Abdominal Pregnancy (Abdominal Pregnancies)

Intra-abdominal fetus being delivered[1]

Abdominal pregnancy is a rare type of ectopic pregnancy, in which the embryo attaches to virtually any surface in the abdominal cavity. The diagnosis can often be missed until advanced fetal age is reached, while main symptoms include abdominal tenderness, an easy palpation of the limbs of the fetus and gastrointestinal complaints. Both maternal and fetal mortality rates are substantially higher in abdominal pregnancy, implicating that an early diagnosis is detrimental.


Presentation

Abdominal pregnancy (AP), in which the fetus grows outside the female reproductive tract and within the peritoneum, is a very rare type of ectopic pregnancy (EP), accounting for 1% of all EPs [1]. The incidence rate ranges considerably from study to study (1 in 400-50,000 live births), but it must be noted that abdominal pregnancy is the only type of EP that can end as a successful delivery of a full-term newborn [1] [2] [3]. AP is further divided into primary, when the fertilized ovum directly implants at a site within the peritoneal cavity (bowels, the appendix, spleen, and virtually any other organ, as well as blood vessels, uterine structures, and the omentum, are reported sites), whereas secondary implies implantation of the ovum in the peritoneum after initial adhesion in the reproductive tract and its rupture from various reasons [3] [4]. Regardless of the type, the clinical presentation is comprised of the following symptoms - persistent pain, either in the abdomen or in the suprapubic area, nausea, vomiting, painful movements of the fetus, regular menstruation cycles, vaginal discharge (bloody), and malaise [1] [3] [5] [6]. Because the fetus grows adjacent to several vital organs and blood vessels, both the mother and the fetus are at a much higher risk for complications such as severe and uncontrollable bleeding, maternal bowel obstruction, infections, pulmonary embolism, fistula formation (between the amniotic sac and the intestines) and even disseminated intravascular coagulation [1] [2] [7]. Furthermore, perinatal mortality rates reach as high as 50%, and up to half of all children born after an abdominal pregnancy have some congenital abnormality - torticollis, facial or cranial asymmetry, limb defects or deficits of the central nervous system (CNS) are most common, with oligohydramnios being the presumably pathogenic mechanism [1] [4] [6]. Maternal mortality rates, on the other hand, are somewhat lower (around 12%), but these numbers suggest that an early diagnosis can be life-saving [6].

