Full-term extrauterine abdominal pregnancy: a case report

Amal A Dahab1, Rahma Aburass1, Wasima Shawkat2, Reem Babgi1, Ola Essa1 andRazaz H

Mujallid3*

*Corresponding author: Razaz H Mujallid rmujallid@gmail.com

Author Affiliations

1Department of Obstetrics and Gynecology, Maternity and Children Hospital, Jeddah, Saudi Arabia

2Department of Surgery, Maternity and Children Hospital, Jeddah, Saudi Arabia

3Department of Anesthesia, Maternity and Children Hospital, Jeddah, Saudi Arabia

For all author emails, please log on.

Journal of Medical Case Reports 2011, 5:531  doi:10.1186/1752-1947-5-531

The electronic version of this article is the complete one and can be found online

at:http://www.jmedicalcasereports.com/content/5/1/531

Received: 4 April 2011Accepted:

31 October 2011

Published:

31 October 2011

© 2011 Dahab et al; licensee BioMed Central Ltd. 

This is an Open Access article distributed under the terms of the Creative Commons Attribution License

(http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction

in any medium, provided the original work is properly cited.

Abstract

IntroductionExtrauterine abdominal pregnancy is extremely rare and is frequently missed during antenatal care. This is a

report of a full-term extrauterine abdominal pregnancy in a primigravida who likely had a ruptured ectopic

pregnancy with secondary implantation and subsequently delivered a healthy baby.

Case presentationA 23-year-old, Middle Eastern, primigravida presented at 14 weeks gestation with intermittent suprapubic

pain and dysuria. An abdominal ultrasound examination showed a single viable fetus with free fluid in her

abdomen. A follow-up examination at term showed a breech presentation and the possibility of a bicornute

uterus with the fetus present in the left horn of her uterus. Our patient underwent Cesarean delivery under

general anesthesia and was found to have a small intact uterus with the fetus lying in her abdomen and

surrounded by an amniotic fluid-filled sac. The baby was extracted uneventfully, but the placenta was

implanted in the left broad ligament and its removal resulted in massive intraoperative bleeding that

necessitated blood and blood products transfusion and the administration of Factor VII to control the

bleeding. Both the mother and newborn were discharged home in good condition.

ConclusionsAn extrauterine abdominal pregnancy secondary to a ruptured ectopic pregnancy with secondary

implantation could be missed during antenatal care and continue to term with good maternal and fetal

outcome. An advanced extrauterine pregnancy should not result in the automatic termination of the

pregnancy.

Introduction

An extrauterine abdominal pregnancy is a very rare form of ectopic pregnancy where implantation occurs

within the peritoneal cavity, outside the Fallopian tube and ovary. It is estimated to occur in 10 out of

100,000 pregnancies in the United States [1]. The diagnosis of such a condition is frequently missed during

antenatal care, despite the routine use of abdominal ultrasonography. However, it is extremely important to

detect an extrauterine abdominal pregnancy because the associated maternal mortality rate is estimated at

about five per 1000 cases, which is approximately seven times higher than the estimated rate for ectopic

pregnancy in general, and about 90 times the maternal mortality rate associated with normal delivery in the

United States[1]. Survival of the newborn is also affected with a perinatal mortality rate of 40% to 95% [2].

We report on a successful operative delivery of a healthy baby following a full-term extrauterine abdominal

pregnancy in a primigravida in whom the diagnosis was missed despite repeated ultrasonography during the

antenatal period.

Case presentation

A 23-year-old, Middle Eastern primigravida presented to our Emergency Department at 14 weeks gestation

with a two-week history of intermittent suprapubic pain associated with dysuria. On examination, she had a

heart rate of 102 beats/min, her blood pressure was 109/71 mmHg, a respiratory rate of 15 breaths/min and

temperature of 37.4°C. Examination of her cardiac and respiratory systems was unremarkable. Her abdomen

was soft, but with mild suprapubic tenderness. Her laboratory results showed a hemoglobin level of 7.9 g/dL,

hematocrit 25.7%, white blood cells 9700 cells/mm3, platelets 367 cells/mm3, serum urea 14.8 mmol/L and

