Challenging Diagnosis of Late Abdominal Pregnancy: A Case Study of Misdiagnosis and Fetal Death in the Third Trimester.

BACKGROUND Abdominal pregnancy is a rare form of extrauterine pregnancy that usually results in a poor outcome; it is associated with serious fetal and maternal morbidity. The diagnosis of advanced abdominal pregnancy is sometimes challenging and should be identified early, at a routine antenatal examination. There are still no evidence-based management strategies for late abdominal pregnancy. This report presents a case of a patient with an abdominal pregnancy and a non-viable fetus. CASE REPORT A 34-year-old woman presented as an emergency 2 months after the diagnosis of intrauterine fetal death at 33 weeks of gestation. During subsequent surgery, the pregnancy was found to be an undiagnosed abdominal pregnancy. The patient had been admitted due to abdominal pain and increasingly deteriorating general condition. On admission, clinical examination and abdominal ultrasound were carried out and the diagnosis of fetal death was confirmed. The diagnosis of extrauterine pregnancy, however, was initially missed, and a decision to induce labor was made. After unsuccessful induction of labor and deterioration of the patient's general condition, a laparotomy was performed, and the diagnosis of abdominal pregnancy was confirmed. A severely macerated fetus and placenta were delivered. Relative to others with this condition, the patient had a very good postoperative outcome with prolonged healing of the surgical incision. Informed consent for publication was obtained from the patient. CONCLUSIONS The diagnosis of late abdominal pregnancy can be missed despite clinical and sonographic examination. This diagnosis should be considered and excluded in similar suspected clinical findings. Proper operative planning in a tertiary center with a well-experienced team is crucial.

Omentum pregnancy resulting in severe hemoperitoneum: Lessons learned from a review of the literature along with a case report.

Abdominal pregnancies are a rare form of ectopic pregnancy with omentum pregnancies being even rarer. Ectopic pregnancy should be diagnosed and terminated early to prevent the risk of harm to the mother. This case report describes a rare case of omentum pregnancy with severe hemoperitoneum. The patient had not visited a doctor until she failed to menstruate for 3 months, by which point she had developed severe hypogastralgia. The patient was diagnosed with a ruptured ectopic pregnancy after ultrasonography. The omentum pregnancy was complicated by severe hemoperitoneum, which was confirmed by emergency laparotomy. The patient was treated successfully with fetal extraction and partial omentectomy. Ultrasound examination in early pregnancy is essential to detect and treat ectopic pregnancies as early as possible, as surgery is usually required for abdominal pregnancies. Prompt treatment of ectopic pregnancies is critical, as an omentum pregnancy is dangerous and may result in severe intraperitoneal bleeding.

Pregnancy in Morrison Pouch: a case report.

Abdominal pregnancy is a rare form of ectopic pregnancy (accounting for 1% of all ectopic pregnancies). Depending on gestational age and its location various symptoms and signs may be exhibited. This study aimed to report a case of abdominal pregnancy occurring in the Morrison Pouch with a primary presentation of right upper quadrant pain and to highlight complications that may arise in the management of abdominal pregnancy located in the Morrison Pouch. A 22-year pregnant woman at gestation of 22 weeks presented with a right upper quadrant mass and pain. Ultrasound examination revealed a live extrauterine singleton at Morrison Pouch, full blood count showed severe anemia. The patient received a blood transfusion in seven days and underwent emergency laparotomy after experiencing sudden acute internal hemorrhage but died a few hours post laparotomy due to hemorrhagic shock. Abdominal pregnancy carries a high risk of maternal hemorrhage as described in this case.

Primary omental pregnancy after in vitro fertilization complicated by hemoperitoneum-how to manage it laparoscopically.

