Primary hepatic ectopic pregnancy in a patient with polycystic ovary syndrome: A case report.

RATIONALE: Hepatic ectopic pregnancy is an extremely rare ectopic pregnancy. This study aimed to report a case of primary hepatic pregnancy in a patient with polycystic syndrome. PATIENT CONCERNS: A 30-year-old woman presented with vaginal bleeding after 63 days of amenorrhea. DIAGNOSIS: The patient was initially diagnosed with liver ectopic pregnancy using abdominal ultrasound and abdominal computed tomography (CT). INTERVENTIONS: The patient underwent laparoscopic exploration to reconfirm the gestational sac in the liver and abdominal surgery to remove liver gestation. The postoperative review of abdominal CT and the level of serum human chorionic gonadotropin (hCG) was performed. OUTCOMES: The postoperative pathological examination revealed a fluffy tissue in the liver tissue and a blood clot. The patient's vital signs were normal, and she was advised regular follow-up after discharge from the hospital. One month later, the serum hCG level reduced to 0.32 mIU/mL (reference range 0-5 mIU/mL). LESSONS: If the level of beta-human chorionic gonadotropin (ß-HCG) is higher than normal in women of childbearing age and no gestational sac is found in the uterine cavity, the location of pregnancy and gestational sac should be positively confirmed. Also, the possibility of ectopic pregnancy in the abdominal cavity should be considered, and the relevant imaging and biochemical examinations should be improved to avoid delay in diagnosis and treatment.

Neglected intrauterine fetal demise for more than two decades leading to the development of a lithopedion: a case report.

BACKGROUND: Lithopedion is a word derived from the Greek words lithos, meaning stone, and paidion, meaning child, to describe a fetus that has become stony or petrified. Lithopedion is a rare complication of pregnancy which occurs when a fetus dies and becomes too large to be reabsorbed by the body. This entity in rare circumstances can be challenging for physicians to diagnose since it has a range of clinical manifestations. CASE PRESENTATION: We present a case of a 55-year-old, gravida IV para III, Ethiopian woman from Ethiopia with a retained fetus and vesicovaginal fistula after an obstructed labor and a neglected intrauterine fetal demise of approximately 22 years. The diagnosis was confirmed by suggestive clinical history, physical examination findings, and an abdominopelvic computed tomography scan. Laparotomy and removal of the lithopedion was done and our patient was sent to a fistula hospital for vesicovaginal fistula repair. CONCLUSION: This case is a rare phenomenon in which the dead fetus remained in the uterus for a long time after a neglected obstructed labor and uterine rupture.

Laparoscopic Removal of an Abdominal Pregnancy in the Pelvic Sidewall.

STUDY OBJECTIVE: To describe the presentation, diagnosis, and management of a patient with abdominal pregnancy and to illustrate the laparoscopic technique used to manage this patient. DESIGN: A descriptive study approved by our local Institutional Review Board. Consent was given from the patient. SETTING: A university hospital in Ashdod, Israel. PATIENT: On May 15th 2018, a gravida 3, para 2, 37-year-old asymptomatic patient was referred to our hospital's gynecologic emergency department due to a suspected ectopic pregnancy. The patient had no relevant medical or surgical history. Her obstetric history consisted of 2 spontaneous vaginal deliveries with no other significant gynecologic history. Her menses were regular every month. Her last menstrual period was 6 weeks before presentation. Her ß-human chorionic gonadotropin (hCG) level measured on the day before presentation was 24,856 IU/L. Physical examination was unremarkable except for a small amount of brownish vaginal discharge. A transvaginal ultrasound (TVUS) exam on presentation did not demonstrate an intrauterine gestational sac, but revealed a gestational sac and a fetus next to the right adnexa, with a crown-rump length of 1.3 cm, consistent with 7+3 gestational weeks. There was a minimal amount of fluid in the pouch of Douglas. INTERVENTION: Owing to an extrauterine pregnancy with high ß-hCG value, laparoscopic operative management was chosen. On entrance to the abdominal cavity, a normal uterus and 2 ovaries and fallopian tubes were observed. A small to moderate amount of blood was present in the pouch of Douglas. a 3- to 4-cm distension was noted over the right uterosacral ligament. Following delicate probing of the area, moderate to severe bleeding commenced, which was initially controlled with local pressure and oxidized regenerated cellulose. An intraoperative TVUS identified an abdominal pregnancy in the right pelvic sidewall. The gestational sac was completely dissected and removed following ureterolysis and separation of the right ureter from the specimen. Local injection of vasopressin was also used. The ß-hCG level before surgery of 19,008 IU/L decreased to 6339 IU/L on postoperative day 1. The patient was discharged in good condition on postoperative day 2. A final histopathological report confirmed a gestational sac. MEASUREMENT AND MAIN RESULTS: This patient referred for a tubal ectopic pregnancy was eventually diagnosed with an abdominal pregnancy and was treated operatively with complete excision of the abdominal pregnancy, which was located at the right pelvic sidewall. CONCLUSION: Abdominal pregnancy is a rare type of ectopic pregnancy with a reported incidence of 1:10,000 to 1:30,000 pregnancies, and accounts for approximately 1% of ectopic pregnancies [1]. It carries a high risk for maternal morbidity and mortality. Many different locations at different gestational ages have been reported in the literature, including the pouch of Douglas, pelvic sidewall, bowel, broad ligament, omentum, and spleen [2-4]. These varied locations and the rarity of this type of pregnancy make diagnosis and treatment challenging. The location of the growing fetal tissue may endanger the patient's life if it impinges on vital anatomic structures. In the present case, the gestational sac was very close to the right ureter, and we opted to surgically excise the gestational sac in its entirety.