serum creatinine 47 μmol/L. Her serum electrolytes, coagulation profile and liver function tests were all

within normal limits. Her serum β-human chorionic gonadotropin level was 75,542 IU. A bedside urine

analysis showed pus cells and a urine culture subsequently grew Streptococcus agalactiae, which was

sensitive to penicillin and amoxicillin. An ultrasound examination in our Emergency Room showed a single

viable fetus with a crown-rump length corresponding to 13 weeks and five days gestation, the anterior

placenta and a normal amount of liquor. A significant amount of localized fluid in the left side of her

abdomen was also noted and was thought to be either ascites or blood. Our patient received intravenous

amoxicillin/clavulanic acid (1 g) and 500 mL of normal saline; her pain subsided, and she was admitted to the

ward for follow-up and further investigation. Iron deficiency anemia was diagnosed based on a negative

sickle cell test, normal hemoglobin electrophoresis, a serum iron level of 32 μg/dL, serum ferritin of 89.7

μg/dL and a total iron binding capacity of 117 μg/dL. Our patient was placed on iron supplements. Four days

later, repeat abdominal ultrasound examination suggested the presence of a bicornute uterus with the fetus

in the left horn, and free fluid was noted in her pelvis (Figure 1). Her liver, spleen, kidneys and urinary

bladder appeared normal. A speculum examination indicated the presence of a single cervix. An abdominal

fluid tap was offered to our patient but she declined and she was discharged home on iron supplements and

requested to attend outpatient follow-up. At 20 weeks gestation, our patient's hemoglobin was 9.5 g/dL and

a follow-up abdominal ultrasound examination performed by a more experienced radiologist showed similar

findings to the previous examination with a vertical pocket of amniotic fluid that measured 4.2 cm

(Figures 2 and 3). At 40 weeks gestation, a follow-up ultrasound examination showed breech presentation

with a highly vascular placenta. An external cephalic version was offered to our patient but she declined. She

was admitted to the hospital for an elective Cesarean delivery. She opted for general anesthesia which was

induced with propofol and suxamethonium chloride, and was maintained with sevoflurane and an oxygen/air

mixture. A Pfannenstiel incision was made and her uterus was found to be intact and small on entering her

abdomen. The fetus was found in her abdomen surrounded by an amniotic membrane filled with liquor. The

amniotic membrane was dissected and incised and the fetus was extracted (see Additional file 1: Movie 1

showing delivery of the baby). The fetal Apgar scores were 6 and 10 at one and five minutes, respectively.

The placenta was attached to the posterior aspect of the left broad ligament. During its removal, massive

bleeding from the placental bed occurred and our patient became hypotensive. She was aggressively

resuscitated with a total of 4000 mL of Ringer's lactate, 7 units of packed red blood cells, 4 units of fresh

frozen plasma, 10 units of cryoprecipitate and 2 units of platelets. She continued to bleed and was

administered 90 units/kg of intravenous Factor VII, which controlled her bleeding. Her left ovary and tube

were found to be distorted while the right ones were normal. A hemostatic suture was applied on the

distorted tube which was left, together with the ovary, in situ. An abdominal drain was inserted and our

patient was extubated on the table and transferred to our Intensive Care Unit for monitoring. She was

discharged to the ward on the following day and went home with her newborn 10 days after surgery.

Figure 1. Ultrasonography picture at 14 weeks gestation showing a single fetus,

corresponding to date in size, and the possibility of a bicornute uterus.

Figure 2. Ultrasonography picture at 19 weeks showing fetus, amniotic fluid and

the possibility of a bicornute uterus.

Figure 3. Ultrasonography picture at 23 weeks showing fetus, amniotic fluid and

normal fetal morphology.

Additional file 1. Cesarean delivery. Movie file showing Cesarean delivery of the baby.

Format: MOV Size: 4MB Download file

Discussion

Extrauterine abdominal pregnancy beyond 20 weeks gestation and with a viable fetus is a rare condition,

with an estimated prevalence of one out of 8099 hospital deliveries [3], and is classified into two types.

