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Byamukama A, Bibangambah P, Rwebazibwa J, Acan M, Sebikali MJ. Advanced abdominal ectopic pregnancy and the role of antenatal ultrasound scan in its diagnosis and management. Radiol Case Rep 2023; 18:4409-4413. [PMID: 37840888 PMCID: PMC10570543 DOI: 10.1016/j.radcr.2023.09.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 09/12/2023] [Accepted: 09/14/2023] [Indexed: 10/17/2023] Open
Abstract
Abdominal pregnancy is a very rare form of ectopic gestation in which implantation occurs in the peritoneal cavity. It accounts for about 1% of all ectopic pregnancies and is associated with a higher risk of morbidity and mortality due to complications such as preeclampsia, placenta abruption, and oligohydromnios, which necessitate pregnancy termination before term, and the risk of massive hemorrhage associated with abnormal placentation. We present a case of advanced abdominal ectopic pregnancy, diagnosed in the second trimester and complicated by anhydramnios. An abdominal ultrasound scan showed a nongravid uterus and a single live extrauterine fetus within the abdominal cavity, with no surrounding liquor at 23 weeks and 3 days average gestational age. Mother was consented and an emergency laparatomy performed. A premature baby was delivered but died in Neonatal Intensive Care Unit (NICU) after 4 hours due to severe acute respiratory distress syndrome. Mother had good postoperative recovery. Advanced abdominal ectopic pregnancy though very rare, is associated with complications that lead to early termination. Ultrasound scan is a reliable tool for the diagnosis of abdominal pregnancy in settings with limited access to Magnetic Resonance Imaging (MRI). It should be recommended to all mothers at their earliest antenatal care (ANC) visit to help determine the site of pregnancy and guide further intervention.
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Affiliation(s)
- Anacret Byamukama
- Department of Radiology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Prossy Bibangambah
- Department of Radiology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Joseph Rwebazibwa
- Department of Obstetrics & Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Moses Acan
- Department of Radiology, Mbarara University of Science and Technology, Mbarara, Uganda
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Orsi M, Janneh FM, Sesay A, Bah AK, Tiru NA. A Clinical and Ethical Dilemma: Expectant Management for Ectopic Pregnancy with a Vital Fetus in a Low-Resource Setting. J Clin Med 2023; 12:5642. [PMID: 37685709 PMCID: PMC10488410 DOI: 10.3390/jcm12175642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/20/2023] [Accepted: 08/28/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Guidelines recommend the prompt surgical removal of any ectopic pregnancy (EP) in the presence of a vital embryo. This treatment impacts future fertility, particularly in low-resource settings where access to assisted reproductive techniques is limited. In addition, growing evidence is reporting live births after conservative management of initially undiagnosed abdominal pregnancies. Therefore, the discussion on the acceptability of expectant management in selected cases has been recently raised. CASE We present and discuss the case of a woman with vital first trimester EP who refused surgical treatment at Princess Christian Maternity Hospital, Freetown, Sierra Leone. She was initially diagnosed with a 12 week pregnancy located in the left adnexal region without hemoperitoneum. She refused both surgical treatment and hospital admission and did not come back to the hospital for antenatal care until 26 weeks of gestational age. Therefore, she was admitted and finally delivered, at 34 weeks of gestation, a 1.9 kg healthy baby which was alive. To disentangle the potential conflict between the ethical principles of medical treatment's beneficence and the patient's autonomy, we provide an update on counselling for a patient with early vital EP in a resource-limited setting and discuss the knowledge gap in this area. CONCLUSIONS Limited access to fertility treatment in low- and middle-income countries may justify the discussion of expectant management as an option in selected cases of uncomplicated vital EP.