A full term abdominal pregnancy with an isthmic tubal implantation of the placenta.

BACKGROUND: Abdominal pregnancy is defined as the partial or total insertion of the embryo into the abdominal cavity. It is rare, and can evolve towards the full term if it is not recognized in the early pregnancy. It carries a high risk of maternal-fetal morbidity and mortality. CASE PRESENTATION: We report a case of a 22 year-old gravida IV, para II with an asymptomatic and undiagnosed abdominal pregnancy presumed full term, in a context of health centers under-equipment. She had attended 5 routine antenatal care, but had not performed any ultrasound scan. She had been transferred from a medical center to the Hospital of Ouahigouya (Burkina Faso) for bowel sub-obstruction and intrauterine fetal death, with failure of labor induction. On admission, the hypothesis of uterine rupture or abdominal pregnancy with antepartum fetal demise was considered. A laparotomy was then performed, where an abdominal pregnancy was discovered, and a dead term baby weighing 3300 g delivered. The placenta which was implanted into the ruptured isthmus of the left fallopian tube was removed by salpingectomy. Postoperative follow-up was uneventful. CONCLUSION: This case report exposes the necessity for the practitioner to think about the possibility of abdominal pregnancy in his clinical and sonographic practice, irrespective of the gestational age, mainly in contexts where there is under-equipment of the health centers.

Extra-uterine (abdominal) full term foetus in a 15-day pregnant rabbit.

BACKGROUND: While ectopic pregnancies account for 1-2% of all pregnancies, abdominal pregnancy is extremely rare, accounting for approximately 1% of ectopic pregnancies. Extrauterine abdominal pregnancy is defined as the implantation and development of an embryo in the peritoneal cavity. The present report is the first of an incidental case of abdominal pregnancy within four full-term foetus simultaneously with 2 weeks of physiological gestation in a healthy doe rabbit. CASE PRESENTATION: The doe was born on November 3, 2014 and the first partum took place on May 18, 2015. The doe had previously delivered and weaned an average of 12.0 ± 1.41 live kits at birth (no stillbirths were recorded) during 5 consecutive pregnancies. The last mating was on December 18, 2015 and the detection of pregnancy failure post breeding (by abdominal palpation) on December 31, 2015. Then, the doe was artificially inseminated on January 27, 2016, diagnosed pregnant on February 11, 2016 and subsequently euthanized to recover the foetus. A ventral midline incision revealed a reproductive tract with 12 implantation sites with 15 days old foetus and 4 term foetus in abdominal cavity. There were two foetus floating on either side of the abdominal cavity and two suspended near the greater curvature of the stomach. They were attached to internal organs by means of one or 2 thread-like blood vessels that linked them to the abdominal surfaces. CONCLUSIONS: In our opinion a systematic monitoring of rabbit breeding should be included to fully understand and enhance current knowledge of this phenomenon of abdominal pregnancy.

