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Abdominal Pregnancy

Abdominal Pregnancies

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].

Gangrene
  • Ahmed Samy El-Agwany, El-sayed El-badawy, Ahmed El-habashy, Hesham El-gammal and Mahmoud Abdelnaby, Secondary Advanced Abdominal Pregnancy after Suspected Ruptured Cornual Pregnancy with Good Maternal Outcome: A Case with Unusual Gangrenous Fetal Toes[doi.org]
Respiratory Distress
  • 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.[ncbi.nlm.nih.gov]
Abdominal Pain
  • She suffered from abdominal pain at 16 weeks gestation. At admission, obstetrical examination and transabdominal ultrasonography revealed that it was uterine pregnancy with a single living fetus and oligohydramnios.[ncbi.nlm.nih.gov]
  • She experienced several weeks of postoperative abdominal pain and ultimately was diagnosed with a 14-week size intra-abdominal pregnancy.[ncbi.nlm.nih.gov]
  • CASE REPORT: We report the case of a 28-year-old woman with a history of cesarean hysterectomy 3 years prior who was referred to our institution for evaluation of abdominal pain.[ncbi.nlm.nih.gov]
  • How to Manage Upper Abdominal Pain During Pregnancy Here are a few tips on how to relieve abdominal pain during pregnancy.[newkidscenter.com]
  • A 29-year-old Indonesian woman presented with abdominal pain seven months after an intra-abdominal pregnancy.[ncbi.nlm.nih.gov]
Abdominal Mass
  • This case highlights the importance of excluding pregnancy in any woman of reproductive age with undiagnosed abdominal mass and utero-vaginal prolapse before any manipulation.[ncbi.nlm.nih.gov]
  • 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.[web.archive.org]
  • On examination, there may be abnormal presentation, easily palpable fetal parts, uneffaced and displaced cervix and palpation of abdominal mass seperate from uterus [8]. High index of suspicion is first step in the diagnosis.[ijcasereportsandimages.com]
  • Obstet Gynecol Surv 1991, 46: 515-525. 10.1097/00006254-199108000-00003 View Article Google Scholar Ede J, Sobnach S, Castillo F, Bhyat A, Corbett JH: The lithopedion – an unusual cause of an abdominal mass. S Afr J Surg 2011, 49: 140-141.[doi.org]
  • 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]
Periumbilical Pain
  • We attribute the patient’s continuous periumbilical pain at presentation to irritation of the visceral peritoneum somewhere between the jejunum and transverse colon, originating from the placental attachment site.[doi.org]
Hypertension
  • […] and edema and protein in the urine abdominal aortic aneurysm an aneurysm of the abdominal aorta associated with old age and hypertension abdominal aorta a branch of the descending aorta toxaemia of pregnancy an abnormal condition of pregnancy characterized[vocabulary.com]
  • Methyldopa and nifedipine were commenced for pregnancy-induced hypertension from 22 weeks of gestation.[doi.org]
  • 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]
Thrombosis
  • Venous thromboembolism - deep vein thrombosis or pulmonary embolus may cause lower or upper abdominal pain respectively. [ 15 ] Myocardial infarction. Gastroenteritis. Irritable bowel syndrome.[patient.info]
Cranial Asymmetry
  • The most common deformations observed were facial and/or cranial asymmetry and various joint abnormalities. Among the most common malformations were limb deficiency and central nervous system malformations.[ncbi.nlm.nih.gov]
  • 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]
  • Besides slight cranial asymmetry the examination of the newborn baby was unremarkable. The baby’s head circumference was 32cm (5th centile).[doi.org]
Amenorrhea
  • A 34-year-old woman with amenorrhea for 8 weeks and a positive pregnancy test was referred for evaluation of ectopic pregnancy.[ncbi.nlm.nih.gov]
  • A 35-year-old, para 2, unbooked, Ethiopian Somali woman presented with amenorrhea of 9 months' duration, abdominal pain, and painful fetal movements of 4 months' duration.[ncbi.nlm.nih.gov]
  • 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]

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].