OBJECTIVE: To report an uncommon case of primary OP treated laparoscopically. Ectopic pregnancy (EP) is the leading cause of maternal mortality during the first trimester and the incidence increases with assisted reproductive techniques, occurring in approximately 1.5%-2.1% of patients undergoing in vitro fertilization.1 Omental pregnancy (OP) is an extremely rare form of EP accounting for less than 1% of all EPs. OP can be classified as primary or secondary on the basis of Studdiford's criteria2. The preoperative diagnosis of OP is complex and usually occur in acute circumstances during a throughout intraoperative evaluation of the abdomen.3-5 A delayed diagnosis poses a serious threat to the survival of the patient; therefore, it is important to remark that EP can exist in unusual locations and prompt surgical intervention may be necessary. DESIGN: A step-by-step narrated video of a rare clinical case and description of the surgical procedure. SETTING: Tertiary Level Academic Hospital "IRCCS Azienda Ospedaliero - Universitaria di Bologna" Bologna, Italy. PATIENT: A 36-year-old woman was referred to our emergency room because of acute abdominal pain and nausea for 2 hours with no signs of hemodynamic instability. The patient also complained that poor vaginal bleeding appeared during the last 24 hours. The patient has undergone a cycle of in vitro fertilization with an elective single frozen embryo transfer of a blastocyst on day 5, 2 months before. She had no relevant clinical or surgical history. Diffuse abdominal tenderness and a painful uterus at mobilization were appreciated at clinical examination. A massive hemoperitoneum was diagnosed using transvaginal-transabdominal ultrasound, and no uterine or adnexal lesions were identified. The ß-human chronic gonadotropin level was 43.861 mIU/mL, and the hemoglobin value was 10.5 g/dL. INTERVENTIONS: On suspicion of a ruptured EP, after detailed counseling and the acquisition of informed consent, a laparoscopic exploration was planned. First, the hemoperitoneum was evacuated to allow visualization of the abdominal cavity. At pelvic inspection, no EP was found. Throughout the exploration of the abdominal cavity, a 4-cm bluish cystic mass of friable consistency was detected infiltrating the omentum and the mesentery. According to Studdiford's criteria, the diagnosis of a primary OP was established. A careful and complete excision of the ectopic implant was performed with an ultrasonic system and required a considerable hemostatic effort using bipolar energy, endoscopic clips, and mechanical compression. The postoperative course was uneventful. The ß-human chronic gonadotropin levels gradually decreased to negative values within 29 days after surgery. MAIN OUTCOME MEASURE(S): Omental ectopic pregnancy can be successfully managed with a laparoscopic approach even in an emergency setting. CONCLUSION: Omental pregnancy can easily be overlooked, even by skilled surgeons, during laparoscopic exploration. It is mandatory that all peritoneal surfaces and the omentum be carefully inspected during surgery in patients without other signs of pelvic EP.We confirm that the patient included in this video gave consent for publication of the video and posting of the video online, including on social media, the journal website, scientific literature websites, and other applicable sites.

Successful laparoscopic resection of retroperitoneal ectopic pregnancy between the abdominal aorta and inferior vena cava: A case report.

Retroperitoneal ectopic pregnancies are extremely rare; only a few cases having been reported. Here, we report laparoscopic removal of an asymptomatic retroperitoneal ectopic pregnancy from a 29-year-old woman who was referred to our hospital for a suspected ectopic pregnancy. Transvaginal ultrasound did not reveal a gestational sac in the uterus or pelvic cavity. However, abdominal contrast-enhanced computer tomography showed a gestational sac between the abdominal aorta and inferior vena cava. On laparoscopy, the gestational sac was confirmed to be in this retroperitoneal location and successfully removed with minimal bleeding. Histopathologic examination revealed chorionic villi surrounded by lymphatic tissue, suggesting lymphatic spread of the retroperitoneal ectopic pregnancy. In summary, contrast-enhanced computer tomography is very useful for locating the site of pregnancy in women suspected of having a retroperitoneal ectopic pregnancy. Timely diagnosis of a retroperitoneal ectopic pregnancy before bleeding occurs can enable their safe laparoscopic removal.

Prolonged abdominal pregnancy incidentally discovered during cesarean section: a case report.

BACKGROUND: Abdominal pregnancy is a rare medical condition that is still missed in developing countries due to inadequate medical facilities. The clinical indicators manifest in various forms and are nonspecific, making it challenging to diagnose and often leading to delayed detection. However, obstetric ultrasound serves as an essential tool in early detection. Our objective was to share our experience dealing with this condition and emphasise the importance of early ultrasound diagnosis through efficient pregnancy monitoring in our regions. CASE PRESENTATION: 35-year-old Black African woman who had ten months of amenorrhea sought consultation due to an absence of active foetal movements. Her pregnancy was of 39 weeks with fetal demise which was confirmed following clinical examination and ultrasound. She underwent cesarean section in view of transverse position of fetus. During cesarean section, the fetus was found within the abdominal cavity with the placenta attached over the left iliac fossa including surface of left ovary. The uterus and right adnexa were within normal limits. A 2600 g macerated fetus with placenta and membranes were extracted without any complications. The maternal outcome was successful. CONCLUSIONS: Abdominal pregnancy remained an inadequately diagnosed condition in developing countries. It is imperative to increase awareness among pregnant women regarding high-quality prenatal care, including early obstetric ultrasound, from conception. Meanwhile, healthcare professionals should receive continuous training and the technical platform modernised. To ensure accurate diagnosis, the location of the gestational sac must be identified for every pregnant woman during their initial ultrasound appointment.