Incidentally Detected Lithopedion in an 87-Year-Old Lady: An Autopsy Case Report.

A lithopedion is a rare complication of pregnancy that occurs when a fetus in an intraabdominal location dies, and it is too large to be reabsorbed by the body. The case was an 87-year-old woman, and she was transferred to the morgue department in April 2014 to determine the cause of death. During autopsy, an intraabdominally located calcified dead fetus and a 12-cm diameter calcified cyst in the right ovary were incidentally detected. It was aged 25 to 29 weeks (according to femur and humerus measurements) with a size of 12.5 × 8 × 5 cm and a weight of 227 g. According to investigation reports, her husband died in 1990, and she had 3 deliveries, the most recent of which was in 1946. Because the menopause age of the case was not exactly known, the retention time of the lithopedion was supposed to be 24 to 68 years according to the date of the most recent pregnancy and the date of her spouse's death. It is the first case that has been incidentally detected and identified during an autopsy in Turkey and also one of the oldest cases in the literature.

A case report of an asymptomatic late term abdominal pregnancy with a live birth at 41 weeks of gestation.

BACKGROUND: Despite advances in diagnostic imaging and focused antenatal care, cases of undiagnosed abdominal pregnancies at term are still reported in obstetric practice. It is atypical and very rare for a patient to be asymptomatic late in pregnancy and for the pregnancy to result in a live birth with no evidence of intrauterine growth restriction despite the unfavourable implantation site. This late term asymptomatic presentation despite routine antenatal care demonstrates a diagnostic challenge. CASE PRESENTATION: We report a case of a 26 year old Primigravida with an asymptomatic and undiagnosed abdominal pregnancy carried beyond 41 weeks of gestation espite routine antenatal care and serial ultrasound reports. She presented for a routine antenatal care visit at 41 weeks of gestation. Induction of labour was initiated due to the late term gestation but was unsuccessful. At this point the fetus developed severe tachycardia and CTG confirmed persistent non-reassuring foetal heart rate patterns. The mother was then prepared for an emergency caesarean delivery. Abdominal pregnancy was only diagnosed at laparotomy where a term male baby weighing 3108 g was delivered with an Apgar Score of 7 and 8 at 1 and 5 min respectively. The placenta which was implanted into the omentum, ileal mesentery and extending to the pouch of Douglas was removed following active bleeding from its detached margins. She was transfused with two units of blood and four units of fresh frozen plasma. Postoperative morbidity was minimal with transient paralytic ileus on the second post-operative day. Her recovery was otherwise uneventful and she was discharged on the seventh post-operative day in good condition. The neonate developed meconium aspiration syndrome and passed away on the 2nd day of life despite having undergone standard care. A post-mortem examination was not performed because the family did not consent to the procedure. Follow up of the mother at 2, 6 weeks and 6 months postpartum was uneventful. CONCLUSIONS: This atypical presentation of an asymptomatic abdominal pregnancy carried tolate term and only diagnosed at laparotomy despite routine antenatal care demonstrates a significant lapse in diagnosis. Clinicians and radiologists must always bear this possibility in mind during routine client evaluation. Skills training in Obstetric ultrasound and in the clinical assessment of obstetric patients should emphasize features suggestive of abdominal pregnancy. This will improve diagnosis, ensure appropriate management and minimise complications. Immediate termination of pregnancy can be offered if the diagnosis is made before 20 weeks of gestation. Patients diagnosed with advanced abdominal pregnancies and are stable can be monitored under close surveillance and delivered at 34 weeks of gestation after lung maturity is achieved. Although removal of the placenta carries a higher risk of haemorrhage, a partially detached placenta can be delivered with minimal morbidity and a good maternal outcome. Given the documented low survival rates of neonates in such cases, neonatal units must be adequately equipped and staffed to support them. Post-mortem examination is important to confirm cause of death and exclude other complications and congenital anomalies. Communities need to be educated about the importance of this procedure.

Advanced abdominal ectopic pregnancy: lessons from three cases from Zimbabwe and a literature appraisal of diagnostic and management challenges.