Primary abdominal pregnancy refers to pregnancy where implantation of the fertilized ovum occurs directly

in the abdominal cavity. In such cases, the Fallopian tubes and ovaries are intact. There were only 24 cases

of primary abdominal pregnancy reported up to 2007[4]. In contrast, secondary abdominal pregnancy

accounts for most cases of advanced extrauterine pregnancy. It occurs following an extrauterine tubal

pregnancy that ruptures and gets re-implanted within the abdomen [5]. Under these circumstances, there is

evidence of tubal or ovarian damage.

In this report, the intermittent suprapubic pain that our patient experienced early in her pregnancy, the free

fluid seen on ultrasound examination, and the intraoperative findings of a severely distorted left Fallopian

tube and ovary are highly suggestive of a tubal pregnancy that ruptured and resulted in secondary

implantation in the broad ligament. Accordingly, this was most likely a case of secondary abdominal

pregnancy. The diagnosis was unfortunately missed during antenatal care, and the ultrasound examination

findings were repeatedly misinterpreted as an intrauterine pregnancy in a bicornute uterus. A recent report

of 163 cases of extrauterine abdominal pregnancy demonstrated that the diagnosis of this condition is

frequently missed, with only about 45% of cases diagnosed during the antenatal period [3]. The fact that our

patient's low hemoglobin was explained by the presence of iron deficiency, her suprapubic pain was

attributed to a urinary tract infection and that the free fluid in her abdomen was thought to be ascites

collectively contributed to the failure to consider the possibility of an extrauterine pregnancy. Had this been

discovered at an earlier stage, our patient could have been admitted to hospital for closer monitoring and

her operative delivery would have been performed at an earlier gestational age.

It is interesting to note that patients with an extrauterine abdominal pregnancy typically have persistent

abdominal and/or gastrointestinal symptoms during their pregnancy [5]. Our patient, however, did not have

any symptoms during her pregnancy other than the intermittent suprapubic pain that she experienced at the

end of her first trimester.

Extrauterine abdominal pregnancy is typically suspected when the baby's parts are easily felt on clinical

examination or when the baby's lie is abnormal [6]. In our current patient, the baby was always in the breech

position and the abdominal examination was always reported as being unremarkable. This could be

attributed, at least in part, to the fact that our patient was examined by different physicians during her

antenatal visits and the attending physician only reviewed her records. The amniotic fluid around the baby

could have also contributed to the difficulty in feeling the baby's parts on abdominal examination.

Ultrasonography, however, remains the main method for the diagnosis of extrauterine pregnancy. It usually

shows no uterine wall surrounding the fetus, fetal parts that are very close to the abdominal wall, abnormal

lie and/or no amniotic fluid between the placenta and the fetus [6]. Interestingly, amniotic fluid was detected

in all ultrasound examinations in this patient but it was technically difficult to estimate its amount. The

impression that the patient had a bicornute uterus was likely due to the fact that the fetus was lying behind

the uterus and the empty uterine cavity was mistaken for the empty horn. Magnetic resonance imaging and

serum α-fetoprotein have been used to diagnose abdominal pregnancy [4,7], however, there was no

justification to perform these tests in this patient as the diagnosis was not suspected.

About 21% of babies born after an extrauterine abdominal pregnancy have birth defects, presumably due to

compression of the fetus in the absence of the amniotic fluid buffer. Typical deformities include limb defects,

facial and cranial asymmetry, joint abnormalities and central nervous malformation [8]. In this case, the

baby was protected by the surrounding amniotic fluid and sac which could explain the absence of

deformities in the baby.

The massive bleeding that occurred when the placenta was removed was due to the adherence of the

placenta to the broad ligament which, unlike the uterus, does not contract. It has been reported that, unless

the placenta can be easily tied off or removed, it may be preferable to leave it in place and allow for its

natural regression [5,6]. However, leaving the placenta in situ has been associated with increased

postoperative morbidity and mortality [9] and is thus not advisable. There have been many reports of

advanced extrauterine pregnancy that ended with a viable fetus and a healthy mother [3]. Since the

diagnosis is frequently missed preoperatively [3] and adverse fetal and maternal outcome does not

necessarily occur in association with the continuation of pregnancy, one could argue that the termination of

an advanced extrauterine pregnancy upon antenatal diagnosis might not be warranted. However, these

cases should be followed-up closely when the diagnosis is made to prevent adverse outcomes.