Hyponatremia
  • Her blood pressure was 160/93mmHg; she had hypokalemia (3.3mmol/L, reference range (RR) 3.6 to 5.0mmol/L) and hyponatremia (124mmol/L, RR 135 to 145mmol/L).[doi.org]

Treatment

  • BACKGROUND Laparoscopic treatments of abdominal pregnancy have been reported; however, resection of an implanted gestational sac could lead to massive bleeding and treatment failure.[ncbi.nlm.nih.gov]
  • We compared and analyzed the pregnancy history, gestational age when the diagnosis was confirmed, the placental colonization position, the course of treatment and surgical processes, related concurrency rate, post-operative drug treatment programs, and[ncbi.nlm.nih.gov]
  • Early diagnosis and treatment are advised and the choice of treatment is crucial. A successful case of conservative treatment with combined systemic and intra-amniotic methotrexate is presented.[ncbi.nlm.nih.gov]
  • Preoperative embolization and the postoperative methotrexate therapy facilitate the safe surgical treatment of abdominal pregnancy.[ncbi.nlm.nih.gov]
  • Super-selective arterial embolization with a microcatheter is a useful treatment of abdominal bleeding due to abdominal pregnancy.[ncbi.nlm.nih.gov]

Prognosis

  • Uterine anomalies, their imaging and diagnosis, as well as the patient's subsequent reproductive prognosis are discussed.[ncbi.nlm.nih.gov]
  • With timely diagnosis and appropriate management, the prognosis in most cases is favourable.[ncbi.nlm.nih.gov]
  • Treatment and prognosis It is a serious and potentially life-threatening condition.[radiopaedia.org]
  • Treatment and prognosis It is a serious and potentially life-threatening condition. Maternal mortality associated with intra-abdominal pregnancy is estimated at 7.7 times that of other locations of ectopic pregnancy 6, with a mortality rate of 5% 8.[radiopaedia.org]
  • Tamarit G, Lonjedo E, Gonzalez M, Tamarit S, Domingo S, Pellicer A: Combined use of uterine artery embolization and local methotrexate injection in interstitial ectopic pregnancies with poor prognosis. Fertil Steril 2010;93:1348 e1341-e1344.[karger.com]

Etiology

  • Ectopic pregnancies should be identified early and evaluated for the etiology of the presentation. Rarely, an ectopic pregnancy implants at an extratubal location.[ncbi.nlm.nih.gov]
  • The etiology and mechanism of development of idiopathic CTEV is unknown [44]; one can only speculate about the role of AAP in the development of CTEV.[doi.org]
  • […] further clarify the disease pre-eclampsia which was previously thought (1980's) to require a uterus for it to occur, however pre-eclampsia's occurrence in abdominal pregnancy (with the conceptus outside the uterus) helped throw light on pre-eclampsia's etiology[en.wikipedia.org]
  • Fylstra, Ectopic pregnancy not within the (distal) fallopian tube: etiology, diagnosis, and treatment, American Journal of Obstetrics and Gynecology, 206, 4, (289), (2012).[doi.org]

Epidemiology

  • Article information Author: Gwinyai Masukume First submitted: 13 November 2014 Accepted: 20 November 2014 Last updated: 1 January 2019 Reviewer comments Author info: Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health[en.wikiversity.org]
  • Article information Author: Gwinyai Masukume First submitted: 13 November 2014 Accepted: 20 November 2014 Last updated: 01 January 2019 Reviewer comments Author info: Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health[en.wikiversity.org]
  • […] placental regression. [18] Complications of leaving the placenta can include residual bleeding, infection, bowel obstruction, pre-eclampsia (which may all necessitate further surgery) [19] [18] and failure to breast feed due to placental hormones. [20] Epidemiology[doi.org]
  • Multiparity and poor socio-economic status are implicated as epidemiological factors 7 . Clinical presentation can be variable with abdominal pain occurring at 16-17 weeks gestation 8 , 9 as was observed in our patient.[ncbi.nlm.nih.gov]
Sex distribution
Age distribution

Prevention

  • However, only one of nine women who reached the hospital alive had an accurate preoperative diagnosis of abdominal pregnancy, which suggests that preventing abdominal pregnancy-related death may depend, at least in part, upon increasing physicians' awareness[ncbi.nlm.nih.gov]
  • Enough fluid intake Drinking sufficient quantities of water can prevent abdominal pain caused by constipation and bloating. It keeps the metabolic system up and going and prevents dehydration.[newkidscenter.com]
  • When an abdominal pregnancy is ended surgically, the surgeon must take steps to prevent heavy bleeding at the place of implantation.[everydayhealth.com]
  • Treatment and Prevention “Modern medicine can provide open treatment only and keep the tube in some cases. In case of surgical procedure, laparoscopy procedure is used.[pinkycloud.com]

References

Article

  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.

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Last updated: 2019-06-28 11:18