Unidentified chronic pelvic pain due to hematometra non-communicating left horn uterus unicornuate with history of abdominal pregnancy

INTRODUCTION

This study aimed to characterize unicornuate uterus with noncommunicating horns, an uncommon Müllerian abnormality. With a 0.06 % incidence rate, this disorder can lead to endometriosis linked to retrograde menstruation or hematometra, which can cause significant pelvic pain.

CASE PRESENTATION

A 39-year-old woman with chief complaints of severe dysmenorrhea for five years. Despite receiving hormone therapy, the patient's symptoms persisted. She has only one living child born at laparotomy for an abdominal pregnancy 19 years ago. Upon ultrasound inspection, a 2.8 × 3 cm endometrioma was the only finding. Prior to her laparoscopic procedure, the woman had a unicornuate uterus on her right side with a normal cervix, and also a non-communicating hemiuterus in her left horn that had burst due to adhesion separation and was leaking chocolate fluid. On the left side, there was also a 3 × 3 cm endometrioma. Following that, a laparoscopic hysterectomy was carried out.

DISCUSSION

Although misread occasionally, the correct diagnosis of a unicornuate uterus with a noncommunicating horn is clinically important. The history of this patient's abdominal pregnancy may have developed in the rudimentary horn after sperm or fertilized eggs moved trans peritoneally, with life-threatening consequences if ruptured. This patient developed severe dysmenorrhea after receiving hormonal therapy, possibly caused by a noncommunicating left horn uterine hematometra and endometrioma. In this case, a laparoscopic hysterectomy was afterward chosen due to the patient's request according to her symptoms.

CONCLUSION

Unicornuate uterine with non-communicating horns is scarce however may cause severe complications. Considered a treatment to prevent related morbidity, laparoscopy is necessary to affirm the diagnosis.

Early abdominal pregnancy in a spontaneous heterotopic pregnancy: Case report

INTRODUCTION AND SIGNIFICANCE

Spontaneous heterotopic pregnancies, concurrently occurring intrauterine and ectopic pregnancies, pose a substantial risk to maternal health and are often misdiagnosed. This case report details the challenges in identifying and managing an exceptionally rare case of abdominal pregnancy without assisted reproduction. The patient's initial misdiagnosis underscores the complexities in diagnosis, emphasizing the importance of comprehensive imaging techniques.

CASE PRESENTATION

We present the case of a 36-year-old gravida 5, para 3, with a history of dilation and curettage, experiencing a heterotopic pregnancy involving delayed miscarriage in both uterine and abdominal cavities. Despite presenting symptoms of pelvic pain and abnormal vaginal bleeding, the abdominal pregnancy was initially overlooked in ultrasound examinations. The accurate diagnosis was only achieved post-miscarriage, leading to a timely intervention through laparotomy.

CLINICAL DISCUSSION

The absence of identifiable risk factors, except for the patient's history of dilation and curettage, highlights the spontaneous nature of this non-assisted reproduction-related pregnancy. This case emphasizes the challenges in diagnosing and managing spontaneous heterotopic pregnancies, particularly when an abdominal pregnancy is involved. Vigilance and advanced imaging techniques are crucial for early recognition and appropriate intervention.

CONCLUSION

This unique case underscores the difficulties in diagnosing and managing spontaneous heterotopic pregnancies, especially when an abdominal pregnancy is present. Vigilance and advanced imaging are essential to identify rare occurrences like abdominal pregnancies that may go unnoticed in conventional ultrasound examinations. Early recognition and intervention are critical in averting potential life-threatening consequences associated with this uncommon condition.

Prolonged abdominal pregnancy incidentally discovered during cesarean section: a case report

BACKGROUND

Abdominal pregnancy is a rare medical condition that is still missed in developing countries due to inadequate medical facilities. The clinical indicators manifest in various forms and are nonspecific, making it challenging to diagnose and often leading to delayed detection. However, obstetric ultrasound serves as an essential tool in early detection. Our objective was to share our experience dealing with this condition and emphasise the importance of early ultrasound diagnosis through efficient pregnancy monitoring in our regions.

CASE PRESENTATION

35-year-old Black African woman who had ten months of amenorrhea sought consultation due to an absence of active foetal movements. Her pregnancy was of 39 weeks with fetal demise which was confirmed following clinical examination and ultrasound. She underwent cesarean section in view of transverse position of fetus. During cesarean section, the fetus was found within the abdominal cavity with the placenta attached over the left iliac fossa including surface of left ovary. The uterus and right adnexa were within normal limits. A 2600 g macerated fetus with placenta and membranes were extracted without any complications. The maternal outcome was successful.

CONCLUSIONS

Abdominal pregnancy remained an inadequately diagnosed condition in developing countries. It is imperative to increase awareness among pregnant women regarding high-quality prenatal care, including early obstetric ultrasound, from conception. Meanwhile, healthcare professionals should receive continuous training and the technical platform modernised. To ensure accurate diagnosis, the location of the gestational sac must be identified for every pregnant woman during their initial ultrasound appointment.

Challenges and perspectives of abdominal pregnancy in a resource-limited setting: A case series

INTRODUCTION AND IMPORTANCE

Abdominal pregnancies, although rare, present unique challenges in both diagnosis and management. This case series reports on four cases of abdominal pregnancies diagnosed in a remote and underserved region of the Democratic Republic of Congo, highlighting the difficulties encountered in an under-equipped environment.

CASE PRESENTATION

The cases were documented in a remote village of DRC, which lacks specialized medical personnel and relies heavily on traditional healers. We report here 4 cases of abdominal pregnancies, their clinical presentations, diagnostic modalities, and surgical approaches. The cases varied in terms of clinical symptoms, gestational age, and placental implantation sites. Delayed diagnosis and presentation were common, resulting in significant hemoperitoneum and adverse fetal outcomes. All cases required laparotomy for both diagnosis and intervention.

CLINICAL DISCUSSION

Abdominal pregnancies can go undetected until advanced gestational age, with common physical findings including abdominal tenderness, abnormal fetal lie, fetal body parts readily palpable, and a displaced cervix. Laboratory tests may raise suspicion, but treatment options depend on intraoperative findings and gestational age. Advanced abdominal pregnancies are associated with high mortality rates for both the mother and the fetus. Laparotomy is typically required for diagnosis and intervention, with variations in placental implantation sites. Management of the placenta remains a debated topic, with partial or complete removal both viable options.

CONCLUSION

Abdominal pregnancies pose significant challenges in resource-poor settings, where limited healthcare resources and a shortage of specialized medical personnel can impede early diagnosis and appropriate management. Enhancing prenatal care, improving diagnostic capabilities, and increasing awareness among healthcare providers and communities are essential for optimizing outcomes in these complex obstetric cases.