Conclusion

This is a report of an extrauterine abdominal pregnancy that had likely originated in the left Fallopian tube

which ruptured and resulted in secondary implantation in the broad ligament. The pregnancy continued

uneventfully to full term and ended successfully with operative delivery of a healthy baby. The importance of

this case report is the fact that an extrauterine abdominal pregnancy could be missed during antenatal care

despite repeated ultrasound examinations. Furthermore, the antenatal diagnosis of advanced extrauterine

pregnancy does not necessarily justify the termination of the pregnancy since good maternal and fetal

outcome is not uncommon.

Consent

Written informed consent was obtained from the patient for publication of this case report and the

accompanying images and video. A copy of the written consent is available for review by the Editor-in-Chief

of this journal.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

AAD, RB and OE performed the Cesarean delivery and followed up the patient and baby postoperatively until

discharge from the hospital. WS helped during the surgery from a general surgical stand point. RA was the

consultant who followed up the patient during antenatal care and performed the ultrasound examinations.

RHM provided the perioperative anesthetic care for the patient and was a major contributor in writing the

manuscript. All authors read and approved the final manuscript.

Acknowledgements

The authors acknowledge the help of the operating room and intensive care personnel who assisted in the

care of this patient. The authors also acknowledge the help of Prof. Jamal Alhashemi, King Abdulaziz

University, Jeddah, Saudi Arabia for his critical review of the manuscript.

References

1. Atrash HK, Friede A, Hgue CJR: Abdominal pregnancy in the United States: frequency and

mortality.

Obstet Gynecol 1987, 69:333-337. PubMed   Abstract  

2. Martin JN Jr, Sessums JK, Martin RW, Pryor JA, Morrison JC: Abdominal pregnancy: current

concepts of management.

Obstet Gynecol 1988, 71:549-557. PubMed   Abstract  

3. Nkusu Nunyalulendho D, Einterz EM: Advanced abdominal pregnancy: case report and review

of 163 cases reported since 1946.

Rural Remote Health 2008, 8:1087. PubMed   Abstract  | Publisher   Full   Text  

4. Krishna D, Damyanti S: Advanced abdominal pregnancy: a diagnostic and management

dilemma.

J Gynecol Surg 2007, 23:69-72. Publisher   Full   Text  

5. King M, Bewes PC, Cairns J, Thornton J (Eds): Chapter 8. Abdominal pregnancy

In Primary Surgery. Volume 1: non-trauma

On-line edition available

at http://www.meb.uni-bonn.de/dtc/primsurg/docbook/html/x5173.html webcite

6. 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, 6:425-427. PubMed   Abstract  | Publisher   Full   Text  

7. Tromans PM, Coulson R, Lobb MO, Abdulla U: Abdominal pregnancy associated with extremely

elevated serum alph-fetoprotein: case report.

Br J Obstet Gynaecol 1984, 91:296-298. PubMed   Abstract  | Publisher   Full   Text  

8. Stevens CA: Malformations and deformations in abdominal pregnancy.

Am J Med Genet 1993, 47:1189-1195. PubMed   Abstract  | Publisher   Full   Text  

9. Rahman MS, Al-Suleiman SA, Rahman J, Al-Sibai MH: Advanced abdominal pregnancy-

observation in 10 cases.