Unrecognized abdominal pregnancy with six months' evolution revealed by acute intestinal obstruction in women with PCOS.

Abdominal pregnancy is a rare form of ectopic pregnancy where implantation and development of the egg take place in the peritoneal cavity outside the tubo-uterine mucosa, in contact with intestinal loops. Diagnosis is most often difficult. We report the case of a 32-year-old woman (gravida 1, para 1), with a history of PCOS, diagnosed with abdominal pregnancy at 20 weeks of amenorrhea complicated by acute intestinal obstruction. Diagnosis was confirmed by abdomino-pelvic scan. Surgery was performed with the patient under general anesthesia. She presented a macerated fetus with an infiltration of the placenta causing a perforation of the sigmoid colon and uterus. Hartmann's procedure was performed and the perforation of the uterus was sutured. Abdominal pregnancy remains a rare variety of ectopic pregnancy. Preoperative diagnosis is difficult due to the presence of a variety of non-specific symptoms. This type of ectopic pregnancy remains challenging for gynecologists and radiologists.

Non-tubal ectopic pregnancy treatment experiences of a tertiary care center.

AIM: To evaluate the incidence, the risk factors, and the treatment outcomes of Non-tubal ectopic pregnancies (NTEP) treated in a tertiary care center. MATERIAL AND METHODS: A total of 110 NTEP cases treated between 2014 and 2019 were included in the retrospective study. The study cohort was divided into 6 groups according to the pregnancy localization: 87 cesarean scar pregnancies (CSPs), 7 ovarian pregnancies, 6 interstitial pregnancies, 4 rudimentary horn pregnancies, 4 abdominal pregnancies, and 2 cervical pregnancies. One woman rejected all treatment modalities. Demographic characteristics, treatment modalities, and outcomes of each group were evaluated. RESULTS: In the study cohort, expectant management was performed in one (0.9%) woman. The methotrexate (MTX) treatment was administered in 29 (26.3%) women. Seventeen (15.4%) women underwent surgery, and 63 (57.2%) women underwent manual vacuum aspiration (MVA). A woman rejected all treatment modalities. Although 70.1% (n = 61) of CSPs were cured with MVA, 24.1% (n = 21) of them were treated with a single-dose MTX regimen in addition to MVA. The higher mean gestational sac size (33,9 ± 12,96 mm vs. 17,34 ± 9,87 mm), the higher mean gestational week (8,43 ± 1,16w vs. 6,66 ± 1,49w), the presence of fetal heartbeat (FHB) (90.5% vs. 26,2%) and the history of pelvic inflammatory disease (PID) (38.1% vs. 6,6%) were found in the CSPs with MVA treatment failure (p < 0.05). CONCLUSION: The management of NTEPs should be individualized according to the clinical and ultrasonographic findings. The size of the ectopic pregnancy mass, the gestational week, the presence of FHB, and the PID history were the predictive factors for the failure of MVA in CSP cases.

Chronicles of an uncommon term abdominal pregnancy with successful outcome: a case report.

BACKGROUND: Intra-abdominal pregnancies, while rare, present with unique diagnostic and management challenges. We present a case of a 25-year-old para 2 + 1, black African woman, who was referred from a peripheral Health Centre level IV in the Northern part of Uganda to a Regional Referral Hospital due to an abnormal presentation with easily palpable fetal parts. This case emphasizes the significance of prompt diagnosis, interdisciplinary collaboration, surgical planning, and managing the placenta in advanced intra-abdominal pregnancies. CASE PRESENTATION: A 25 year African black female, para 2 + 1 upon arrival at Regional Referral Hospital, a University Teaching Hospital during a weekend, an ultrasound was sourced from a nearby private clinic revealing an extra-uterine intra-abdominal pregnancy at 38 weeks of gestation and she was promptly sent back to the University Teaching Hospital. Following this diagnosis, the patient, who hailed from a remote village over 30 km away, returned to her family for discussions. After three days, she was readmitted. Emergency laparotomy unveiled an omental gestation sac with extensive placental attachment. A live female infant was delivered successfully, placenta was left in situ. The postoperative course was uneventful, with initial concerns about inadequate breast milk flow which resolved after placental removal during the second exploratory laparotomy. CONCLUSION: This case highlights the uncommon occurrence of an advanced intra-abdominal pregnancies and emphasizes the importance of multi-disciplinary teamwork and placental management. The favorable outcome in the management was based on thorough assessment of the placental location, attachments and blood supply during surgery. It demonstrates the possibility of reduced risk of massive bleeding if there is a delayed removal of placenta with favorable attachment. This is particularly important for milk letdown as well as reducing the needs of blood transfusion in resource limited settings.