We report three cases illustrating difficulties in diagnosis and challenges with management of the placenta in a low-resource country where ultrasound scanning, methotrexate, interventional radiology or blood products are often not accessible for the majority of patients. Even in situations where an ultrasound scan is available prenatally as in our three cases, the diagnosis is often missed. All the cases presented with vague abdominal symptoms, which are common in pregnancy anyway. Only one case was correctly diagnosed before surgery by ultrasound scan. For the two cases in the second trimester as expected the fetuses did not survive. The one advanced pregnancy had a good perinatal outcome. Maternal morbidity and mortality usually results from perioperative hemorrhage from the placental attachment site. The most important aspect of management is the management of the placenta. In the two cases with second trimester pregnancies, it was possible to remove the placentas, even though blood loss was significant, hemostasis was achieved at surgery. All three mothers recovered well and survived.

A 16-week secondary abdominal ectopic pregnancy with a simultaneous intratubal placenta and abdominal fetus.

An unusual case of a simultaneous tubal and abdominal ectopic pregnancy with the placenta in the intact tube and fetus in the abdominal cavity demonstrating the pathogenesis of secondary abdominal pregnancy subsequently managed by laparoscopic salpingectomy and removal of the abdominal fetus.

Secondary abdominal appendicular pregnancy: case report.

INTRODUCTION: The case report describes a 29-year-old nulliparous woman that was admitted at the Department of Gynecology and Obstetrics of the Clinical Hospital Osijek complaining of mild abdominal pain without vaginal discharge. CASE OUTLINE: The patient's menstrual cycle was irregular, from 30-45 days. An ultrasound examination showed suspicion of an ectopic pregnancy with a betaHCG level of 1358 IU/L. Due to the presence of liquid in the pouch of Douglas the patient underwent emergency laparoscopy, which showed the presence of tumor mass between the right Fallopian tube and the appendix. These two structures associated with adhesions corresponded to secondary implantation after spontaneous tubal abortion which was confirmed by histopathologic analysis. CONCLUSION: Laparoscopy has emerged as the"gold standard"in the diagnosis and treatment of ectopic pregnancy, in this case the secondary abdominal pregnancy. From the diagnostic point of view, all women of reproductive age should be considered pregnant until proven otherwise, also keeping in mind that ectopic pregnancies can have different locations and many clinical features.

Omental pregnancy: case report and review of literature.

Pregnancy, the implantation of a fertilized ovum outside the endometrial cavity, occurs in 1.5%-2% of pregnancies. It is one of the major causes (about 6%) of maternal death during the first trimester of pregnancy. The remaining 5% implant in the ovary, peritoneal cavity, within the cervix, and the omental pregnancy is the least common form of abdominal pregnancies. A review of the literature on Medline for the period 1958-2012 reported only 16 cases of omental pregnancy. Here we report a case of primary omental pregnancy in a nulliparous woman. A 24 year-old woman gravid 1, para 0, with lower abdominal pain. Her last menstrual period occurred 8 weeks before the visit. The physical examination revealed abdominal tenderness in the lower quadrants, she was not bleeding. Transvaginal ultrasound showed: a free anechoic/hypoechoic area of 30 x 57 mm in the pouch of Douglas and the endometrium was homogeneus with a thickness of 12 mm and no evidence of gestational sac in the uterine cavity. Laboratory data revealed a normal cell blood count and beta hcg levels of 8047 IU / L. Because of continuing abdominal pain and a diagnosis of ectopic pregnancy a diagnostic laparoscopy was performed, which showed hemoperitoneum. Further inspection of abdominal cavity revealed a bloody lesion that was tenaciously adherent to the omentum, using non traumatic laparoscopic forceps and bipolar scissors we carefully removed a friable mass of about 30 mm from the omental attachments. Histological examination showed the presence of blood clot material mixed with trophoblastic tissue. Ultrasound evaluation and and hCG assessment are important to determine the extrauterine location of the ectopic pregnancy but the early diagnosis of abdominal pregnancy requires also a laparoscopic evaluation and, as our case has highlighted, thorough abdominal exploration especially in the absence of adnexal findings when ectopic pregnancy is highly suspected. Early diagnosis of omental pregnancy is difficult but essential to reduce the high mortality risk for the mother.