Acute generalized peritonitis revealing an ovarian pregnancy: a case report

Introduction and importance

Abdominal pregnancy is still seen in developing countries due to inadequate medical facilities. The clinical indicators manifest in various forms and are nonspecific, making it challenging to diagnose and often leading to delayed detection. The occurrence of an infectious complication that leads to the development of generalised acute peritonitis is rare. The author present a case of 34-year-old patient who presented with febril generalised acute peritonitis caused by an abdominal pregnancy. The result of the abdominal ultrasound and the serum β-human chorionic gonadotropin (β-HCG) level led to initial diagnostic confusion.

Case presentation

A 34-year-old primigravida with no medical or surgical history of comorbidity prior consulted in the authors' department for generalised abdominal pain in the context of fever and amenorrhoea for more than 4 months. Physical examination revealed a painful and contracted abdomen. The biological assessment showed white blood cells at 27 100/ul, the haemoglobin level at 11.8 g/dl. The serum β-HCG level was less than 5 UI/l. The abdominal ultrasound noted a peritonitis secondary to an abscess of the appendix. Exploratory laparotmy revealed 200 ml of pus in the peritoneum and a mass in the right iliac fossa at the expense of the ovary with agglutination of the intestines loops. After adesyolysis, a single-piece excision of the mass was performed, the break-in showing a macerated foetus, a right adnexectomy and an appendectomy. The maternal outcome was good.

Clinical discussion

Abdominal pregnancy remains an inadequately diagnosed condition in developing countries. This case reminds clinicians that abdominal pregnancy remains a differential diagnosis of all abdominal pain in a woman of childbearing age including when the serum β-HCG level was less than 5 UI/l.

Conclusion

It is imperative to increase awareness among pregnant women about high-quality prenatal care, including early obstetric ultrasound, from conception. Meanwhile, healthcare professionals should receive continuous training and the technical platform modernised.

Case Report of an exceptional spontaneous abdominal heterotopic pregnancy with superfetation: Diagnosis and treatment: Heterotopic pregnancy with superfetation (8+1 WG & 5+4 WG)

Heterotopic pregnancy is an extremely rare condition in which an intrauterine and an extrauterine pregnancy co-exist. In spontaneous conceptions, heterotopic pregnancy occurs in only 1/30 000 pregnancies. The treatment of heterotopic pregnancy must be as minimally invasive as possible to preserve the development of the intrauterine pregnancy. Superfetation, defined as the coexistence of 2 or more foetuses of different gestational ages, remains particularly exceptional and poorly explained (second ovulation? embryonic diapause?). Here, we present an extremely rare case of a spontaneous heterotopic evolutive pregnancy with superfetation, consisting of an embryo in the pouch of Douglas estimated at 8 + 1 weeks of gestation (WG) and a progressive intrauterine pregnancy estimated at 5 + 4 WG. We treated the extrauterine pregnancy with an intra-cardiac injection of potassium chloride echo-guided via the vaginal route, and the patient then underwent exploratory laparoscopy 9 days later and lavage and aspiration of the abdominal heterotopic pregnancy due to pain and biological inflammatory syndrome probably caused by pelvic mass syndrome and peritoneal irritation from the foetal necrosis. She has not yet given birth and is currently at 36 WG.

Advanced abdominal ectopic pregnancy and the role of antenatal ultrasound scan in its diagnosis and management

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.

Nontubal ectopic pregnancies: overview of diagnosis and treatment

Nontubal ectopic pregnancies occur as a result of embryo implantation outside the uterine cavity and fallopian tubes. Sites include ovary, cervix, abdominal cavity, interstitial portion of fallopian tube, and cesarean scar. Nontubal pregnancies are uncommon. Nonspecific signs and symptoms of nontubal ectopic pregnancies make diagnosis challenging and, in many cases, significantly delayed, resulting in a high rate of morbidity. Although surgical management remains the mainstay of treatment, there is growing evidence that some of these can be managed medically or with the use of a combination of medical and surgical approaches with good outcome. This review summarizes the current diagnostic modalities, therapeutic options, and outcomes for nontubal ectopic pregnancies. Diagnostic and management options may be limited, especially in resource-restricted settings. Therefore, an understanding of the available options is critical. It needs to be emphasized that the rarity of cases and the difficulties in organizing ethically justified randomized trials result in the lack of well-established management guidelines for nontubal ectopic pregnancies.

A delayed spontaneous second-trimester tubo-abdominal pregnancy diagnosed and managed by laparotomy in a "self-identified" infertile woman, a case report and literature review

BACKGROUND

Abdominal pregnancy, a rare form of ectopic pregnancy, is associated with high morbidity and adverse consequences for future fertility. Early recognition and management reduce mortality and allow minimal invasive and conservative treatment. In modern medicine, primitive prevention to unexpected fatal pregnancies is crucial.

CASE PRESENTATION

A divorced 33-year-old "self-identified" infertile polycystic ovary woman diagnosed as repeated implantation failure in previous in vitro fertilization with her ex-husband ever presented in surgery department with a history of 15-day abdominal pain, nausea, and vomiting and 3-h worsening abdominal pain. The serum beta-human chorionic gonadotropin value was more than 10,000 m-international units per milliliter. Sonogram findings were significant for the absence of intrauterine gestation; a placenta and well-formed living fetus of second-trimester gestation were seen in the abdomen, accompanied by hemoperitoneum. A unique spontaneously second-trimester tubo-abdominal pregnancy was confirmed in emergent laparotomy by gynecologists, she received a removing of the living fetus, a right total salpingectomy, resection of partial omentum and blood transfusion. The patient recovered uneventfully and her serum beta-human chorionic gonadotropin returned to normal range on the 30th postoperative day, till now, she has weak fertility awareness because of her catastrophic experiences in the unexpected abdominal pregnancy.

CONCLUSIONS

This case highlights woman with a previous in vitro fertilization history may be in is a high risk to be delayed or missed in diagnosis in an intended ectopic pregnancy due to a fixed belief in infertility. Educational interventions and contraceptive care should be provided by fertility and healthcare practitioner. The possibility of abdominal pregnancy must always be suspected and dealt with promptly and appropriately by the astute clinician.

Conservative management of complete fetal expulsion into the abdominal cavity after silent uterine rupture - case report

BACKGROUND

Clinically silent uterine rupture with complete fetal expulsion into the abdominal cavity is an extremely rare complication. Diagnosis can be difficult and the risk to the mother and fetus is high. Conservative management has been described only in a few cases of partial expulsion of the fetus so far.

CASE PRESENTATION

We present a case of 43-year-old tercigravida with a history of previous laparotomic myomectomy and subsequent cesarean section. The subsequent pregnancy was complicated by uterine wall loosening and rupture at the site of the previous uterine scar after myomectomy and complete fetal expulsion into the abdominal cavity. The diagnosis was made at 24 + 6 weeks of gestation. Considering the absence of clinical symptomatology and the good condition of the fetus, a conservative approach was chosen with intensive monitoring of the maternal and fetal conditions. The pregnancy ended by elective cesarean section and hysterectomy at 28 + 0 weeks of gestation. The postpartum course was uneventful and the newborn was discharged to home care 63 days after delivery.