Case Report of an exceptional spontaneous abdominal heterotopic pregnancy with superfetation: Diagnosis and treatment: Heterotopic pregnancy with superfetation (8+1 WG & 5+4 WG).

Heterotopic pregnancy is an extremely rare condition in which an intrauterine and an extrauterine pregnancy co-exist. In spontaneous conceptions, heterotopic pregnancy occurs in only 1/30 000 pregnancies. The treatment of heterotopic pregnancy must be as minimally invasive as possible to preserve the development of the intrauterine pregnancy. Superfetation, defined as the coexistence of 2 or more foetuses of different gestational ages, remains particularly exceptional and poorly explained (second ovulation? embryonic diapause?). Here, we present an extremely rare case of a spontaneous heterotopic evolutive pregnancy with superfetation, consisting of an embryo in the pouch of Douglas estimated at 8 + 1 weeks of gestation (WG) and a progressive intrauterine pregnancy estimated at 5 + 4 WG. We treated the extrauterine pregnancy with an intra-cardiac injection of potassium chloride echo-guided via the vaginal route, and the patient then underwent exploratory laparoscopy 9 days later and lavage and aspiration of the abdominal heterotopic pregnancy due to pain and biological inflammatory syndrome probably caused by pelvic mass syndrome and peritoneal irritation from the foetal necrosis. She has not yet given birth and is currently at 36 WG.

Broad ligament ectopic pregnancy at 18 weeks: diagnosis and management in a resource-limited setting (a case report).

Broad ligament ectopic pregnancy is a relatively rare condition described in the literature. We did not find enough data concerning this subject in Cameroon. It is therefore important to know about its existence because late management can lead to increased maternal mortality. This paper reports the case of a 22-year-old lady at 18 weeks gestation who had generalized abdominal pain for two months. Prior to her arrival at our service, an abdominal and pelvic ultrasound done revealed a viable singleton 18-weeks intra-abdominal pregnancy with a moderate amount of abdominal fluid collection. The diagnosis of haemorrhagic shock complicating an abdominal pregnancy at 18 weeks of gestation was retained. An emergency laparotomy was done, and a right total salpingectomy and oophorectomy with resection of the right broad ligament were carried out. After surgery, dissection of the mass revealed a non-viable male foetus weighing 218 grams. In conclusion, there´s a very high morbidity and mortality rate associated with broad ligament pregnancies. Due to the fact that there is late access to antenatal care, the prognosis of pathologic pregnancies is endangered.

Large unruptured tubal pregnancy mimicking abdominal pregnancy.

Ectopic pregnancy accounts for 1-2% of all pregnancies. Ultrasound is the primary diagnostic tool to locate pregnancy outside the uterus and identify complications such as haemoperitoneum. In inconclusive cases, MRI is an adjunctive imaging modality offering more precise tissue differentiation and helpful to location identification. Presented is an unusual case of tubal pregnancy. The patient in her 30s, who was 14 weeks into her first pregnancy, had a suspected abdominal pregnancy. Both transabdominal ultrasound and an MRI indicated an ectopic pregnancy, likely originating from the right fallopian tube. A successful laparotomy and right salpingectomy were performed without complications. Rarely, as in this case, large unruptured and advanced tubal pregnancies can mimic an abdominal pregnancy, underscoring the importance of disease recognition and familiarity with uncommon image findings. An accurate diagnosis of pregnancy location is crucial for effective case management.

A case report of dangerous pelvic infundibulum ligament in the second trimester of pregnancy with massive hemorrhage.