urogenital
Amenorrhea
  • The 28-year-old woman in this instance had a history of amenorrhea and pelvic inflammatory disease. She had previously undergone dilatation and curettage, as well as tuboplasty. Fertility treatment was used for her to successfully conceive.[auntminnie.com]
  • A 34-year-old woman with amenorrhea for 8 weeks and a positive pregnancy test was referred for evaluation of ectopic pregnancy.[karger.com]
  • At 2 months amenorrhea she gave a history of acute abdominal pain associated with spotting per vaginum. Emergency ultrasound done elsewhere at that time confirmed the presence of single live intrauterine gestation.[appliedradiology.com]
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  • Breast
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  • cardiovascular
    Hypertension
    • Traditionally, pregnant mommies experience low blood pressure when pregnant; however, it is also likely that women may develop hypertension due to disturbance in vessels or alteration in the secretion of some hormones/neurotransmitters.[newkidscenter.com]
    • Learn more about placental abruption Preeclampsia According to the Preeclampsia Foundation of America, preeclampsia and other hypertensive disorders are experienced by 5 to 8 percent of all pregnant women.[parents.com]
    Hypotension
    • During its removal, massive bleeding from the placental bed occurred and our patient became hypotensive.[jmedicalcasereports.com]
    • […] risks of exploratory surgery must be balanced against the risks of delayed diagnosis. [ 1 ] Emergencies [ 2 ] Do a 'primary survey' and start treatment following 'ABCD' resuscitation principles: Do not place a heavily pregnant woman on her back (risk of hypotension[patient.info]
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  • musculoskeletal
    Cranial Asymmetry
    • Furthermore, perinatal mortality rates reach as high as 50%, and up to half of all children born after an abdominal pregnancy have some congenital abnormality - torticollis, facial or cranial asymmetry, limb defects or deficits of the central nervous[symptoma.com]
    • Typical deformities include limb defects, facial and cranial asymmetry, joint abnormalities and central nervous malformation [ 8 ].[jmedicalcasereports.com]
    • asymmetries and joint abnormalities and the most common malformations are limb defects and central nervous malformations. [33] Once the baby has been delivered placental management becomes an issue.[en.wikipedia.org]
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  • gastrointestinal
    Abdominal Pain
    • How to Manage Upper Abdominal Pain During Pregnancy Here are a few tips on how to relieve abdominal pain during pregnancy.[newkidscenter.com]
    • When Abdominal Pain During Pregnancy is Serious Although many women who experience abdominal pain have healthy pregnancies, there are times when abdominal pain can pose a serious risk.[americanpregnancy.org]
    • Is it normal to have abdominal pain during pregnancy? Occasional abdominal pain during pregnancy is a common and often harmless complaint, but it can also be a sign of a serious problem. Never ignore severe or persistent abdominal pain.[babycenter.com]
    • When is abdominal pain a worry in the second trimester? Abdominal pain on its own in the second trimester is probably nothing to worry about (Kilpatrick and Orejuela 2017) .[babycentre.co.uk]
    • Gray J, Wardrope J, Fothergill DJ ; Abdominal pain, abdominal pain in women, complications of pregnancy and labour. Emerg Med J. 2004 Sep21(5):606-13.[patient.info]
    Abdominal Mass
    • If she presents with an ABDOMINAL MASS and a SINUS on her abdominal wall (rare), the sinus may be arising in an ectopic pregnancy. Probe it, you may feel fetal bones. Open it with great care not to injure her gut.[meb.uni-bonn.de]
    • mass, confusing the diagnosis. 2 Computerized tomography (CT) and nuclear magnetic resonance clearly define the pathology and help the diagnosis of adherence and other organs affected, although these are not absolutely necessary. 2,3,4 Some authors suggest[scielo.br]
    • It looks more like an abdominal mass than a pregnancy. I see a small area that has a glow of white that could be bone, but no definitive pregnancy. I ask if she had a pregnancy test.[veronica-wanderlust.blogspot.com]
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  • respiratoric
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  • neurologic
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  • Face, Head & Neck
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  • Entire body system
    Italian
    • (936–1013), an Arab Muslim physician is credited with first recognizing abdominal pregnancy which was apparently unknown to Greek and Roman physicians and was not mentioned in the writings of Hippocrates ; Jacopo Berengario da Carpi (1460–1530) the Italian[en.wikiversity.org]
    • (936–1013), the Arab Muslim physician is credited with first recognizing abdominal pregnancy which was apparently unknown to Greek and Roman physicians and was not mentioned in the writings of Hippocrates ; Jacopo Berengario da Carpi (1460–1530) the Italian[en.wikipedia.org]
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  • Immune System
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  • Workup

    Unfortunately, the diagnosis of an abdominal pregnancy is often missed, especially in the first few months of gestation, and studies report that more than 50% of cases were not diagnosed on regular ultrasonographic exams [5] [6] [7]. For this reason, clinical judgment is necessary during diagnostic workup. A high index of suspicion must be present if patients report excessive abdominal pain in the first semester, bleeding, previous pelvic surgery, and a history of infertility, implying that a properly obtained patient history is vital in making a presumptive diagnosis [6]. A meticulous physical examination is equally important, as relatively easy palpation of fetal limbs and an abnormal lie, as well as abdominal or suprapubic tenderness, are important features of AP [1] [6]. Once clinical criteria have been solidified, imaging studies are used for confirmation. Standard fetal ultrasonography, however, may not reveal any pathological findings unless the physician patiently looks for the uterus and reveals an empty uterine cavity [1]. Insertion of a balloon catheter into the uterus is often recommended to confirm the absence of the fetus inside the uterus [1] [6]. A definite diagnosis can be made by performing more advanced imaging studies, either computed tomography (CT) or magnetic resonance imaging (MRI) [2] [3]. Laboratory studies are usually normal for a regular pregnancy, showing high levels of human chorionic gonadotropin (βhCG) and/or serum alpha-fetoprotein (AFP) [1].