CONCLUSIONS

Fetal expulsion into the abdominal cavity after silent uterine rupture of the scarred uterus may be accompanied by minimal symptomatology making early diagnosis difficult. This rare complication must be considered in the differential diagnosis in women after major uterine surgery. In selected cases and under conditions of intensive maternal and fetal monitoring, conservative management may be chosen to reduce the risks associated with prematurity.

Right abdominal pregnancy with hemorrhagic shock after previous left tubal pregnancy: A case report

Abdominal pregnancy is the rarest ectopic pregnancies, with an incidence of 1 per 10,000 live births, and life-threatening because the symptoms are not specific and diagnosis is made after abdominal pain, amenorrhea and vaginal bleeding occur. We present a rare case of abdominal pregnancy in a 31-year-old Indonesian woman with severe abdominal pain within 24 hours before hospital admission, accompanied by nausea, vomiting, dizziness and weakness. She felt the pain increasing since the last 2 weeks and limiting her movement. She has a history of a left tubal pregnancy 5 years ago. Ultrasonography examination revealed an ectopic pregnancy, and she was rushed to the operation room for emergency exploratory laparotomy. An abdominal pregnancy was found, located in the right adnexa with excessive fluid in cavum Douglass and a foetus in around 11-12 weeks of gestation accompanied by free fluid in the subdiaphragmatic, subhepatic and pelvic cavity. The surgery was a successful, four units of whole blood were transfused, and the patient was safely discharged from the hospital. The current concept on management of abdominal pregnancy supports immediate surgical intervention with pregnancy termination, as found in this case, because the patient's condition is hemodynamically unstable indicating hemorrhagic shock correlated with massive hemoperitoneum. A prompt diagnosis and good teamwork in treatment plays an important role for such a life-threatening condition to avoid maternal morbidity and mortality in a case of abdominal pregnancy.

Abdominal pregnancy secondary to uterine horn pregnancy: a case report

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.

Rudimentary horn pregnancy, a differential diagnosis of an intraabdominal pregnancy: a case report

BACKGROUND

Rudimentary horn pregnancy is a rare life-threatening obstetric condition with clinical and sonographic presentation resembling that of an abdominal pregnancy. Preoperative diagnosis of advanced rudimentary horn pregnancy is difficult and cases are often identified incidentally during laparotomy for a presumed abdominal pregnancy.

CASE PRESENTATION

We report a case of a 29-year-old African woman, gravida 2 para 1 at 28 weeks of gestation complaining of epigastric pain for 7 days with no other associated gastrointestinal or genitourinary symptoms. On examination, she had normal vital signs and an enlarged abdomen sized at 33 cm with unremarkable fetal lie and presentation. She had normal laboratory blood results with an ultrasound revealing an abdominal pregnancy of 28 weeks. The informed decision for conservative management was planned after informing of the benefit and risks of early termination versus conservative management, however, with worsening symptoms an emergency laparotomy had to be performed in which a left unruptured rudimentary horn pregnancy with a viable fetus was identified incidentally and delivery of the fetus followed by surgical excision of the horn was done. The postoperative period was uneventful, and the patient was discharged home with her newborn.

CONCLUSION

Rudimentary horn pregnancy is very rare and often indistinguishable from an abdominal pregnancy in advanced gestation age. First trimester ultrasound is by far the only noninvasive sensitive diagnostic modality for rudimentary horn pregnancy. Laparotomy with horn excision remains the standard of care for advanced rudimentary horn pregnancy.

Abdominal pregnancy with a live newborn in a low-resource setting: A case report

Abdominal pregnancy is defined as pregnancy anywhere within the peritoneal cavity, exclusive of tubal, ovarian, or broad ligament locations. It is a rare form of ectopic pregnancy with high morbidity and mortality for both the mother and the fetus. Diagnosis can be frequently missed in low-resource settings because of poor antenatal healthcare provision, low socioeconomic patient status as well as lack of adequate medical resources. Clinical diagnosis can be difficult and ultrasound scan is helpful during the early stages of gestation but can be disappointing thereafter. A case of abdominal pregnancy in a 25-year-old woman, who presented at 26 weeks of gestation with severe abdominal pain not relieved by any medication, is reported. An emergency laparotomy was undertaken as her vital signs deteriorated. An abdominal pregnancy was found and a live neonate delivered. Ministries of health in developing countries should ensure routine access to ultrasound in early pregnancy. Obstetricians should bear in mind that abdominal pregnancy can present late in gestation.

Abdominal pregnancy: a case report and review of 17 cases

PURPOSE

To analyze the clinical characteristics of abdominal pregnancy, and to explore the diagnosis and prognosis of different treatment methods.

METHODS

The cases of patients with abdominal pregnancy admitted to Peking Union Medical College Hospital between January 1, 1989 and January 1, 2021, were analyzed retrospectively.

RESULTS

The median age of 17 patients was 34 years (22-42 years); the median gestational duration was 57 days (from 41 days to 32 weeks). Among all 17 patients, 15 (88.24%) presented with abdominal pain. The implantation sites of the gestational sac included the bladder peritoneal reflection, anterior wall of the rectum, omentum, serous membrane of the uterus, and inside or on the surface of uterosacral ligament. In all, only 29.41% cases (5/17) were diagnosed before surgery. All 17 patients were treated via surgery. Further, 58.82% (10/17) patients recovered without complications, 29.41% (5/17) developed fever, 5.88% (1/17) underwent reoperation because of intra-abdominal bleeding, and 5.88% (1/17) developed double lower limb venous thrombosis. All 17 patients survived.

CONCLUSION

The preoperative diagnosis rate of abdominal pregnancy is low. Planting sites in the pelvic peritoneum and pelvic organs are more common than the others. Laparoscopic surgery in the first trimester of pregnancy can achieve better therapeutic effects. However, the blood supply of the placenta should be fully evaluated before surgery. When it is expected that attempts to remove the placenta will cause fatal bleeding, the placenta can be left in place, but long-term close follow-up should be paid attention to.

A unique case of coexisting intrauterine and abdominal pregnancy which progress to term with a positive birth outcome

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.

Term Spontaneous Heterotopic Pregnancy (Abdominal and Intrauterine): A Case Report

Spontaneous heterotopic pregnancy is a potentially life-threatening condition rarely considered when a patient with an intrauterine pregnancy is asymptomatic or presents with complaints such as abdominal pain. An advanced abdominal pregnancy is even more unusual as the form of the ectopic component outside the context of assisted reproduction and is difficult in diagnosis with very few cases reported in the literature. We report such a case in a 31-year-old primigravida with heterotopic pregnancy which is a fetus in the uterine cavity and the other in the abdominal cavity. Her pregnancy was initially misdiagnosed and managed as a di-amniotic di-chorionic gestation. The correct diagnosis was only made after term delivery of the intrauterine pregnancy. The patient was complicated with severe bleeding which led to disseminated intravascular coagulopathy and massive transfusion. Two other operations were imposed on the patient because of bleeding. The clinical risk factor for ectopic pregnancy was only previous pelvic inflammatory disease in this woman.