Role of serial MRI assessment in the management of an abdominal pregnancy.

A 33-year-old woman was admitted to the hospital with an abdominal pregnancy at a gestational age of 20 weeks. An initial MRI mapping of fetal location and placental vascular invasion was obtained. The patient refused surgical intervention until fetal survival would be possible. Serial MRIs were essential in timing delivery and avoiding an emergency surgical situation. The baby was delivered at 24 weeks with the assistance of a multidisciplinary surgical team. The mother as well as the baby survived. This case report highlights the role of serial MRI evaluations in the diagnosis and expectant management of an abdominal pregnancy. It also highlights the importance of interdisciplinary communication for a successful outcome.

Successfully treated abdominal pregnancy causing hemoperitoneum using combined surgical and systemic methotrexate therapy: a case report and review of cases treated at Kyushu University Hospital.

Abdominal pregnancy is a rare condition that accounts for only 1% of all ectopic pregnancies but results in high maternal morbidity and mortality. We present a case of abdominal pregnancy with massive peritoneal bleeding successfully treated using systemic methotrexate (MTX). A 34-year-old woman with amenorrhea for 8 weeks and a positive pregnancy test was referred for evaluation of ectopic pregnancy. Transvaginal ultrasonographic scan showed a gestational sac measuring 25 mm in diameter containing a viable embryo in the cul-de-sac and a considerable amount of free fluid in the patient's lower abdomen and pelvis. Laboratory parameters showed that her hemoglobin concentration was 5.8 g/dl and serum human chorionic gonadotropin concentration was 13,195 mIU/ml. Emergency surgery revealed an abdominal pregnancy in the cul-de-sac and a massive intra-abdominal hemorrhage. After a hemostasis procedure, the patient was successfully treated using systemic MTX. We also present the review of abdominal pregnancy cases treated using systemic MTX at our institution over 10 years. Systemic MTX treatment for abdominal pregnancy is safe and effective and makes it possible to avoid the risk of excessive bleeding by surgical resection of the implantation site.

Sudden death in advanced abdominal pregnancy: a case report and discussion of the related medicolegal issues.

We report sudden unexpected death in a 35-year-old woman with pregnancy of seven months duration. There was an allegation by the parents of the woman that she was subjected to an assault prior to death. Autopsy examination showed an abdominal pregnancy with a dead fetus, ruptured gestational sac, massive haemorrhage and secondary placental attachment. During her antenatal check-ups, she had persistently complained of abdominal pain and loose stools, but the diagnosis of abdominal pregnancy was missed clinically and on ultrasound scan. In this paper we discuss the diagnostic difficulties and medicolegal issues in such cases.

Lactogenesis failure following successful delivery of advanced abdominal pregnancy.

Abdominal pregnancy is a rare condition with significant risk of maternal and fetal morbidity and mortality. Because of the vascular involvement, the placenta is often left in situ. Prior reports have neglected to discuss the implications of leaving the placenta in situ on breastfeeding and lactation. We present a case of failure of lactogenesis II following the successful delivery of an advanced abdominal pregnancy in which the placenta was left in situ. This is the first report to discuss the effects on lactation of leaving the placenta in situ as a conservative management option in advanced abdominal pregnancy.

Abdominal pregnancy: a perfusion confusion?

BACKGROUND: The uteroplacental blood supply is usually portrayed as a 'series' circuit. Differences seen in the uterine artery (UA) waveform in pregnancies destined to develop pre-eclampsia are often attributed to back pressure effects from the downstream flow through the spiral arteries of the placental bed. CASE: A third trimester abdominal pregnancy was successfully delivered by laparotomy at 30 weeks gestation. The UA waveforms of were recorded at 27 weeks. Both were 'normal' for the gestation, despite limited blood supply from the right uterine and the left not supplying the placenta at all. CONCLUSION: In the absence of pre-eclampsia, UAs can convert to a 'low resistance' waveform even when not directly connected to the placental bed. This case report adds to the evidence against the 'cause and effect' mechanism often used to explain the correlation between trophoblastic invasion and the UA waveform. Both may independently develop in response to a common underlying mechanism.