    Laboratory

    Serum
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  • Imaging

    Ultrasound
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  • Test Results

    Amniocentesis
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  • Treatment

    Prognosis

    Complications

    Hypertension
    • Traditionally, pregnant mommies experience low blood pressure when pregnant; however, it is also likely that women may develop hypertension due to disturbance in vessels or alteration in the secretion of some hormones/neurotransmitters.[newkidscenter.com]
    • Learn more about placental abruption Preeclampsia According to the Preeclampsia Foundation of America, preeclampsia and other hypertensive disorders are experienced by 5 to 8 percent of all pregnant women.[parents.com]
    Oligohydramnios
    • Images in Clinical Medicine Gabriela Gayer, M.D. 3 Citing Articles A 30-year-old woman who had a history of two pregnancies and one birth presented with an uncomplicated pregnancy until routine ultrasonography at 19 weeks revealed severe oligohydramnios[nejm.org]
    • ., may occur due to severe oligohydramnios. 2 Abdominal pain is the most frequent symptom. Rarely, symptoms may relate to placental site attachment, including attachment to the bowel or bladder obstruction.[appliedradiology.com]
    • […] rates reach as high as 50%, and up to half of all children born after an abdominal pregnancy have some congenital abnormality - torticollis, facial or cranial asymmetry, limb defects or deficits of the central nervous system (CNS) are most common, with oligohydramnios[symptoma.com]
    Hypotension
    • During its removal, massive bleeding from the placental bed occurred and our patient became hypotensive.[jmedicalcasereports.com]
    • […] risks of exploratory surgery must be balanced against the risks of delayed diagnosis. [ 1 ] Emergencies [ 2 ] Do a 'primary survey' and start treatment following 'ABCD' resuscitation principles: Do not place a heavily pregnant woman on her back (risk of hypotension[patient.info]
    Preterm Labor
    • If it’s preterm labor, you’ll need to seek medical attention. Plus, more from The Bump: Braxton Hicks Contractions Preterm Labor Abdominal Pain During Pregnancy[thebump.com]
    • Learn more about miscarriage Preterm labor If you're experiencing regular contractions before you're 37 weeks pregnant, and you have a persistent backache, you could be having preterm labor.[parents.com]
    • Preterm labor You're in preterm labor , also known as premature labor, if you start to have contractions that efface or dilate your cervix earlier than 37 weeks of pregnancy.[babycenter.com]

    Etiology

    Epidemiology

    Sex distribution
    Age distribution

    Pathophysiology

    Prevention

    Summary

    Patient Information

    Other symptoms

    Retained Placenta
    • ., Colic, G. and Mrden, D. ( 1983 ) Complications after surgery for abdominal pregnancy due to a retained placenta. Jugosl. Ginekol. Opstet. , 23 , 93 –94.[humrep.oxfordjournals.org]
    • "Embolization for advanced abdominal pregnancy with a retained placenta. A case report". Reproductive Medicine . 47 (10): 861–3. PMID 12418072 . Pieh-Holder, K. L.; Scardo, J. A.; Costello, D. H. (2012).[en.wikipedia.org]
    • In 10 (26.3%) cases, the placenta was not removed, in four of these cases a re-laparatomy had to be done because of complications resulting from the retained placenta.[webmedcentral.com]
    Diaphragmitis
    • "Early pregnancy on the diaphragm with endometriosis". Obstetrics and Gynecology . 49 (5): 620–2. PMID 850582 . a b Krishna Dahiya; Damyanti Sharma (June 2007). "Advanced Abdominal Pregnancy: A Diagnostic and Management Dilemma" .[en.wikipedia.org]
    • […] sudden pain that doesn't go away, comes and goes, or happens only on one side) Vaginal spotting or bleeding Pain that gets worse during physical activity or while moving your bowels or coughing Pain in your shoulder (from a buildup of blood under your diaphragm[babycenter.com]
    Mifepristone
    • […] of amniotic fluid surrounding the unborn baby. [16] Blood transfusion is frequent in the management of patients with this kind of pregnancy, with others even using tranexamic acid and recombinant factor VIIa , which both minimize blood loss. [4] [17] Mifepristone[en.wikiversity.org]
    • […] gonadotropin levels and by ultrasound scanning (in particular using doppler ultrasonography . [22] Use of methotrexate to accelerate placental regression is controversial as the large amount of necrotic tissue is a potential site for infection, [9] mifepristone[en.wikipedia.org]
    Tobacco
    • […] pregnancy with sexually transmitted disease playing a major role; [9] however about half of those with ectopic pregnancy have no known risk factors (which include damage to the Fallopian tubes from previous surgery or from previous ectopic pregnancy, and tobacco[en.wikipedia.org]
    Large Placenta
    • Transabdominal sonography revealed a large placenta (15 x 15 x 12 cm) attached to the uterine fundus. The women returned to the hospital twice, complaining of fever, pain, and vaginal discharge.[auntminnie.com]