"Nerve-sparing" laparoscopic treatment of parametrial ectopic pregnancy

OBJECTIVE

To demonstrate laparoscopic surgical management of parametrial ectopic pregnancy.

DESIGN

Video presentation of laparoscopic nerve-sparing treatment of parametrial pregnancy.

SETTING

Tertiary university center.

PATIENT(S)

A 33-year-old patient, nullipara at 8 weeks of gestation, with no comorbidity and no previous surgery, was admitted to a spoke hospital for acute abdominal pain. During hospitalization, a transvaginal gynecologic ultrasound revealed pregnancy with ectopic localization. Free pelvic fluid was detected, and a subsequent diagnostic laparoscopy was performed because of worsening symptoms. During the procedure, hemoperitoneum drainage was instituted and American Society of Reproductive Medicine stage III pelvic endometriosis was diagnosed. A round formation approximately 3 cm in diameter was found at the left posterior parametrium (Fig. 1). Due to the pregnancy position and β-human chorionic gonadotropic (β-hCG; 820 mUI /mL) values, conservative treatment was chosen. Thus, methotrexate at 50 mg/m² body surface area was administered. A second dose of methotrexate was administered seven days after the first one, and the β-hCG increased to 1068 mUI. On day 14 after treatment, the β-hCG was 1053 mUI/mL. Therefore, surgical treatment was chosen, and the patient was transferred to our center. An ultrasound assessment confirmed the ectopic pregnancy with a live fetus in the left posterior parametrium.

INTERVENTION(S)

The patient underwent operative laparoscopy to remove the ectopic pregnancy. Surgery was performed using a 3-dimensional optical system (TIPCAM 1, S D3-LINK; Karl Storz SE & Co., Tuttlingen, Germany). After drainage of the hemoperitoneum, the gestational sac was identified in the left posterior parametrium. The uterus, tubes, and ovaries showed normal morphology. Pelvic endometriosis was confirmed. After accessing the left pelvic retroperitoneum with the medial and lateral pararectal spaces' opening and development, ipsilateral ureterolysis was necessary to isolate the parametrial pregnancy in close contact with it. Coagulation and sectioning of the deep uterine veins were essential to control hemostasis. Identification of the left hypogastric nerve, which was partially infiltrated by the chorionic villi, and the pelvic splanchnic nerves, was required to safeguard them (Fig. 2). Subsequently, the surgeon decided to place a ureteral stent to prevent urologic complications.

MAIN OUTCOME MEASURE(S)

The laparoscopic approach proved to be safe and feasible to manage parametrial pregnancy.

RESULT(S)

The pregnancy was removed entirely. The patient was discharged 72 hours after the procedure with an uneventful postoperative course. The histologic report confirmed the diagnosis of parametrial pregnancy on decidualized endometriotic tissue. The β-hCG serum level became negative in 20 days.

CONCLUSION(S)

Extrauterine pregnancies represent one of the leading causes of maternal death in the first trimester and constitute approximately 1%-2% of total pregnancies. Of these percentages, only 5%-8.3% are nontubal. Cases of abdominal pregnancy are even rarer, estimated at <1%, and among these, according to a recent review, only 20 cases of retroperitoneal pregnancy were described in the literature. The intraoperative finding of multiple endometriotic implants on the parietal peritoneum above the retroperitoneal pregnancy, together with the decidualized endometriosis result of the histologic examination have been considered to explain the pathogenesis of the condition. It is plausible to suppose that endometriosis has represented the access route for the fertilized ovum, which implanted on endometriotic superficial tissue and then moved toward the retroperitoneal vascularized structures. The diagnosis and treatment are challenging for the gynecologist. Medical treatment is a valid approach to uninterrupted early ectopic pregnancies; however, symptomatic patients' medical therapy failure is one indication for a surgical procedure. The laparoscopic method is optimal, especially in cases like the reported one, in which minimally-invasive techniques allowed complete removal of the pregnancy, respecting the anatomic structures of the retroperitoneum using nerve-sparing techniques. Furthermore, it ensured a safe ureteral stent placement without imaging. The laparoscopic surgical approach can be a safe and feasible option. It allows an early discharge, with a minimum risk of dysfunctional complications, and improves life quality compared to more destructive interventions. In conclusion, to control vascular, nervous, and urinary tract structures, surgical treatment should be based on anatomic knowledge of retroperitoneal anatomy to guarantee the best surgical outcome.

Abdominal pregnancy diagnosed by ultrasonography and treated successfully by laparotomy: Two cases report

Introduction

Abdominal pregnancy is one of the rare types of ectopic pregnancies that has a high rate of mortality. Its clinical presentation is similar to those of the other types of ectopic pregnancies.

Cases presentation

we report two cases of abdominal pregnancies whose the diagnosis was made by ultra-sonography and successfully treated by laparotomy in emergency obstetrical department of Ibn Rochd University Hospital of Casablanca.

Clinical discussion

the ultra-sonography based on precise criteria represents the fundamental paraclinical examination in the diagnosis of abdominal pregnancies. The treatment of early form is based on surgery; And despite the advent of laparoscopic surgery, laparotomy retains its indications including forms with hemorrhagic shock.

Conclusion

Due to the high risk of complications and maternal mortality, abdominal pregnancies should be surgically treated as soon as possible when the diagnosis is confirmed.

•

Abdominal pregnancy is an exceptional type of ectopic pregnancies.

•

Their diagnosis is difficult to distinguish from other types of ectopic pregnancies.

•

Abdominal pregnancies should be surgically treated as soon as possible when the diagnosis is confirmed.

The use of FIESTA sequence MRI in successful management of abdominal pregnancy

Identification of fetal location and its relations to abdominal organs is extremely important in reducing fetal and maternal morbidity in rare cases of abdominal pregnancy. Ultrasound examination is inadequate for helping to successfully manage such cases. In this case report, FIESTA sequence MRI is used to provide high-resolution, better contrast, and higher signal-to-noise ratio fetal and abdominal images. A case of advanced abdominal pregnancy with a live fetus is reported. The surgery was conducted successfully on 34 weeks of gestation.

Managing Ruptured Splenic Ectopic Pregnancy Without Splenectomy: Case Report and Literature Review

Splenic ectopic pregnancy is extremely rare but carries a high risk of uncontrollable life-threatening bleeding. Our aim is to try to diagnose those cases earlier and to include splenic preservation as good alternative for selected cases. Extensive review of the literature has been performed. Thirty-one case reports were identified, of which 4 have been excluded because they were not written in English. A 36-year-old woman presented to the Emergency Department with haemorrhagic shock. Despite the levonorgestrel intrauterine system (LNG-IUS) being in situ for 4 months, urinary and serum tests were both positive for pregnancy, and an ultrasound scan revealed haemoperitoneum suggestive of a ruptured ectopic pregnancy. An emergency Pfannenstiel laparotomy was performed and a diagnosis of spontaneous tubal abortion was made and the abdomen was subsequently closed. Following a period of cardiovascular instability on the Intensive Care Unit postoperatively, an urgent CT scan was performed which revealed bleeding from the spleen. A midline laparotomy was performed by the general surgeon, which involved resection of the gestational sac and splenorrhaphy. Twenty-seven cases were reviewed, and 73% of them presented as an emergency and 21 cases (81%) had been managed with splenectomy. CT scan had been used in eight of the previous case reports of splenic ectopic pregnancy with 100% diagnostic accuracy rate. Non-tubal ectopic pregnancies are very rare. Splenorrhaphy is a safe alternative to splenectomy in cases of splenic ectopic pregnancy. CT abdomen and pelvis with intravenous contrast can be very helpful in relatively stable patients with a vaginal ultrasound demonstrating an empty uterus, no clear adnexal masses or free fluid.

