Delayed diagnosis and management of second trimester abdominal pregnancy.

Second trimester abdominal ectopic pregnancies are rare and life threatening. Early diagnosis and treatment are paramount in reducing maternal morbidity and mortality. We describe an unusually late diagnosis of abdominal pregnancy despite multiple ultrasounds beginning in early pregnancy. A 28-year-old G2P1001 sought pregnancy termination at 22 weeks' gestation after fetal anomalies were noted on an 18-week ultrasound during evaluation for elevated maternal serum alfa-fetoprotein. Due to abortion restrictions in her home state, she travelled over 500 miles for abortion care. During dilation and evacuation, suspected uterine perforation led to the finding of a previously undiagnosed abdominal pregnancy. At laparotomy, she underwent left salpingo-oophorectomy and removal of abdominal pregnancy and placenta. A multidisciplinary team approach was paramount in optimising the patient's outcome. Abortion restrictions requiring travel away from the patient's home community interrupted her continuity of care and created additional hardships, complicating management of an unexpected, rare and life-threatening condition.

Embarazo abdominal avanzado con feto vivo / Advanced abdominal pregnancy with live fetus

La incidencia del embarazo ectópico se ha incrementado durante los últimos años. La variedad abdominal es una de las menos frecuentes, representando alrededor del 1 por ciento de los mismos y se asocian con una alta tasa de mortalidad materna y fetal. Algunos casos pueden llegar al término y muchos menos obtener un recién nacido en buenas condiciones. Se presenta el caso de un inusual embarazo abdominal avanzado, con feto vivo. Se realiza laparotomía de urgencia a las 31,2 semanas de gestación, motivada por una sepsis grave; se extrajo un recién nacido masculino, de 1450 gramos, con Apgar 4/6/7. Madre e hijo sobrevivieron y se encuentran en buen estado de salud(AU)

The incidence of ectopic pregnancy has increased during the last years. The abdominal kind is one of the least frequent ones; only 1 percent of the ectopic pregnancies are abdominal and they are associated with a high maternal and fetal mortality rate. Some cases can arrive at full term, and fewer cases can obtain a newborn in good conditions. The following case is an unusual presentation of an advanced abdominal ectopic pregnancy with a live fetus. After an emergency laparotomy at 31,2 weeks of gestation, brought about by a severe sepsis, a live male newborn, weighing 1450 gr, with Apgar 4/6/7 was extracted. Mother and son survived and they are in good state of health(AU)

Late Abdominal Pregnancies (≥20 Weeks Gestation): A Review from 1965 to 2012.

BACKGROUND: Information about the diagnosis and management of late abdominal pregnancies (≥20 weeks gestation) is limited to case reports and small case series. METHODS: We performed a literature review of abdominal pregnancies ≥20 weeks gestation from 1965 to November 2012. Excluded were abdominal ectopic pregnancies that did not primarily implant in the peritoneal cavity, including tubal, ovarian, and intraligamentary pregnancies, and those prior to 20 weeks gestation. RESULTS: The 31 cases identified were at 30.4 ± 7.4 weeks at diagnosis and 33 ± 8.3 weeks at delivery. The most common sites of placental implantation were uterus or adnexa (47.8%), bowel (30%), and the potential spaces surrounding the uterus (8.7%). There were 5 cases of an intra-abdominal abscess in the 14 patients in whom the placenta had been left in situ. Maternal outcomes were documented in 26 cases with 7 deaths; 27 fetal outcomes were documented in 22 cases with 3 fetal deaths (13.6%). CONCLUSION: An abdominal ectopic pregnancy is an uncommon but serious event and should be considered in all patients until intrauterine gestation is confirmed. Management should be undertaken by an experienced surgical team in a tertiary care facility.

Developmental and clinical overview of lithopaidion.

Lithopaidion, or stone child, is generally a single rare asymptomatic formation that evolves from an undiagnosed and untreated advanced abdominal pregnancy. The dead fetus is retained in the maternal abdominal cavity, which causes calcification. In this paper, we review the literature on the epidemiology, etiopathogenesis and clinical features of lithopaidion and report a unique case of lithokelyphos in a patient with an ectopic fallopian pregnancy. We propose a model to unify the data. The new word 'lithopaidion' can be utilized instead of lithopedion.

Unusual ectopic pregnancies: a retrospective analysis of 65 cases.

