive wound care (wound kept discharging bloody
serosity on its lower extremity)
 ATBs/Painkillers.
 V/S monitoring (were all time normal).
 MTX IM weekly (4 doses) started on 19/11/2023

12. Investigations:
• Hb: Decreasing from 10.4  8.8
• Weekly Bhcg: Decreasing 1447  1218 382 189.512.49
• MRI: Well circumscribed retained placenta with areas of necrosis and
hemorrhage within the central pelvis, abuting the fundal surface of the
uterus and extending superiorly in the central abdomen displacing the
related bowels. No bowel compression nor obstruction

13. Discharged on 18/12/2023 for nearest HF wound care and montly
OPD follow up.

14. Follow up
1 month later:
 Decrement of abdominal girth, discharge from wound still (2 openings
with necrotic superficial tissue and pus like discharge), soft abdomen
with no sign of peritoneal irritation.
 US: Mass with doppler uptake, no fluid collection
 Bhcg: <0.1
 Ass: Retained placenta with superficial wound infection
 Plan: Keep wound care, RDV in one month.

15. DISCUSSION

16. Introduction
• Abdominal pregnancy (AP): Gestation that implants within the
abdominal cavity but outside of the female reproductive organs.
• Extremely rare. 1% of all ectopic pregnancy.
• High maternal morbidity and mortality (>7.7x in tubal pregnancy &
>89.8 x in IUP.
• Early recognition and treatment may improve outcomes
• Often poses significant challenges in diagnosis and treatment.
• However, full-term abdominal pregnancies with live births have been
reported in the literature

17. Pathophysiology
• Several theories:
• Cavanagh: Fertilization may occur in the posterior cul-de-sac where
sperm is known to accumulate.
• Iwama et al: Reversion of the path of the embryo or along lymphatic
channels.
• Through fistulous tracts post prior tubal surgeries.

18. Cont’
• In other cases, after uterine or tubal rupture
• ART: via uterine perforation during IVF or retrograde flow of transfer
media

19. Location of implatation
• In a review of case reports of AP,
• The most common location was the pelvic peritoneum (24%) with the
posterior cul de sac (20%) than the anterior (4%)
• Other commonly reported locations: uterine and tubal serosa (23.95%),
omentum and bowel.
• More rarely reported: liver, spleen, retropertoneum.
In our case, it implanted to small bowels, omentum and anterior wall of
abdomen

20. Types
By Physiological mechanism:
• Primary AP: Fertilized ovum implants directly on the peritoneal
surface
• Secondary AP: Implants into the abdominal cavity that was previously
located elsewhere

21. • By GA at diagnosis:
• Early AP: If diagnosed at or before 20wks
• Diagnosis is challenging, difficult to distinguish from other types of
extra-uterine pregnancies.
• Late/ advanced AP: If diagnosed after 20wks
Our case, it was advanced (diagnosed at 34wks) but was not reported if
was primary or secondary.

22. Incidence
• Very rare
• Studies report incidence rates of 1 per 10,000 to 30,000 live births or 1
% of all ectopic pregnancies
• Secondary AP is thought to be more common but most studies do not
specify the type of AP.

23. Risk factors
• No specific RFs were particularly associated w/ AP.
• Mostly:
• Tubal factor infertility
• Higher number of embryos transferred during IVF.
In one systematic review including 28 case reports of abdominal
pregnancy after IVF, a history of tubal surgery and ectopic pregnancy
were reported in 50 and 39 % of patients, respectively
A high index of suspicion is needed

24. Clinical findings
• Physical examination:
The clinical presentation is variable and
not specific.
In advanced AP: findings include:
• Easily palpable fetal parts
• Painful FMs
• Fetal malpresentation
• FGR
• Failed IOL or absence of labor at term
• Fetal demise  Sepsis
• Marked oligohydramnios
• life threatening IA hemorrhage

25. Imaging findings
U/S features proposed by Allibone
et al remain useful:
1. Fetus in GS outside the uterus
2. No uterine wall btn the fetus and
the urinary bladder,
3. Fetus close to maternal abdominal
wall,
4. Placenta outside the uterine
cavity
5. Eccentric position of fetus,
6. Visualization of the placenta
immediately adjacent to the fetal
chest and head with no amniotic
fluid.

26. However, these findings are missed in approximately 50 % of patients
commonly in the 2nd and 3th trimesters.
For our case, it not known which US features were identified.

27. Imaging findings
• MRI
Is helpful especially for Placental mapping, surgical planning,
determination of vascular supply prior to treatment.
In a retrospective study including 9 patients with AP in which MRI
images were reviewed, It accurately located the placenta in all patients.
MRI may also be used for patients undergoing expectant management
(to evaluate fetal growth, amniotic fluid levels, placental invasion).
For our case, MRI was done only during follow up.

28. • Despite advanced imaging modalities, only 20–40% abdominal
pregnancies are diagnosed preoperatively
• Majority of cases diagnosed definitely during laparotomy
• In our case, the diagnosis was pre-operatively with U/S

29. • Contrast studies: Essential to assess areterial and venous
vascuralisation

30.  Studdiford criteria for 1ary AP:
• Intact bilateral fallopian tubes and ovaries
• Absence of utero-peritoneal fistula
• Attachment of the pregnancy exclusively to the peritoneal surface.