Retroperitoneal ectopic pregnancy: A literature review of reported cases

To provide reference for the diagnosis and treatment of retroperitoneal ectopic pregnancy (REP), we conducted a review on all of the reported cases in English by summarizing their clinical manifestation, diagnosis, management and prognosis. A total of 25 literatures including 26 REP cases were collected from PubMed database. 40 % (10/25) of the patients had a history of tubal pregnancy, 65.4 % (17/26) was spontaneous pregnancy, and the average period of amenorrhea was 56.7 days. Abdominal pain is the most common (53.8 %, 14/26) symptom of REP. Ultrasound is the main method of diagnosing REP. Only 30.8 % (8/26) were diagnosed as REP at the initial visit, and 55.6 % (10/18) of those who were misdiagnosed received unnecessary invasive treatment. The pregnancy sites of REP are complex, and it can be simply divided into pelvic REP and abdominal REP. Due to preoperative misdiagnosis, 46.2 % (9/26) of REP experienced two or more treatments. Except for 2 patients who received local methotrexate (MTX) injection in the gestational sac, the other 24 patients underwent surgical treatment, and all patients had a good prognosis. Due to insufficient knowledge, the rate of misdiagnosis and mistreatment of REP is high. The key to diagnosing REP is to consider the possibility of REP and the scanning field during examination can cover the site of pregnancy. Local MTX injection and surgical resection are both effective methods for the treatment of REP.

Abdominal pregnancy during the COVID-19 pandemic

Description of the emergency approach used for management of an abdominal pregnancy during the COVID‐19 pandemic.

Early Abdominal Ectopic Pregnancy Masquerading as a Missed Miscarriage

A 43-year-old lady, gravida 2 para 0, presented to our emergency department with complaints of vaginal bleeding and lower abdominal pain. Her urine pregnancy test was positive. She was unable to recall her last menstrual period. A trans-vaginal ultrasound revealed a pregnancy with a crown rump length of 47 mm corresponding to 11.4 weeks with no fetal heartbeat detected. She was diagnosed with a missed miscarriage and was sent for a second confirmatory scan. The repeat scan was concordant with the initial scan and she was counseled for an evacuation of uterus. Her serum beta human chorionic gonadotropin level was 45,195 IU/L and her hemoglobin level was 6.5 g/dL. She underwent an evacuation of uterus as planned, but the Hegar dilator was only able to be advanced to a cavity length of 6 cm with minimal products of conception obtained. A bedside ultrasound was performed and it showed that the Hegar dilator was in the uterine cavity but not in continuity with the gestational sac and fetus. The diagnosis of an ectopic pregnancy was made and the surgery was converted to a diagnostic laparoscopy. On entry into the abdominal cavity, there was frank hemoperitoneum with adhesions limiting access to the pelvis, therefore decision was made to convert to laparotomy. The findings at laparotomy revealed a large inflamed left tubo-ovarian complex with tubal rupture and expulsion of the entire fetus and placenta into the Pouch of Douglas (POD). The diagnosis of a secondary implantation of the ectopic pregnancy in the POD after tubal rupture was confirmed and we performed adhesiolysis and left salpingectomy. The patient recovered uneventfully and the final histology showed products of conception within the lumen of the left fallopian tube in keeping with ruptured tubal ectopic pregnancy.

Late abdominal pregnancy in a post-conflict context: case of a mistaken acute abdomen - a case report

Background

Abdominal pregnancies have been reported in both high-income countries as well as low- and middle-income countries. They are frequently missed in routine antenatal care in resource-limited settings and delayed diagnosis is usually associated with poor fetal and maternal outcomes including death. This case report is among the first from eastern Democratic Republic of Congo (DRC), a post-conflict region.

Case presentation

In this case study, we present a 25 year-old primigravida patient referred to HEAL Africa hospital for management of an acute abdomen at 33-weeks gestation. Her chief complaint was severe abdominal pain associated with each fetal movement for a period of 1 week prior to admission. A diagnosis of peritonitis was made. Emergency laparotomy revealed a normal live 2 kg baby with placental implantation on the greater omentum and small intestine mesentery. The placenta was not removed. Both maternal and fetal outcomes were good.

Conclusion

Abdominal pregnancy with a normal live fetus at such an advanced gestational age is rare. This case reminds clinicians that abdominal pregnancy remains a differential diagnosis for painful fetal movements.

Perivascular epithelioid cell tumors (PEComa) in pregnancy with uterine rupture and ongoing abdominal gestation: A case report

Perivascular epithelioid cell tumors (PEComa) represent a rare family of tumors characterized by distinct histology and immunohistochemistry characteristics. Approximately one-quarter of reported cases are gynecologic in origin and associated pregnancies are rare. We report a case of PEComa in pregnancy with initial undiagnosed presentation at 18 weeks of gestation and subsequent presentation and diagnosis at 30 weeks of gestation. Abdominal pain led to the use of magnetic resonance imaging, which raised concerns about placentation abnormality and abdominal pregnancy. Exploratory laparotomy was notable for a 10 cm by 15 cm posterior uterine defect through which the placenta and amniotic sac containing the fetus were extruded. Placenta-like tissue was noted to be invading through the anterior wall of the uterus, which led to concern regarding placenta percreta. A total abdominal hysterectomy and bilateral salpingectomy were then performed, given the complete loss of normal uterine architecture. Pathology returned with findings of placenta accreta and PEComa. Indolent uterine rupture in the setting of PEComa led to an ongoing viable abdominal pregnancy. Uterine PEComa can masquerade as a placenta and lead to obstetrical complications.

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Perivascular epithelioid cell tumors (PEComa) can masquerade as a placenta.

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Perivascular epithelioid cell tumors can lead to uterine rupture during pregnancy.

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Uterine perivascular epithelioid cell tumors can be associated with tuberous sclerosis complex.