Obstet Gynecol 1982, 59:366-372. PubMed   Abstract  

P Baffoe, C Fofie, and B N Gandau

Author information   ►  Copyright and License information   ►

Summary

Go to:

Introduction

Ectopic pregnancy represents about 1–2% of all pregnancies with 95% occurring in the fallopian tube. Abdominal pregnancies represent just about 1% of ectopic pregnancies.1 The incidence of abdominal pregnancy differs in various publications and ranges between 1: 10000 pregnancies and 1:30,000 pregnancies.1,2 It was reported for the first time in 1708 as an autopsy finding and numerous cases have been reported worldwide ever since. In most of these cases, the diagnosis is made on the basis of the ensuing complications such as hemorrhage and abdominal pain. Maternal mortality and morbidity are also very high especially if the condition is not diagnosed and managed appropriately. These pregnancies generally do not get to 37 weeks (term gestation) and usually the end result is the extraction of a dead fetus. Another challenge for babies from abdominal pregnancy is the very high incidence of congenital malformations.

Abdominal pregnancy at term with a healthy viable fetus is therefore an extremely rare condition and very few of such cases have been published during the last ten years. We present a case of abdominal pregnancy that resulted in a term live baby without malformations.

Case Report

A 31- year- old woman, Gravida 3 Para 1, was referred from a District Hospital on 17th June 2008 at 8:00am. Her principal complaint on arrival was severe abdominal pain. She had irregular menstrual cycles prior to her pregnancy and was not sure of her last date of menstruation. The patient suffered from severe abdominal pain and vaginal bleeding which kept her out of work during the first trimester but the second trimester was incident free. She was, however, again kept out of work during the third trimester with abdominal pain. Her antenatal card indicated nine visits and a gestational age of 38 weeks at the time of referral.

On examination, she looked generally stable. She was not pale; vital signs were within normal parameters. Cardiovascular and respiratory systems did not reveal any abnormalities. The abdominal examination revealed symphysio-fundal height of 33cm, transverse lie, foetal heart rate of 136 beats per minute and no uterine contractions.

Vaginal examination revealed posterior located cervix measuring 2cm long without dilatation. There was no vaginal bleeding. She had five ultrasound scan examination with the last two within seven days of presentation indicating intrauterine gestation with transverse lie. The rest of her investigations were normal. The haemoglobin level was 10.9g/dl and blood group was O Rhesus positive. She was booked for emergency caesarean section on account of transverse lie at term.

At laparotomy the following findings were made: Abdominal pregnancy with a live female baby weighing 2.3 kilograms and meconium stained liquor. The placenta was extensively adherent to segments of large bowel, omentum and left cornual region of the uterus (Figure1).

Figure1

Normal sized uterus and placenta implanted on segment of bowel

The uterus, right tube and both ovaries were normal but the left tube was not identified. Other abdominal organs were normal.

There was significant bleeding from some detached portions of the placenta, which prompted removal of the detached placenta tissue to facilitate haemostasis. The rest of the placenta was left in situ. Haemostasis was secured. Total estimated trans-operative bleeding was one litre.

A unit of compatible blood was transfused intraoperatively. The patient progressed well and was discharged on the fifth postoperative day. She was followed up weekly for four weeks. Abdominal ultrasound after six weeks showed normal size uterus and ovaries and the portion of placenta that was left in situ was not identified. Beta human chorionic gonadotropin (BhCG) was negative at the same period. All investigations by the neonatologist and the general paediatrician did not show any abnormality on the baby. The patient was finally discharged home.

Go to:

Discussions

Advanced abdominal pregnancy is extremely rare. In a review at the Komfo Anokye Teaching Hospital, Opare-Addo et al reported an incidence of 1:1320 deliveries3 whilst Amirtha et al cited 1:25000 deliveries.4 Most of the cases of abdominal pregnancies are secondary from aborted or ruptured tubal pregnancy. 4 In this case it was obvious that the abdominal implantation was secondary to undiagnosed ruptured left tubal ectopic pregnancy. Clinical diagnosis can be very difficult and ultrasound is very helpful during the early stages of gestation but can also be disappointing in the later stages.

Other radiological studies such as MRI and CT scan are helpful in the later stages.5 Teng et al reported an interesting case in which MRI played a decisive role in the diagnosis6, unfortunately these advanced imaging technologies are not available in most parts of the third world. Our patient had five ultrasound scan examinations and none of these suggested the possibility of abdominal pregnancy. In poorly resourced centres, high index of suspicion is key for prompt diagnosis and timely intervention to prevent life-threatening complications.