31. Laboratory findings
• Abnormal lab findings are typically absent.
• Suboptimal raise of hCG
• Decreased maternal serum unconjugated estriol (uE3):

32. Differential diagnosis
Tubal ectopic pregnancy:
Tends to be located laterally to the uterus while AP in douglas pouch.
Rarely goes > 10wks without rupture, movable.
Rudimentary horn pregnancy:
Myometrial tissue around but not easy in advanced stages
Uterine rupture
IUP

33. Management
• Few guidelines for management of AP exist because the diagnosis is
rare and clinical scenarios are variable.
• Treatment must be individualized depending on patient/fetal factors,
GA, multidisciplinary approach.

34. Management
• Majority of cases are managed surgically:
1. Hemodynamically unstable Pt or Embryonic/Fetal demise.
2. Hemodynamically stable patients choosing termination
3. </= 20wks ( but also medical treatment has been reported if
intervention is deemed to be potentially hemorrhagic
E-laparotomy is a gold standard for both early and late stage.
Some authors prefer laparoscopic approach if GA< 12wks, if
implatation allows a non hemorrhagic excision.

35. • >20 weeks and choosing expectant management: if absent fetal
malformation, adequate AF, maternal or fetal decompensation, placental
implanted away from the liver/spleen and in tertiary level.
• Inpatient periodic fetal assessment with U/S : 2-4 wks and MRI: every 4 wks
for evaluate FG, AF levels, placental invasion, and for preoperative planning.
• Delivery time: 32+0 - 35+6 wks.
• Some studies argue for expectant management since may have better rates of
fetal viability
• In our case, she was delivered at 34 wks ( time of diagnosis)

36. Key features of delivery
• Placental arterial embolization
• Spinal anesthesia may be used for delivery and subsequently converted
to general anesthesia
• A vertical skin incision is preferred
• Amniotomy of the GS  delivery of the infant  ligation of the
umbilical cord at its placental insertion site.
• In our case, vertical incision done but cord ligated far from placenta
insertion that resulted in its prolapse through the fascia. SAE N/A in
our settings.

37. Placenta management
Depends on the site of placental localization, risks of hemorrhage and
damage to involved structures.
Preoperative imaging may aid in this decision.
• If removal of the placenta is attempted, the placental blood supply is
identified and ligated.
• If placenta left in situ: High rate of complications (50%).

38. Cont’
• Adjuvant therapies: Intra-abdominal sac injection of KCl
/MTX/Selective arterial embolization may be used to induce
degradation of the placenta and decrease risk of intra-abdominal
hemorrhage
• MTX use is controversal mainly in late diagnosis: can lead to rapid
placental lobular necrosis, resulting in IAA, hemorrhage, and even
death.
• In our case, placenta left in situ because of torrential bleeding and lack
of cleavage line during its removal trial and MTX used

39. Follow up
• Weekly hCG levels are typically obtained weekly in all patients until
the level remains undetectable.
• Ultrasound with Doppler to document resolution of the placenta and its
blood supply
• In our case, weekly hcg levels follow up until undetectable was done
and under follow up

40. Complications
• In a review of 22 reports from 13 countries including 163 cases of AP,
the following outcomes were reported:
• Maternal Mortality: 12 %. Other studies report a maternal mortality
between 0.5 and 18 %.
• Maternal hemorrhage requiring blood transfusion: 80%.
• Fetal mortality: 72 %. Others report a fetal mortality rate between 45
and 90 %.
• Fetal morbidity: 20 to 40 % .
• In our case, 2 reoperations, bleeding, infection happened

41. TAKE HOME MESSAGE
• AP is associated with considerable maternal and fetal morbidity and
mortality. However, when diagnosed early and managed appropriately,
it is possible to have successful outcomes.
• No specific criteria to diagnose AP and may be missed on U/S.
• MRI is the gold standard for evaluating placental implantation and
preoperative planning.
• Management depends on the patient/fetal factors and GA
• Multidisciplinary preoperative planning is paramount for optimal
outcome.
• Management of the placenta depends on the degree of penetration and
the organ in which it embeds.

42. References
• Uptodates
• Nwobodo El (2004) Abdominal pregnancy: A case report. Ann Afr Med 3: 195-196.
• Nassali MN, Benti TM, Bandani-Ntsabele M, Musinguzi E (2016) A case report of
an asymptomatic late term abdominal pregnancy with a live birth at 41 weeks of
gestation. BMC Res Notes 9: 31.
• Singh Y, Singh SK, Ganguly M, Singh S, Kumar P (2016) Secondary abdominal
pregnancy. Med J Armed Forces India 72: 186-188.
• Huang K, Song L, Wang L, Gao Z, Meng Y, et al. (2014) Advanced abdominal
pregnancy: An increasingly challenging clinical concern for obstetricians. Int J Clin
Exp Pathol 7: 5461-5472.
• Yildizhan R, Kolusari A, Adali F, Adali E, Kurdoglu M, et al. (2009) Primary
abdominal ectopic pregnancy: A case report. Cases J 2: 8485.

43. • Chitra KL (2007) Viable abdominal pregnancy. J Obstet Gynaecol India 57: 169-
170.
• Nkusu Nunyalulendho D, Einterz EM (2008) Advanced abdominal pregnancy:
Case report and review of 163 cases reported since 1946. Rural Remote Health 8:
1087.
• Williams gynecology, 26th edition
• Varma R, Mascarenhas L, James D (2003) Successful outcome of advanced
abdominal pregnancy with exclusive omental insertion. Ultrasound Obstet Gynecol
21: 192-194.
• Badria L, Amarin Z, Jaradat A, Zahawi H, Gharaibeh A, et al. (2003) Full-term
viable abdominal pregnancy: A case report and review. Arch Gynecol Obstet 268:
340-342.