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    References

    1. Bohiltea R, Radoi V, Tufan C, Horhoianu I, Bohiltea C. Abdominal pregnancy - Case presentation. J Med Life. 2015;8(1):49-54.
    2. Gudu W, Bekele D. A pre-operatively diagnosed advanced abdominal pregnancy with a surviving neonate: a case report. J Med Case Rep. 2015;9:228.
    3. Mengistu Z, Getachew A, Adefris M. Term abdominal pregnancy: a case report. J Med Case Rep. 2015;9:168.
    4. Pannu D, Bharti R, Anand H, Sharma M. Term Live Secondary Abdominal Pregnancy: A Case Report. Malays J Med Sci. 2016;23(5):96-99.
    5. Nkusu Nunyalulendho D, Einterz EM. Advanced abdominal pregnancy: case report and review of 163 cases reported since 1946. Rural Remote Health. 2008;8(4):1087.
    6. Dahab AA, Aburass R, Shawkat W, Babgi R, Essa O, Mujallid RH. Full-term extrauterine abdominal pregnancy: a case report. J Med Case Rep. 2011;5:531.
    7. Kun KY, Wong PY, Ho MW, Tai CM, Ng TK. Abdominal pregnancy presenting as a missed abortion at 16 weeks' gestation. Hong Kong Med J. 2000;6(4):425-427.

    1. Abdominal pain during pregnancy - MS Cappell, D Friedel - Gastroenterology clinics of , 2003 - medicina.iztacala.unam.mx
    2. A fifteen year experience with ectopic pregnancy. - ML Tancer, I Delke, NP Veridiano - Surgery, gynecology & obstetrics, 1981 - ukpmc.ac.uk
    3. Abdominal pain during pregnancy - MS Cappell, D Friedel - Gastroenterology clinics of , 2003 - medicina.iztacala.unam.mx
    4. Abdominal pain during pregnancy - MS Cappell, D Friedel - Gastroenterology clinics of , 2003 - medicina.iztacala.unam.mx
    5. Abdominal pregnancy - JAF Attapattu, S Menon - International Journal of Gynecology & Obstetrics, 1993 - Elsevier
    6. Abdominal pregnancy with lithopedion formation presenting as a pelvic abscess - T Jain, LO Eckert - Obstetrics & Gynecology, 2000 - journals.lww.com
    7. “Idiopathic” Deep Venous Thrombosis: The Value of Routine Abdominal and Pelvic Computed Tomographic Scanning - NA Sannella, DJ O'Connor - Annals of vascular surgery, 1991 - Elsevier
    8. Abdominal radical trachelectomy during pregnancy to preserve pregnancy and fertility - L Ungár, JR Smith, L Pálfalvi - Obstetrics & , 2006 - journals.lww.com
    9. Careful counsel: Management of unintended pregnancy - M O'Reilly - Journal of the American Academy of Nurse , 2009 - Wiley Online Library
    10. A case of Klippel-Feil syndrome - D Latto - British Medical Journal, 1942 - ncbi.nlm.nih.gov
    11. On the Physiology of Reproduction in the Ewe. Part I. The Symptoms, Periodicity, and Duration of Œstrus. Part II. Changes in the Vagina and Cervix. Part III. Gross - R Grant - Transactions of the Royal Society of Edinburgh, 1934 - Cambridge Univ Press

    Media References

    1. Intra-abdominal fetus being delivered, CC BY 2.5

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