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Affiliation(s)
- Michele Orsi
- Unit of Obstetrics, Department of Woman Newborn and Child, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda Ospedale Maggiore Policlinico, Via della Commenda, 12, 20122 Milan, Italy
| | - Foday Musa Janneh
- Princess Christian Maternity Hospital, University of Sierra Leone Teaching Hospital Complex, Fourah Bay Road, Freetown 00232, Sierra Leone
| | - Amadu Sesay
- Princess Christian Maternity Hospital, University of Sierra Leone Teaching Hospital Complex, Fourah Bay Road, Freetown 00232, Sierra Leone
| | - Abdul Karim Bah
- Princess Christian Maternity Hospital, University of Sierra Leone Teaching Hospital Complex, Fourah Bay Road, Freetown 00232, Sierra Leone
| | - Nitsuh Addis Tiru
- Princess Christian Maternity Hospital, University of Sierra Leone Teaching Hospital Complex, Fourah Bay Road, Freetown 00232, Sierra Leone
- Doctors with Africa CUAMM, Via San Francesco, 126, 35121 Padova, Italy
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Zheng X, Zhou Y, Sun Z, Yan T, Yang Y, Wang R. Abdominal pregnancy secondary to uterine horn pregnancy: a case report. BMC Pregnancy Childbirth 2023; 23:412. [PMID: 37270533 DOI: 10.1186/s12884-023-05704-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 05/15/2023] [Indexed: 06/05/2023] Open
Abstract
BACKGROUND Pregnancy begins with a fertilized ovum that normally attaches to the uterine endometrium. However, an ectopic pregnancy can occur when a fertilized egg implants and grows outside the uterine cavity. Tubal ectopic pregnancy is the most common type (over 95%), with ovarian, abdominal, cervical, broad ligament, and uterine cornual pregnancy being less common. As more cases of ectopic pregnancy are diagnosed and treated in the early stages, the survival rate and fertility retention significantly improve. However, complications of abdominal pregnancy can sometimes be life-threatening and have severe consequences. CASE PRESENTATION We present a case of intraperitoneal ectopic pregnancy with fetal survival. Ultrasound and magnetic resonance imaging showed a right cornual pregnancy with a secondary abdominal pregnancy. In September 2021, we performed an emergency laparotomy, along with additional procedures such as transurethral ureteroscopy, double J-stent placement, abdominal fetal removal, placentectomy, repair of the right uterine horn, and pelvic adhesiolysis, in the 29th week of pregnancy. During laparotomy, we diagnosed abdominal pregnancy secondary to a rudimentary uterine horn. The mother and her baby were discharged eight days and 41 days, respectively, after surgery. CONCLUSIONS Abdominal pregnancy is a rare condition. The variable nature of ectopic pregnancy can cause delays in timely diagnosis, resulting in increased morbidity and mortality, especially in areas with inadequate medical and social services. A high index of suspicion, coupled with appropriate imaging studies, can help facilitate its diagnosis in any suspected case.
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Affiliation(s)
- Xingju Zheng
- Department of Radiology, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Yao Zhou
- Department of Radiology, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Zhucheng Sun
- Department of Vascular Surgery, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Ting Yan
- Department of Gynecology, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Yan Yang
- Department of Radiology, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Rongpin Wang
- Department of Radiology, Guizhou Provincial People's Hospital, Guiyang, 550002, China.
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Utalo T, Getu J. A unique case of coexisting intrauterine and abdominal pregnancy which progress to term with a positive birth outcome. BMC Pregnancy Childbirth 2022; 22:243. [PMID: 35331173 PMCID: PMC8944064 DOI: 10.1186/s12884-022-04561-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 03/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The term heterotopic pregnancy is defined as a uterine pregnancy coexisting with a second pregnancy in an extrauterine location. Spontaneous, full-term heterotopic pregnancy with alive birth is very rare. The diagnosis and management of such exceptionally unique case is difficult. When the patient presented with an advanced labor with no antenatal care follow up and with no risk factors is even more challenging for poorly equipped facilities like ours. CASE PRESENTATION A 25 years old gravida 3, para 2 (both are alive) mother presented to the labor and delivery ward of Bele Primary Hospital, Southern Ethiopia with the complaint of pushing down pain of 18 h duration. Immediately after arrival, she gave birth to a 3300gm female neonate spontaneously. After delivery, an abdominal mass was recognized and manual exploration of the uterus was done to look for the presence of after coming second twin but the uterus was empty. On ultrasound examination, there was an alive fetus in transverse lie outside the uterus. With the impression of 2nd twin in a separate horn of bicornuate uterus and to rule out abdominal pregnancy, laparotomy was done. On laparotomy, there was abdominal pregnancy in the Pouch of Douglas with an intact amniotic sac. The sac was attached with the left broad ligament, left ovary, small bowel mesentery, and posterior wall of the uterus. The sac opened, a 1600gm alive female neonate with features of fetal growth restriction and left club foot was delivered. The placenta was detached spontaneously and removed without any complication. CONCLUSIONS The coexistence of spontaneous full-term intrauterine with advanced abdominal ectopic pregnancy is one of the rarest forms of heterotopic pregnancy. Every health professional should bear in mind that intrauterine and extrauterine pregnancy may happen simultaneously and it can progress to term without any symptoms. Ultrasound is the diagnostic method of choice but the existence of an intra-uterine pregnancy cannot rule out ectopic pregnancy. The life-threatening complication of abdominal ectopic pregnancy is bleeding from the detached placental site. Therefore, the decision to remove the placenta should be individualized.
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Affiliation(s)
- Tadiwos Utalo
- Bele Primary Hospital, Wolaita Zone, Wolaita Sodo, Southern Ethiopia, Ethiopia.
