Question 1 of 10

    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.

    This disorder is promted by the following process: anatomic/foreign.

    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].

    Liver, Gall & Pancreas
    Hepatomegaly
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  • Entire body system
    Italian
    • (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]
    • (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]
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  • Face, Head & Neck
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  • neurologic
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  • Immune System
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  • respiratoric
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  • gastrointestinal
    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.[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.[veronica-wanderlust.blogspot.com]
    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]
    • Gray J, Wardrope J, Fothergill DJ ; Abdominal pain, abdominal pain in women, complications of pregnancy and labour.[patient.info]
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  • musculoskeletal
    Cranial Asymmetry
    • The rate of malformations and deformations is estimated to be about 21%; typical deformations are facial and cranial asymmetries and joint abnormalities and the most common malformations are limb defects and central nervous malformations.[en.wikipedia.org]
    • An abdominal pregnancy is often associated with fetal deformities [ 13 ], such as facial and cranial asymmetry, joint abnormalities and limb deformity, and central nervous deformities in about 21% of cases.[hindawi.com]
    • Typical deformities include limb defects, facial and cranial asymmetry, joint abnormalities and central nervous malformation [ 8 ].[jmedicalcasereports.com]
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  • urogenital
    Amenorrhea
    • The 28-year-old woman in this instance had a history of amenorrhea and pelvic inflammatory disease.[auntminnie.com]
    • At 2 months amenorrhea she gave a history of acute abdominal pain associated with spotting per vaginum.[appliedradiology.com]
    Chadwick's Sign
    • Early in labor this plug is expelled and there is slight bleeding; expulsion of the mucous plug is known as show and indicates the beginning of cervical dilatation. chadwick's sign of pregnancy refers to a bluish color of the vagina which is a result[medical-dictionary.thefreedictionary.com]
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  • Breast
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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].

    Test Results

    Amniocentesis
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  • Laboratory

    Serum
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  • Imaging

    X-ray
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  • Ultrasound
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  • Treatment

    Prognosis

    Complications

    Embolism
    • Total removal is preferable with ligation of blood supply or preoperative embolization.[appliedradiology.com]
    • Placental vessels have also been blocked by angiographic embolization.[en.wikipedia.org]
    • If at the time of diagnosis or during conservative management the neonate dies, the laparotomy should be hastened to avoid complications of amniotic fluid embolism, disseminated intravascular coagulopathy or severe sepsis.[caribbean.scielo.org]
    • Morbidity is also high resulting from bleeding, infection, DIC, anemia, pulmonary embolism, fistula formation, etc. [6] .[dx.doi.org]
    • She might have even had preoperative embolization of the pregnancy in order to reduce the intraoperative bleeding.[veronica-wanderlust.blogspot.com]
    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]
    • Diseases that increase the risk of obstetrical complications include diabetes, heart disease, hypertension, kidney disease, and anemia. rubella (German measles) can be responsible for many types of birth defects, particularly if the mother contracts it[medical-dictionary.thefreedictionary.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]
    Lithopedion
    Oligohydramnios
    • ., may occur due to severe oligohydramnios. 2 Abdominal pain is the most frequent symptom.[appliedradiology.com]
    Pulmonary Embolism
    • Morbidity is also high resulting from bleeding, infection, DIC, anemia, pulmonary embolism, fistula formation, etc. [6] .[dx.doi.org]
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  • Etiology

    Epidemiology

    Sex distribution
    Age distribution

    Pathophysiology

    Prevention

    Summary

    Patient Information

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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.

    • Abdominal pregnancy - JAF Attapattu, S Menon - International Journal of Gynecology & Obstetrics, 1993 - Elsevier
    • Abdominal pain during pregnancy - MS Cappell, D Friedel - Gastroenterology clinics of , 2003 - medicina.iztacala.unam.mx
    • Abdominal pain during pregnancy - MS Cappell, D Friedel - Gastroenterology clinics of , 2003 - medicina.iztacala.unam.mx
    • A fifteen year experience with ectopic pregnancy. - ML Tancer, I Delke, NP Veridiano - Surgery, gynecology & obstetrics, 1981 - ukpmc.ac.uk
    • Abdominal pain during pregnancy - MS Cappell, D Friedel - Gastroenterology clinics of , 2003 - medicina.iztacala.unam.mx
    • Abdominal pregnancy with lithopedion formation presenting as a pelvic abscess - T Jain, LO Eckert - Obstetrics & Gynecology, 2000 - journals.lww.com
    • 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
    • Careful counsel: Management of unintended pregnancy - M O'Reilly - Journal of the American Academy of Nurse , 2009 - Wiley Online Library
    • A case of Klippel-Feil syndrome - D Latto - British Medical Journal, 1942 - ncbi.nlm.nih.gov
    • Diagnosis of acute and persistent ectopic pregnancy - JW Graczykowski, DB Seifer - Clinical obstetrics and gynecology, 1999 - journals.lww.com
    • Abdominal radical trachelectomy during pregnancy to preserve pregnancy and fertility - L Ungár, JR Smith, L Pálfalvi - Obstetrics & , 2006 - journals.lww.com

    Media References

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

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