Abdominal pregnancy with a healthy newborn: a new case

Abdominal pregnancy is a rare form of ectopic pregnancy with very high morbidity and mortality for both the mother and the fetus. Diagnosis and management can pose some difficulties especially in low-resource centers. We report a case of abdominal pregnancy with a healthy newborn. A 34-year-old Moroccan woman, G4P3 (3 alive children), presented with shortness of breath and progressive abdominal distension and pain at 37 weeks' gestation. An emergency laparotomy was performed with the impression of abdominal pregnancy. Intraoperatively, the fetus was seen in an intact amniotic sac in her abdomen, the placenta was strongly adhered to the fundus and enveloped the left adnexa. A total hysterectomy with a left adnexectomy was performed. The patient and neonate progressed well and were discharged. Term abdominal pregnancy is an extremely rare diagnosis. The life-threatening complication is bleeding from the detached placental site. High index of suspicion is vital in making prompt diagnosis in such situations.

Laparoscopic Removal of an Abdominal Pregnancy in the Pelvic Sidewall

STUDY OBJECTIVE

To describe the presentation, diagnosis, and management of a patient with abdominal pregnancy and to illustrate the laparoscopic technique used to manage this patient.

DESIGN

A descriptive study approved by our local Institutional Review Board. Consent was given from the patient.

SETTING

A university hospital in Ashdod, Israel.

PATIENT

On May 15th 2018, a gravida 3, para 2, 37-year-old asymptomatic patient was referred to our hospital's gynecologic emergency department due to a suspected ectopic pregnancy. The patient had no relevant medical or surgical history. Her obstetric history consisted of 2 spontaneous vaginal deliveries with no other significant gynecologic history. Her menses were regular every month. Her last menstrual period was 6 weeks before presentation. Her β-human chorionic gonadotropin (hCG) level measured on the day before presentation was 24,856 IU/L. Physical examination was unremarkable except for a small amount of brownish vaginal discharge. A transvaginal ultrasound (TVUS) exam on presentation did not demonstrate an intrauterine gestational sac, but revealed a gestational sac and a fetus next to the right adnexa, with a crown-rump length of 1.3 cm, consistent with 7+3 gestational weeks. There was a minimal amount of fluid in the pouch of Douglas.

INTERVENTION

Owing to an extrauterine pregnancy with high β-hCG value, laparoscopic operative management was chosen. On entrance to the abdominal cavity, a normal uterus and 2 ovaries and fallopian tubes were observed. A small to moderate amount of blood was present in the pouch of Douglas. a 3- to 4-cm distension was noted over the right uterosacral ligament. Following delicate probing of the area, moderate to severe bleeding commenced, which was initially controlled with local pressure and oxidized regenerated cellulose. An intraoperative TVUS identified an abdominal pregnancy in the right pelvic sidewall. The gestational sac was completely dissected and removed following ureterolysis and separation of the right ureter from the specimen. Local injection of vasopressin was also used. The β-hCG level before surgery of 19,008 IU/L decreased to 6339 IU/L on postoperative day 1. The patient was discharged in good condition on postoperative day 2. A final histopathological report confirmed a gestational sac.

MEASUREMENT AND MAIN RESULTS

This patient referred for a tubal ectopic pregnancy was eventually diagnosed with an abdominal pregnancy and was treated operatively with complete excision of the abdominal pregnancy, which was located at the right pelvic sidewall.

CONCLUSION

Abdominal pregnancy is a rare type of ectopic pregnancy with a reported incidence of 1:10,000 to 1:30,000 pregnancies, and accounts for approximately 1% of ectopic pregnancies [1]. It carries a high risk for maternal morbidity and mortality. Many different locations at different gestational ages have been reported in the literature, including the pouch of Douglas, pelvic sidewall, bowel, broad ligament, omentum, and spleen [2-4]. These varied locations and the rarity of this type of pregnancy make diagnosis and treatment challenging. The location of the growing fetal tissue may endanger the patient's life if it impinges on vital anatomic structures. In the present case, the gestational sac was very close to the right ureter, and we opted to surgically excise the gestational sac in its entirety.

Abdominal Pregnancy: A Case Report of a Viable Nondysmorphic Fetus

Abdominal pregnancy is a rare form of ectopic gestation. It accounts for about 0.4% of all cases of ectopic pregnancy, and often associated with significant morbidity and mortality. Clinical presentation varies, and diagnosis is commonly challenging. Although ultrasound is helpful in early gestation, this could be unsatisfactory at advanced gestational age. Hence, a high index of suspicion is required in the diagnosis. We present a case of secondary abdominal pregnancy in a 27-year-old gravida 2 para 0 + 1 at an estimated gestational age of 33 weeks and 5 days. She had ultrasound scan done at 9 weeks and 2 days confirming the diagnosis, but declined surgery to seek spiritual intervention. She subsequently presented with generalized abdominal pain and fainting attack. She had exploratory laparotomy with delivery of a live female baby with no congenital anomaly. The placenta was attached to the left infundibulopelvic ligament and was delivered wholly without remnants. She was discharged on the 8^th postoperative day, and the baby was discharged after 14 days from the neonatal intensive care unit. Accurate diagnosis and prompt intervention with evaluation of placenta attachment is vital to prevent adverse consequences.

Diagnosis of abdominal pregnancy still a challenge in low resource settings: a case report on advanced abdominal pregnancy at a tertiary facility in Western Kenya

Abdominal pregnancy is a rare form of ectopic pregnancy, occurring in 1: 10,000 to 1: 30,000 pregnancies and accounting for up to 1.4% of all ectopic pregnancies. It is classified as primary or secondary depending on the site of fertilization. However, when it does happen, it may remain unnoticed until term because the pregnancy can appear normal during clinical examination. Advanced abdominal pregnancy is associated with high mortality rate for both the mother and the baby at 1-20% and 40-95% respectively. We report a case of a 30-year-old female para 2+0, gravida 3 at 35⁺¹ who presented at a Tertiary facility in Eldoret Kenya with one-day history of per vaginal bleeding and 2 weeks' history of no fetal movements. The importance of this case report is to highlight the challenges associated with diagnosis of advanced abdominal pregnancy in low resource settings. Ultrasound alone cannot be relied on to make the diagnosis. Whenever an induction is not working, abdominal pregnancy should be considered.

Magnetic resonance imaging of common, uncommon, and rare implantation sites in ectopic pregnancy

OBJECTIVE

To review the MRI appearances of tubal and non-tubal implantation sites in ectopic pregnancy.

CONCLUSION

Transvaginal ultrasound is the primary imaging modality in ectopic pregnancy and MRI is used as a problem-solving tool in selected indications as detailed in the article. MRI features of tubal, interstitial, cervical, cesarean scar, cornual, ovarian, abdominal, and heterotopic pregnancies are provided to familiarize the radiologists with their appearances thereby assisting them in making early and accurate diagnosis.

A full term abdominal pregnancy with an isthmic tubal implantation of the placenta

Background

Abdominal pregnancy is defined as the partial or total insertion of the embryo into the abdominal cavity. It is rare, and can evolve towards the full term if it is not recognized in the early pregnancy. It carries a high risk of maternal-fetal morbidity and mortality.