In our opinion, bleeding from placental implantation site is the most life-threatening complication during laparotomy. The decision to remove the placenta or not can be a determining factor for the survival or otherwise of the woman and this decision is subject to the surgeon's expertise and the particular case in question. It is generally recommended to leave the placenta in situ and make a follow up with human chorionic gonadotropin levels.7 In this case there was significant bleeding from some detached portions of the placenta that prompted removal of these portions to secure haemostasis. The patient was transfused with one unit of blood during the operation and that was enough. For the newborn, it is very important to rule out congenital malformations. There are reports of foetal malformations as high as 40% associated with abdominal pregnancies and only 50% of these babies survive up to one week post delivery.8,9

In his extensive review, Stevens found some varying degrees of deformations and malformations in 21.4% of these infants. In this case that has been presented; no malformation has been found on the child after ten months.

Go to:

Conclusions

Abdominal pregnancy with resultant healthy newborn is very rare. Diagnosis of the condition can be difficult especially if the pregnancy is advanced. High level of suspicion, careful clinical and ultrasound examinations are the routine means of diagnosis though C T scan and MRI can be useful. Bleeding is the single most important life-threatening complication for the mother whilst fetal malformation is one of the numerous challenges that can confront the newborn.

Go to:

Acknowledgement

We wish to acknowledge the kind comments and guidance of Dr R.M.K Adanu on this case report.

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References

1. Nwobodo EI. Abdominal pregnancy. A case report. Ann Afr Med. 2004;3(4):195–196.

2. Badria L, Amarin Z, Jaradat A, Zahawi H, Gharaibeh A. Full-term viable abdominal pregnancy. A case report and review. Arch Gynaecol Obstet. 2003;268(4):340–342. [PubMed]

3. Opare-Addo HS, Daganus S. Advanced abdominal pregnancy: a study of 13 consecutive cases seen in 1993 and 1994 at Komfo Anokye Teaching Hospital, Kumasi, Ghana. Afr J Reproductive Health.2000;4(1):28–39. [PubMed]

4. Amritha B, Sumangali T, Priya B, Deepak S, Rai S. A rare case of term viable secondary abdominal pregnancy following rupture of a rudimentary horn. A case report. J Med case reports. 2009;3:38.[PMC free article] [PubMed]

5. Karat LS. Viable Abdominal Pregnancy. J Obstet Gynecol India. 2007;57(2):169–170.

6. Cunningham F, Gant N, Leveno K, et al. Williams Obstetrics. 21. Mcgraw-Hill; 2001. Ectopic Pregnancy; pp. 899–902.

7. Jianping Z, Fen L, Qiu S. Full-Term Abdominal Pregnancy. A Case Report and Review of the Literature. Gynecol Obstet Invest. 2008;65(2):139–141. [PubMed]

8. Teng H, Kumar G, Ramli N. A viable secondary intra-abdominal pregnancy resulting from rupture of uterine scar: role of MRI. Br J Radiol. 2007;80:134–136. [PubMed]

9. Kun K, Wong P, Ho M, Tai C. Abdominal pregnancy presenting as a missed abortion at 16 weeks gestation. Hong Kong Med J. 2000;6(4):425–427. [PubMed]

10. Stevens CA. Malformations and deformations in abdominal pregnancy. Am J Med Genet.1993;47(8):1189–1195. [PubMed]

Abdominal Ectopic PregnancyAbdominal pregnancy may account for up to 1.4% of ectopic pregnancies. [54-

56] Abdominal pregnancies refer to those with extrauterine implantations in omentum, vital organs, or large vessels. These pregnancies can go undetected until an advanced gestational age and often result in severe hemorrhage. [56] Rates of maternal mortality have been reported as high as 20%. [57,58]Advanced abdominal pregnancy carries a risk of hemorrhage, disseminated intravascular coagulation, bowel obstruction, and fistulae. [59] Frequently, these pregnancies are encountered with a viable fetus, which complicates their management.