AIM: The aim of this study was to retrospectively investigate unusual ectopic pregnancies (EP) and compare them with fallopian ones. MATERIAL AND METHODS: A total of 1000 cases of ectopic pregnancies were analyzed, including 65 unusual cases. We discussed distribution, incidence, risk factors, examinations, treatments and prognoses. RESULTS: Ovarian pregnancy was associated with placement of intrauterine device and pelvic inflammatory diseases. Extratubal EP have a high rate of misdiagnosis and presented more serious manifestations. Some unusual EP could be diagnosed by ultrasonography. Ovarian pregnancy was usually manifested as positive culdocentesis. Most of the unusual EP underwent surgery, except some early cervical and corneal pregnancies. CONCLUSION: Although extratubal pregnancies are difficult to diagnose, some histories and auxiliary examinations could make diagnosis easier for clinical physicians. Surgery is still the most effective approach for treatment of unusual EP, while conservative treatment of mifepristone combined with methotrexate or curettage could be used for early diagnosis and treatment of cervical pregnancy.

[Abdominal pregnancy in Libreville from 1999 to 2009]. / Grossesse abdominale à Libreville de 1999 à 2009.

INTRODUCTION: Abdominal pregnancy (AP) is defined as the implantation and development of the fertilised egg in the cavity of peritoneum. It causes severe perinatal morbity and mortality. OBJECTIVE: Underline the epidemiologic, diagnostic, therapeutic and prognostic aspects of the AP. METHODOLOGY: Retrospective study conducted at Maternité Joséphine Bongo (maternity hospital) and at the Centre Hospitalier de Libreville (hospital centre) from January 1999 to December 2009 on 19 cases of abdominal pregnancies. RESULTS: The frequency of AP in Libreville is one per 4447 deliveries (0.2 ‰) and one per 141 tubal ectopic pregnancies (0.7%). The mean age was 30.5 ± 7.2 years old and the mean parity 2.7 ± 1.7. The mean term of occurrence was 24.3 weeks of amenorrhoea (WA) with extremes at 14 and 39 WA. The diagnosis was made in the face of abdominal and pelvic pains in all the patients and an amenorrhoea in 11 cases (57%). It was confirmed by ultrasound scan in 14 cases (73.7%) and further to a laparotomy in five (26.3%) patients. We had two live births at 39 and 38 WA with respective birth weights of 2,380 and 2,550 g. Expulsion of the placenta was complete in seven (36.8%) cases. Five (26.3%) patients experienced hemorrhagic complications. CONCLUSION: AP is a rare pathology. Its diagnosis beyond of the second quarter is difficult with an often-pejorative foetal forecast.

A 30-year review of advanced abdominal pregnancy at the Mater Misericordiae Hospital, Afikpo, southeastern Nigeria (1976-2006).

PURPOSE: This analysis attempts to highlight the varied presentations, diagnostic difficulties, management and subsequent obstetric performances of women managed for advanced abdominal pregnancy. METHODS: A retrospective analysis of all 20 cases of abdominal pregnancies between 1976 and 2006, at the Mater Misericordiae Hospital, Afikpo, southeastern Nigeria was performed. RESULTS: There were 20 cases of abdominal pregnancy out of 58,000 deliveries, giving an incidence of 0.34 per 1,000 deliveries. The diagnoses were missed in 10 cases and there was one maternal death. There were four live births, two early neonatal deaths and four cases of lithopedion. The placenta was removed in 11 cases. Though the duration of hospital stay was longer in women in whom the placenta was left in situ compared to those in whom the placenta was removed, the observed difference was, however, not statistically significant (p value, 0.538). The majority of the women were lost to follow-up over the years; however, of the five women successfully followed up, only two (40%) had subsequent childbirth. CONCLUSION: The rate of 50% missed diagnosis in this study highlights the need for a high index of suspicion in the diagnosis of abdominal pregnancies as the clinical features are varied. It calls for vigilance on the part of the obstetrician. The maternal and fetal outcomes relate to early diagnosis and skilled management.

Embarazo abdominal a término: presentación de un caso / Term abdominal pregnancy: presentation of a case

El embarazo ectópico es una entidad extremadamente peligrosa que, de no realizar un diagnóstico adecuado y un tratamiento precoz, conlleva una alta mortalidad. En las últimas décadas ha aumentado la frecuencia, oscilando entre 4,5 y 12,5 por mil embarazos. Hemos realizado un estudio retrospectivo tomando como base un caso que tuvimos la oportunidad de tratar mientras nos encontrábamos cumpliendo misión internacionalista en Guatemala. Se presenta el testimonio gráfico del mismo.