Case presentation

We report a case of a 22 year-old gravida IV, para II with an asymptomatic and undiagnosed abdominal pregnancy presumed full term, in a context of health centers under-equipment. She had attended 5 routine antenatal care, but had not performed any ultrasound scan. She had been transferred from a medical center to the Hospital of Ouahigouya (Burkina Faso) for bowel sub-obstruction and intrauterine fetal death, with failure of labor induction. On admission, the hypothesis of uterine rupture or abdominal pregnancy with antepartum fetal demise was considered. A laparotomy was then performed, where an abdominal pregnancy was discovered, and a dead term baby weighing 3300 g delivered. The placenta which was implanted into the ruptured isthmus of the left fallopian tube was removed by salpingectomy. Postoperative follow-up was uneventful.

Conclusion

This case report exposes the necessity for the practitioner to think about the possibility of abdominal pregnancy in his clinical and sonographic practice, irrespective of the gestational age, mainly in contexts where there is under-equipment of the health centers.

[Acute intestinal occlusion revealing abdominal pregnancy: a case study]

Abdominal pregnancy (AP) is defined as the implantation and the development of the fertilized egg in the peritoneal cavity. It is a rare type of ectopic pregnancy, whose detection can be fortuitous, mimicking surgical emergency. We report a rare case of acute febrile bowel obstruction revealing abdominal pregnancy in a 27-year old patient, with no particular past medical history, admitted to hospital for the treatment of occlusive syndrome evolving over the last week. Physical examination showed shiny, distended, meteoric, completely sensitive abdomen. Laboratory tests showed white blood cell count 20300, haemoglobin 7,2g/dL. Surgical exploration showed hemoperitoneum 2000ml, retrouterine encapsulated mass, strongly adherent to the mesosigmoid and to the sigmoid, responsible of a stenosis of the descending colon. The patient underwent monobloc exeresis, which showed a portion of placenta next to the mesosigmoid attached to the fetus, right annexectomy and colostomy.

Extra-uterine (abdominal) full term foetus in a 15-day pregnant rabbit

BACKGROUND

While ectopic pregnancies account for 1-2% of all pregnancies, abdominal pregnancy is extremely rare, accounting for approximately 1% of ectopic pregnancies. Extrauterine abdominal pregnancy is defined as the implantation and development of an embryo in the peritoneal cavity. The present report is the first of an incidental case of abdominal pregnancy within four full-term foetus simultaneously with 2 weeks of physiological gestation in a healthy doe rabbit.

CASE PRESENTATION

The doe was born on November 3, 2014 and the first partum took place on May 18, 2015. The doe had previously delivered and weaned an average of 12.0 ± 1.41 live kits at birth (no stillbirths were recorded) during 5 consecutive pregnancies. The last mating was on December 18, 2015 and the detection of pregnancy failure post breeding (by abdominal palpation) on December 31, 2015. Then, the doe was artificially inseminated on January 27, 2016, diagnosed pregnant on February 11, 2016 and subsequently euthanized to recover the foetus. A ventral midline incision revealed a reproductive tract with 12 implantation sites with 15 days old foetus and 4 term foetus in abdominal cavity. There were two foetus floating on either side of the abdominal cavity and two suspended near the greater curvature of the stomach. They were attached to internal organs by means of one or 2 thread-like blood vessels that linked them to the abdominal surfaces.

CONCLUSIONS

In our opinion a systematic monitoring of rabbit breeding should be included to fully understand and enhance current knowledge of this phenomenon of abdominal pregnancy.

The challenge in the diagnosis and management of an advanced abdominal pregnancy in a resource-low setting: a case report

Background

Abdominal pregnancy is a rare form of ectopic pregnancy that is frequently left undiagnosed by inexperienced obstetricians and radiologists. It is associated with higher risk of maternal hemorrhage at any gestation and more at advanced gestation.

Case presentation

We present the case of a 22-year-old sub-Saharan African woman, gravida 3 para 0, who was diagnosed with advanced abdominal pregnancy of 25 weeks’ gestation by a transvaginal ultrasound after the failure of two medical terminations of pregnancy in the first and second trimesters and a series of repeated obstetric ultrasounds showing intrauterine pregnancy. Laparotomy was done and her recovery was uneventful.

Conclusions

The management of advanced abdominal pregnancy is more challenging as compared to earlier gestation so patients with failed medical termination of pregnancy should be critically analyzed for ectopic pregnancy as early as possible.

Secondary abdominal pregnancy in human immunodeficiency virus-positive woman

We report on an abdominal pregnancy in human immunodeficiency virus-positive mother, currently on antiretroviral therapy, which was discovered incidentally while training the obstetric ultrasound capacity building program. Although abdominal pregnancy is a rare form of ectopic pregnancy, it may be more common in women with HIV infection because they tend to have a higher rate of sexually transmitted diseases than the general population. The positive diagnosis of abdominal pregnancy is difficult to establish and is usually missed during prenatal assessment particularly in settings that lack routine ultrasound examination as is the case in most developing countries. For the management of abdominal pregnancy, surgical intervention is recommended and removal of the placenta is a key controversy. Ultrasonography is considered the front-line and most effective imaging method and an awareness with a high index of suspicion of abdominal pregnancy is vital for reducing associated high maternal and even higher perinatal mortality.

Primary Abdominal Pregnancy: A Case Report

Abdominal pregnancy is a potentially life threatening form of ectopic gestation with an incidence of 1% of all the ectopic pregnancies. Rarely, it may reach at advanced gestation and a viable fetal outcome is indeed a rare event. Most of them are terminated earlier due to poor fetal prognosis and higher chances of maternal mortality secondary to haemorrhagic shock following spontanous placental separation. A high index of suspicion is important for making a diagnosis of abdominal pregnancy and its timely management after correct diagnosis. We report a case of primary abdominal pregnancy in a 30-year-old gravida 3, para 2 at 7+2 weeks of gestation. She presented with haemorrhagic shock due to spontanous separation of gestational sac from the site of implantaion. She had persisitent nausea, vomiting, diarrhoea and always had an urge to defecate which never goes off even after she defecates. She underwent termination of pregnancy by dilatation and curattage without having any antenatal ultrasound. After 72 hours of the procedure, her symptoms were aggravated and she went into haemorrhagic shock. During laparotomy haemoperitoneum of 3litres, 1kg of clots were evident and size of the uterus was about 10-12 week, bilateral tubes and ovary were healthy. A ensac fetus of 10+2 weeks along with the separated placenta was lying in the abdominal cavity. Site of implantation was identified over sigmoid colon which was not bleeding. Patient was transfused with blood and blood products. She was discharged satisfactorily on 5th postoperative day. Hence, an Ultrasound should be done to rule out abdominal pregnancy before medical termination of pregnancy, especially in those with persistent Gastrointestinal Tract (GIT) symptoms as clinically uterus may correspond to the period of gestation in abdominal pregnancy.