| | - Jenenu Getu
- Bele Primary Hospital, Wolaita Zone, Wolaita Sodo, Southern Ethiopia, Ethiopia
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Mushema BN, Nkwama BS, Rweyemamu GA, Makanda IH, Chiduo M. Challenges in Diagnosis and Management of Second Trimester Omental Pregnancy in Limited Resource Settings: Case Report. East Afr Health Res J 2022; 6:11-17. [PMID: 37928869 PMCID: PMC10624215 DOI: 10.24248/eahrj.v6i1.673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 06/29/2022] [Indexed: 11/07/2023] Open
Abstract
Background Abdominal pregnancies are a rare occurrence and are associated with high maternal and perinatal mortality rates compared to intra-uterine and other ectopic pregnancies. Localization of sites of abdominal pregnancies and determining the gestational age at the time of diagnosis play a fundamental role in guiding the treatment approach and minimizing potential complications. However, the vague presentation coupled with low accuracy of ultrasound detection often leads to misdiagnosis of abdominal pregnancy, and hence delaying initiation of appropriate management. We present a case of a second trimester abdominal pregnancy detected following failure of induction for an initial diagnosis of missed abortion, and the ensuing outcome, rarely reported in limited-resource settings. Case presentation A 19 year old unbooked woman, gravida 2 para 1 at 17th week gestation age by ultrasound presented with loss of foetal movement for one week. Based on clinical assessment and referral ultrasound findings, she was initially diagnosed with missed abortion and planned for induction. Failure of induction prompted a repeat ultrasound which revealed a non-viable abdominal pregnancy. Laparotomy was done, localisation of the pregnancy at the omentum was observed and a dead foetus was extracted with the placenta left in-situ. A complication of surgical wound dehiscence with infection developed post-operatively and was managed with secondary sutures. The patient recovered and was discharged in a stable condition. Conclusion This case demonstrates that the diagnosis of abdominal pregnancy remains a challenge especially in settings where skilled human resources for health are few and equipment and supplies for effective and timely treatment are limited. The case sheds some light on the broader challenges in maternal and perinatal health in developing countries. Accurate pre-operative diagnosis requires a high index of suspicion, especially due to the variability of its presentation. This case emphasises the important of quality antenatal care and the need for clinicians to conduct comprehensive assessments of patients and receive training on obstetric ultrasound skills.
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Affiliation(s)
- Beata Nyangoma Mushema
- Department of Obstetrics and Gynaecology, Hubert Kairuki Memorial University, Dar es Salaam, Tanzania
| | | | | | - Isaac Hamis Makanda
- Department of Obstetrics and Gynaecology, Hubert Kairuki Memorial University, Dar es Salaam, Tanzania
| | - Monica Chiduo
- Department of Obstetrics and Gynaecology, Hubert Kairuki Memorial University, Dar es Salaam, Tanzania
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Abstract
Abdominal pregnancy is a rare form of ectopic pregnancy with high morbidity and mortality. There are a limited number of case reports of abdominal ectopic pregnancies. We present a case of a 29-year-old woman who presented to her obstetrician at 17 weeks' gestation with abdominal pain. A sonogram and confirmatory magnetic resonance imaging demonstrated an abdominal ectopic pregnancy. The patient underwent exploratory laparotomy with removal of the ectopic pregnancy. Our case presents an opportunity to discuss a rare form of ectopic pregnancy and the importance of proper diagnosis and treatment to reduce morbidity and mortality.
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Affiliation(s)
- Reshma George
- College of Medicine, Texas A&M Health Science Center, Dallas, Texas
| | - Edward Powers
- Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, Texas
| | - Robert Gunby
- Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, Texas
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Eisner SM, Ebert AD, David M. Rare Ectopic Pregnancies - A Literature Review for the Period 2007 - 2019 on Locations Outside the Uterus and Fallopian Tubes. Geburtshilfe Frauenheilkd 2020; 80:686-701. [PMID: 32675831 PMCID: PMC7360401 DOI: 10.1055/a-1181-8641] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 05/19/2020] [Indexed: 02/05/2023] Open
Abstract
The majority of ectopic pregnancies (EP) are tubal pregnancies, but other implantation sites outside the uterus and tubes are also found. These rare EP locations present a particular diagnostic and therapeutic challenge. We present an overview of potential very rare locations of ectopic pregnancies, their symptoms, diagnosis and treatment, based on a systematic analysis of case reports. A literature review of the databases PubMed, Livivo and Google Scholar for the period 2007 to 2019 was carried out. A total of 113 publications were included in our review. These studies describe EP implantations in the posterior cul-de-sac, on the uterine serosa and uterine ligaments, in the vicinity of almost all intraperitoneal organs, on the abdominal wall as well as in retroperitoneal sites. The most common presenting symptom was abdominal pain occurring in different locations. The diagnostic procedures included various imaging procedures and/or explorative surgery at different advanced stages of pregnancy. The most common and preferred option was laparotomy for surgical treatment. The placenta was successfully resected in the majority of cases. A rare EP location should be considered when making a differential diagnosis in patients of child-bearing age with abdominal pain.
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Affiliation(s)
- Sophie M. Eisner
- Charité – Universitätsmedizin Berlin, Klinik für Gynäkologie, Campus Virchow Klinikum, Berlin, Germany
| | - Andreas D. Ebert
- Praxis für Frauengesundheit, Gynäkologie und Geburtshilfe, Berlin, Germany
| | - Matthias David
- Charité – Universitätsmedizin Berlin, Klinik für Gynäkologie, Campus Virchow Klinikum, Berlin, Germany
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