Ectopic pregnancy is an extremely dangerous entity, leading to a high mortality if an adequate diagnosis and an early treatment are not made. During the last decades its frequency has increased, oscillating form 4, 5 to 12, 5/1 000 pregnancies. We carried out a retrospective study, beginning from a case we attended when were in an international mission in Guatemala. We present a graphic testimony of the case.

Embarazo abdominal a término. Presentación de un caso / Term abdominal pregnancy. Presentation of a case

El embarazo ectópico es una entidad extremadamente peligrosa que, de no realizar un diagnóstico adecuado y un tratamiento precoz, conlleva una alta mortalidad. En las últimas décadas ha aumentado la frecuencia, oscilando entre 4,5 y 12,5 por mil embarazos. Hemos realizado un estudio retrospectivo tomando como base un caso que tuvimos la oportunidad de tratar mientras nos encontrábamos cumpliendo misión internacionalista en Guatemala. Se presenta el testimonio gráfico del mismo

Advanced abdominal pregnancy--a diagnostic and management dilemma.

Advanced abdominal pregnancy is a complex condition demanding challenging management. High index of suspicion may reduce the diagnostic error. Management varies from patient to patient. Expectant management is a feasible option in a well-equipped tertiary care hospital in case of alive viable fetuses. This evidence-based report describes the author's experience of managing a series of advanced abdominal pregnancies at 24 weeks or more of gestation.

A case of simultaneous tubal-splenic pregnancy after assisted reproductive technology.

OBJECTIVE: To present a case of simultaneous splenic and tubal pregnancy following in vitro fertilization. DESIGN: Case report. SETTING: University hospital. PATIENT(S): A 37-year-old woman who had undergone in vitro fertilization and embryo transfer for unexplained infertility at another clinic. INTERVENTION(S): Laparoscopy and laparotomy. MAIN OUTCOME MEASURE(S): Serum concentration of human chorionic gonadotropin (hCG) after salpingosplenectomy. RESULT(S): After transfer of three embryos following fertilization by intracytoplasmic sperm injection (ICSI) at another clinic, the patient was referred to our hospital with suspicion of ectopic pregnancy. Because tubal pregnancy was suspected, laparoscopic right salpingectomy was performed. Although villi were detected in the resected fallopian tube, the serum hCG concentration did not decrease after the operation and a new intraabdominal hemorrhage was detected. We then suspected abdominal pregnancy in the epigastric region, and performed magnetic resonance imaging, computed tomography, and ultrasound examinations, which revealed implantation at the inferior pole of the spleen. Splenectomy was performed, with the resulting disappearance of intraabdominal hemorrhage and rapid fall of the serum concentration of hCG. CONCLUSION(S): Assisted reproduction sometimes results in heterotopic pregnancy, but an abdominal pregnancy involving the upper abdominal organs is considered extremely rare. Particularly, splenic pregnancy is usually overlooked and may only be discovered after a sudden intraabdominal hemorrhage. If hemorrhaging is present in the abdominal cavity but pregnancy is not detected within the pelvis, it is advisable to examine patients using imaging techniques to detect any upper abdominal pregnancies.

Ovarian pregnancy-a 12-year experience of 19 cases in one institution.

OBJECTIVES: To report the prevalence, presentation, diagnostic modalities, and treatment of ovarian pregnancy in one institution. STUDY DESIGN: Retrospective case control study of 19 cases of ovarian pregnancy treated between 1990 and 2001 at Assaf Harofeh Medical Center, Zerifin, Israel. MAIN OUTCOME MEASURES: Prevalence, presentation, diagnostic modalities, surgical treatment, and relation to intrauterine device (IUD) use. RESULTS: Nineteen ovarian pregnancies, diagnosed between 1990 and 2001, comprised (19/694) 2.7% of all ectopic pregnancies, 1:3000 of all live births leading to a mean ovarian pregnancy per year of 1.6. Presenting symptoms were similar to those of tubal pregnancies including circulatory collapse which was present in 4/19 (21%) of patients. Culdocentesis for diagnostic purposes, has become an unnecessary procedure. Wedge resection by laparotomy was the treatment of choice in the past, and from 1994, it was performed exclusively by laparoscopy. When an ovarian pregnancy was diagnosed, intrauterine device was present in 68% of the patients and in 76% of the fertile women. CONCLUSIONS: The absolute number of ovarian pregnancies between 1900 and 2001 increased but the prevalence rate per delivery was stable. Despite modern diagnostic modalities patients still present in circulatory collapse-conservative approach may underestimate the potential risk of bleeding. Culdocentesis has no clinical diagnostic benefits. Laparoscopy is invaluable, as diagnosis and treatment can be carried out as a single treatment. Laparoscopic wedge resection is the treatment of choice. The relation between IUD use and ovarian pregnancies is still strong.