Abdominal ectopic pregnancy after in vitro fertilization and single embryo transfer: a case report and systematic review

BACKGROUND

Ectopic pregnancy is the leading cause of maternal morbidity and mortality during the first trimester and the incidence increases dramatically with assisted-reproductive technology (ART), occurring in approximately 1.5-2.1 % of patients undergoing in-vitro fertilization (IVF). Abdominal ectopic pregnancy is a rare yet clinically significant form of ectopic pregnancy due to potentially high maternal morbidity. While risk factors for ectopic pregnancy after IVF have been studied, very little is known about risk factors specific for abdominal ectopic pregnancy. We present a case of a 30 year-old woman who had an abdominal ectopic pregnancy following IVF and elective single embryo transfer, which was diagnosed and managed by laparoscopy. We performed a systematic literature search to identify case reports of abdominal or heterotopic abdominal ectopic pregnancies after IVF. A total of 28 cases were identified.

RESULTS

Patients' ages ranged from 23 to 38 (Mean 33.2, S.D. = 3.2). Infertility causes included tubal factor (46 %), endometriosis (14 %), male factor (14 %), pelvic adhesive disease (7 %), structural/DES exposure (7 %), and unexplained infertility (14 %). A history of ectopic pregnancy was identified in 39 % of cases. A history of tubal surgery was identified in 50 % of cases, 32 % cases having had bilateral salpingectomy. Transfer of two embryos or more (79 %) and fresh embryo transfer (71 %) were reported in the majority of cases. Heterotopic abdominal pregnancy occurred in 46 % of cases while 54 % were abdominal ectopic pregnancies.

CONCLUSIONS

Our systematic review has revealed several trends in reported cases of abdominal ectopic pregnancy after IVF including tubal factor infertility, history of tubal ectopic and tubal surgery, higher number of embryos transferred, and fresh embryo transfers. These are consistent with known risk factors for ectopic pregnancy following IVF. Further research focusing on more homogenous population may help in better characterizing this rare IVF complication and its risks.

Broad Ligament Pregnancy - Success Story of a Laparoscopically Managed Case

Abdominal pregnancies constitute 1% of ectopic pregnancies, among which broad ligament pregnancy is a rare form. The maternal mortality rate has been reported to be as high as 20%. The diagnosis is seldom established before surgery. Laparoscopic management of broad ligament ectopic pregnancy is the ideal form of treatment in appropriately selected patients. We present the case report of successful laparoscopic treatment of a 3x3.5cm broad ligament pregnancy. A search of literature shows that ours is the 6(th) case report of such a rare ectopic pregnancy managed endoscopically successfully.

An unusual case of retained abdominal pregnancy for 36 years in a postmenopausal woman

Abdominal pregnancy is a rare form of ectopic pregnancy which occurs due to ruptured uterine or tubal pregnancy into the abdomen. Fetal loss is a common complication of these pregnancies and patient presents with acute abdominal pain which is a surgical emergency. Another rare but established complication of this ectopic pregnancy is fetal demise with the dead fetus being retained in the abdomen. It gets macerated and mummified over a period of time and is mostly detected incidentally during imaging. Radiological imaging has hallmark appearances of such a macerated fetus showing multiple fetal parts embedded in a calcified sac termed as lithopedion or stone baby. We report a unique case of retained abdominal pregnancy for 36 years in a 60-year-old postmenopausal female presented with abdominal pain and difficulty in micturition. Computed tomography showed multiple fetal bones in the abdomen surrounded by a membrane which was surprisingly not calcified.

Abdominal pregnancy: Methods of hemorrhage control

Abdominal pregnancy is an extremely rare form of ectopic pregnancy, mostly occurring secondarily after tubal rupture or abortion with secondary implantation anywhere in the peritoneal cavity. Massive intra-abdominal hemorrhage is a life threatening complication associated with secondary abdominal pregnancy. Various methods and techniques have been reported in the literature for controlling hemorrhage. Here, we report a case of massive intraperitoneal haemorrhage following placental removal controlled by abdominal packing and review the literature for diagnostic and management challenges.

Viable abdominal pregnancy: a case report in Yaoundé (Cameroon)

We herein report a case of abdominal pregnancy managed in Yaounde (Cameroon). The 33 year old G₅P₂₀₂₂ woman was referred to our setting for management of an abdominal pregnancy of 34 weeks diagnosed during the first routine obstetrical ultrasonography done two days earlier. This ultrasonography revealed a live foetus within intestinal loops with a severe oligoamnios. After two days of lung maturation, laparotomy was carried out and the live male baby weighed 2 600 grammes. The placenta was left on its implantation sites: omentun, uterine fundus and intestinal loops. The mother did well post-operatively and the resorption of the placenta took 11 months. The newborn presented compression deformities and died three days later of respiratory distress. This case illustrates that intra-abdominal fetuses can reach viability. Though rare, abdominal pregnancy remains a threat to mothers. Practitioners should therefore know the traps in its management.

Laparoscopic removal of lithopaedion

Lithopaedion means a calcified Dead foetus and it is usually extrauterine. We report a case of 32 year old female who presented to us with right iliac fossa mass. On diagnostic laparoscopy, it was found to be Lithopaedion and the same was removed in toto through laparoscopic approach.

Successful laparoscopic management of a primary omental pregnancy: case report and review of literature

A 32-year-old gravid 1, parity 0 woman was referred to our hospital with suspicion of ectopic pregnancy 31 days after her previous menstrual period. She had a 5-month history of secondary infertility reported increasing lower abdominal pain. Her serum human chronic gonadotropin level was 8160 mIU/mL. Her medical history was significant for a myomectomy and an enucleation of left ovarian cyst. On suspicion of an ectopic pregnancy, laparoscopic exploration was performed. Dense pelvic adhesion was seen. After dissection of the adhesion, we could not find the blastocyst in her pelvis. Early pregnancy tissue implanted in the omentum was identified and was excised laparoscopically. The postoperative course was uneventful. When no ectopia is found in the fallopian tubes during laparoscopy or laparotomy for ectopic pregnancy, all peritoneal surfaces and the omentum must be carefully inspected during surgery.

A 34-week ovarian pregnancy: case report and review of the literature

Advanced ovarian pregnancy is a quite rare condition. Due to the high maternal and neonatal mortality rates, early and accurate diagnosis is vital. Lack of sufficient data led us to search the literature and compile available data on the topic. A 33-year-old woman presented with acute abdomen at 34 weeks of gestation. She underwent laparotomy, which revealed a live foetus surrounded by an intact amnion membrane located in the left adnexal area. The patient delivered a live female infant. Heavy bleeding from the placenta necessitated salpingo oophorectomy. Histological examination of the removed tissue confirmed the ovarian pregnancy. Because of the substantial risk of adverse outcomes, this condition should be borne in mind, especially in cases presenting with acute abdomen during pregnancy.

Managing a live advanced abdominal twin pregnancy

Advanced abdominal pregnancies with live twin fetuses are extremely rare and are misdiagnosed in up to 60% of the cases. Such a case is presented here, highlighting the diagnostic and management challenges encountered. A high index of suspicion in making the diagnosis of this rare variety of ectopic pregnancy, emphasizing adherence to basic imaging principles, and appropriate placental management is very important in reducing the associated morbidity and mortality.