Implantations have been reported in the pelvic cul-de-sac, broad ligament, bowel, and pelvic sidewall. [55,57,60] The site of implantation and availability of vascular supply are believed to be factors that may influence the possibility of fetal survival. [57] Risk factors for abdominal pregnancy include tubal damage, pelvic inflammatory disease, endometriosis, assisted reproductive techniques, and multiparity. [60,61] Abdominal pregnancies are believed to be a result of

secondary implantation from an aborted tubal pregnancy or as a result of intra-abdominal fertilization of sperm and ovum. [55,57]

Patients with abdominal pregnancy often present with abdominal pain, nausea, vomiting, painful fetal movements, and less frequently, vaginal bleeding.[59] In 1942, Studdiford outlined his criteria for abdominal pregnancy: (1) normal bilateral fallopian tubes and ovaries; (2) absence of uteroperitoneal fistula; or (3) presence of a pregnancy related to the peritoneal surface exclusively. [58] Today, the diagnosis of abdominal pregnancy is often made using ultrasound and x-ray. The classic ultrasound finding is the absence of myometrial tissue between the bladder and pregnancy. [57] Elevated serum alpha-fetoprotein has also been associated with abdominal pregnancy. [62] Diagnostic laparoscopy may also be of value when there is a doubt about pregnancy location. [63] In some cases, the diagnosis is not made until laparotomy. [58] Magnetic resonance imaging (MRI) holds promise as a diagnostic tool. [64,65]

Our knowledge of abdominal pregnancies comes largely from anecdotal case reports. Fisch et al[56] reported a case of abdominal pregnancy after IVF in a patient with previous salpingectomy. Omental implantation has been described. [57] Broad ligament pregnancies account for a small number of abdominal pregnancies. [66] Deshpande et al [67] reported a broad ligament twin pregnancy after IVF. The role of possible perforation with an IVF transfer catheter has been raised. There have also been reports of primary omental pregnancies. [58] Splenic pregnancy has been reported in several cases. Kitade et al [68] reported a first-trimester splenic pregnancy complicated by intra-abdominal hemorrhage and necessitating splenectomy. Cormio et al [69]detailed a ruptured splenic pregnancy in a patient who presented in hypovolemic shock.

The optimal treatment of abdominal pregnancy is unknown. Abdominal pregnancies frequently implant in vascular structures such as abdominal organs, omentum, or pelvic vessels. It has been reported that management of the placenta correlates well with maternal morbidity. When possible, ligation of placental blood supply and removal should be attempted to reduce maternal complications. [57,59,60] Alternatively, the umbilical cord may be ligated and expectant management, arterial embolization, or methotrexate used to facilitate involution. [57,64,70]However, leaving the placenta in situ may lead to further

complications such as infection, secondary hemorrhage, or intestinal obstruction. [59,65] Laparoscopy has been used in the treatment of some early abdominal pregnancies. [55,63] This conservative management should only be undertaken when the abdominal pregnancy has implanted on a less vascular surface. Olsen et al [71] reported laparoscopic management of a broad ligament pregnancy without complication. Primary methotrexate has been attempted for early gestations with minimal success. [72]

Hemorrhage is the most frequent problem encountered in treating abdominal pregnancy. Rahaman et al [65] used preoperative selective arterial embolization to help prevent hemorrhage in an advanced abdominal pregnancy that was removed laparoscopically. However, due to extensive vascular attachments, the placenta was left in situ and treated with methotrexate. Cardosi et al [70] report a similar experience with selective arterial embolization used as a means of reducing intraoperative blood loss during removal of a 33-week abdominal fetal demise. Ginath et al [73] reported a ruptured abdominal pregnancy successfully managed via laparoscopy, although the pregnancy was only 7 weeks gestation. Furthermore, there are reports of heterotopic abdominal pregnancies treated with laparoscopy with preservation of the intrauterine gestation. [56,74]

Abdominal pregnancy is an extremely rare event that may be difficult to diagnose. The advanced gestational age at which most abdominal pregnancies are discovered complicates management further. Because of the propensity for hemorrhage, removal of abdominal pregnancies requires surgical extraction and discrimination in deciding if placental removal is prudent. There is little information known about future fertility after abdominal pregnancy.