Grossesse abdominale au CHU de Yopougon : a propos de 10 cas colliges en trois ans

Notre etude prospective; est realisee dans le service de gynecologie obstetrique du CHU de YOPOUGON sur une periode de trois ans du ler Janvier 2000 au 31 Decembre 2002 L'objectif est de:-Etablir le profil epidemiologique des patientes.-Evaluer la frequence des grossesses abdominales.-Apporter notre experience dans la prise en charge des grossesses abdominales.Dix grossesses abdominales ont ete recensees sur la periode et elles representent 1/723 accouchements. Malgre le petit echantillonnage nous pouvons ressortir un profil des patientes les plus exposees notamment: le bas niveau socio-economique (100pour cent des cas); l'age moyen de 28 ans; la nulliparite (60pour cent des cas); les antecedents d'interruption volontaire de grossesse (70pour cent des cas) qui peut laisser entrevoir un profil infectieux.Le diagnostic est tardif 80pour cent des cas au cours du deuxieme trimestre. Il est domine par l'hemoperitoine 70pour cent des cas et par la douleur abdomino-pelvienne 90pour cent des cas.La prise en charge necessite une intervention chirurgicale. Dans notre contexte; elle a ete realisee en urgence dans 90pour cent des cas. La difficulte chirurgicale reside dans l'extirpation du placenta en fonction de son siege. Dans 100pour cent des cas elle a ete totale; associe a des gestes : hysterectomie 1pour cent; salpingectomie 2pour cent; omentectomie 1pour cent.Le pronostic maternel est bon. Par contre le pronostic foetal est catastrophique avec 100pour cent de deces.La reduction de la frequence de la grossesse abdominale passe par:-la prevention et le traitement precoce et efficace des infections genitales.-La reglementation de la pratique de l'interruption volontaire de grossesse.-le diagnostic precoce de la grossesse abdominale par la systematisation de l'echographie des le premier trimestre.Une sensibilisation du personnel medical dans ce sens parait utile

Sites of ectopic pregnancy: a 10 year population-based study of 1800 cases.

BACKGROUND: Several risk factors for ectopic pregnancy (EP) have been identified, but the site of implantation of EP has been little studied. METHODS: A total of 1800 surgically treated EP was registered between January 1992 and December 2001 in the Auvergne EP register and the women concerned were followed up. In this large population-based sample, we studied the distribution of EP sites, immediate complications, determining factors, and subsequent fertility. RESULTS: EP sites were interstitial (2.4%), isthmic (12.0%), ampullary (70.0%), fimbrial (11.1%), ovarian (3.2%) or abdominal (1.3%). No cervical pregnancies were observed. Complications and treatment depended on the site of EP. In multivariate analysis, the only risk factor associated with EP site was current use of an intrauterine device (IUD), which was more frequent in distal EP. The 2 year cumulative rate of subsequent spontaneous intrauterine pregnancy (IUP) increased progressively from interstitial to ovarian EP. Fair concordance (weighted kappa = 0.31) was observed between the sites of two successive EP if they were homolateral. CONCLUSION: In addition to providing an accurate description of the sites of implantation of EP, this study shows that current IUD use 'protects' against interstitial pregnancies, which are the most difficult to manage. It shows that subsequent fertility tends to be higher in women with distal EP.

[A new case of abdominal pregnancy]. / Un nouveau cas de grossesse abdominale.

The authors report a case of abdominal pregnancy that reached term. This type of pregnancy is now rare except in developing countries due to lack of early diagnosis. Ultrasonography is useful to confirm a clinically suspected diagnosis. MRI is helpful to further characterize the relation between placental tissue and intra-abdominal organs. Prognosis for the fetus is usually poor, and risks to the mother are non-negligible. Management is typically surgical and placental resection is the main concern. In this case, surgical delivery of an otherwise normal appearing infant was performed.

Advanced abdominal pregnancy: a study of 13 consecutive cases seen in 1993 and 1994 at Komfo Anokye Teaching Hospital, Kumasi, Ghana.

Thirteen cases of advanced abdominal pregnancy (AAP) managed at the Komfo Anokye Teaching Hospital (KATH), Kumasi, Ghana, over a two-year period (1993-1994) are presented. An incidence ratio of one advanced abdominal pregnancy to 1,320 deliveries occurred during this period. The ratio of advanced abdominal pregnancy to ectopic pregnancy was 1:43.7. The perinatal mortality rate and maternal case fatality rates were 69.6% and 15.3% respectively. Recurrent abdominal pains in the gravid patient with abnormal fetal lie and prior history of tubal pregnancy and/or previous abdominal surgery were significant findings in the cases reviewed. These findings should, therefore, always prompt lucid and elaborate ultrasound examination of a pregnancy to exclude abdominal pregnancy.

[Abdominal pregnancy, institutional experience]. / Embarazo abdominal experiencia institucional.

Abdominal pregnancy is a rare entity, which has been classified as primary or secondary by Studiford criteria. A retrospective study, between January 1989 and December 1994, realized at Instituto Nacional de Perinatología, found 35,080 pregnancies, from which 149 happened to be ectopic, and 6 of them were abdominal. All patients belonged to a low income society class, age between 24 and 35 years, and average of gestations in 2.6. Gestational age varied from 15 weeks to 32.2 weeks having only one delivery at term with satisfactory postnatal evolution. One patient had a recurrent abdominal pregnancy, with genital Tb as a conditional factor. Time of hospitalization varied from 4 to 5 days, and no further patient complications were reported. Fetal loss was estimated in 83.4%. Abdominal pregnancy is often the sequence of a tubarian ectopic pregnancy an when present, it has a very high maternal mortality reported in world literature, not found in this study. The stated frequency of abdominal pregnancy is from 1 of each 3372, up to 1 in every 10,200 deliveries, reporting in the study 1 abdominal pregnancy in 5846 deliveries. The study had two characteristic entities one, the recurrence and two, the delivery at term of one newborn. Abdominal pregnancy accounts for 4% of all ectopic pregnancies. Clinical findings in abdominal pregnancies are pain, transvaginal bleeding and amenorrea, being the cardinal signs of ectopic pregnancy.

Embarazo abdominal experiencia institucional / Abdominal pregnancy. Institutional experience

El embarazo abdominal es una entidad rara, la cual se ha clasificado como primaria o secundaria, basados en los criterios de Studiford. Se realizó una investigación retrospectiva de enero de 1989 a dicembre de 1994, en el Instituto Nacional de Perinatología. En este periodo hubieron 35080 nacimientos de los cuales 149 fueron embarazos ectópicos y seis de estos abdominales. Todas las pacientes se catalogaron como de estrato socioeconómico bajo, con un rango de edad de entre 24 y 35 años, con un promedio de gestaciones de 2.6 La edad gestacional osciló entre 15 a 32.2 semanas, obteniéndose un solo neonato vivo el cual evolucionó satisfactoriamente. Un caso curso con embarazo abdominal recurrente, quien tenía como antecedente tuberculosis genital. La estancia hospitalaria varió entre cuatro y cinco días. No se informaron complicaciones graves. La mortalidad fetal fue de 83.4 por ciento y cabe señalar que en todos los casos la placenta se extrajo completamente. El embarazo abdominal es generalmente consecuencia de un embarazo tubario y posee una alta mortalidad materna, aunque en nuestra serie no se observó ningún caso. La frecuencia citada varía desde uno en 3372 nacimientos hasta uno de 10,200, siendo nuestra frecuencia de uno por cada 5846 nacimientos y una proporción de 4 por ciento de todos los embarazos ectópicos, estando éste en el límite superior informado. Los datos clínicos más frecuentes fueron dolor abdominal, sangrado trasvaginal y amenorrea, refiriendose a éstos como la triada clásica del embarazo ectópico. Cabe señalar que encontramos dos eventos poco frecuentes, uno la recurrencia del embarazo abdominal y el otro la supervivencia de un producto