RATIONALE: Abdominal pregnancy is a rare ectopic pregnancy and its diagnosis and treatment are more challenging than those of other ectopic pregnancies. Because of a variable pregnancy site, abdominal pregnancy is associated with an increased risk of fatal abdominal hemorrhage, and consequently, an increased risk of maternal death compared with intrauterine pregnancy. DIAGNOSES: Pelvic infundibulum ligament pregnancy complicated with massive hemorrhage. PATIENT CONCERNS: 42-year-old pregnant woman who did not undergo an obstetric examination during the first trimester presented with sudden abdominal pain during the second trimester. Abdominal pregnancy was confirmed after emergency treatment, causing difficulty in the comprehensive preoperative evaluation.Interventions: In order to save the patient life, we actively carried out surgical treatment. OUTCOMES: The patient recovered well after the operation and was discharged on the 11th postoperative day. Blood ß-human chorionic gonadotropin (ß-hCG) levels and routine blood test results were normal 1 month after the surgery, and the patient had recovered. LESSONS: Several challenges are encountered in the diagnosis of abdominal pregnancy with regard to insufficient economic, cultural, and medical resources. In case of ectopic pregnancies, surgery should be the first choice of treatment, and preparations of blood transfusion are essential to combat the risk of rapid hemorrhagic shock caused by placenta implantation in the infundibulum ligament of the pelvis. The operation must be performed by experienced obstetricians and gynecologists.

Abdominal ectopic pregnancy.

An ectopic pregnancy (EP) accounts for 1-2% of all pregnancies, of which 90% implant in the fallopian tube. An abdominal ectopic pregnancy (AEP) is defined as an ectopic pregnancy occurring when the gestational sac is implanted in the peritoneal cavity outside the uterine cavity or the fallopian tube. Implantation sites may include the omentum, peritoneum of the pelvic and abdominal cavity, the uterine surface and abdominal organs such as the spleen, intestine, liver and blood vessels. Primary abdominal pregnancy results from fertilisation of the ovum in the abdominal cavity and secondary occurs from an aborted or ruptured tubal pregnancy. It represents a very rare form of an EP, occurring in <1% of cases. At early gestations, it can be challenging to render the diagnosis, and it can be misdiagnosed as a tubal ectopic pregnancy. An AEP diagnosed >20 weeks' gestation, caused by the implantation of an abnormal placenta, is an important cause of maternal-fetal mortality due to the high risk of a major obstetric haemorrhage and coagulopathy following partial or total placental separation. Management options include surgical therapy (laparoscopy±laparotomy), medical therapy with intramuscular or intralesional methotrexate and/or intracardiac potassium chloride or a combination of medical and surgical management. The authors present the case of a multiparous woman in her early 30s presenting with heavy vaginal bleeding and abdominal pain at 8 weeks' gestation. Her beta-human chorionic gonadotropin (bHCG) was 5760 IU/L (range: 0-5), consistent with a viable pregnancy. Her transvaginal ultrasound scan suggested an ectopic pregnancy. Laparoscopy confirmed an AEP involving the pelvic lateral sidewall. Her postoperative 48-hour bHCG was 374 IU/L. Due to the rarity of this presentation, a high index of clinical suspicion correlated with the woman's symptoms; bHCG and ultrasound scan is required to establish the diagnosis to prevent morbidity and mortality.

Early abdominal wall ectopic pregnancy treated with laparoscopic surgery: A case report and literature review.

The abdominal wall is a rare site of ectopic implantation. Laparoscopic surgery for early abdominal pregnancy, in contrast to its use for tubal ectopic pregnancy, remains controversial because of concerns regarding heavy bleeding at the implantation site. Treatment of early abdominal pregnancy must be individualized for each implantation site. Herein, we present a case of an early abdominal pregnancy implanted in the anterior abdominal wall that was successfully treated with laparoscopic surgery. A 28-year-old multiparous woman with a 6-week amenorrhea presented with acute abdominal pain. An ectopic pregnancy was suspected because of elevated serum human chorionic gonadotropin levels without a visible gestational sac on transvaginal ultrasonography. Diagnostic laparoscopy revealed a gestational sac hanging from the anterior abdominal wall near the previous cesarean section wound. Laparoscopic surgery was successfully performed, and the patient was discharged on postoperative day three. In the present case, laparoscopic surgery was beneficial.

A delayed spontaneous second-trimester tubo-abdominal pregnancy diagnosed and managed by laparotomy in a "self-identified" infertile woman, a case report and literature review.

BACKGROUND: Abdominal pregnancy, a rare form of ectopic pregnancy, is associated with high morbidity and adverse consequences for future fertility. Early recognition and management reduce mortality and allow minimal invasive and conservative treatment. In modern medicine, primitive prevention to unexpected fatal pregnancies is crucial. CASE PRESENTATION: A divorced 33-year-old "self-identified" infertile polycystic ovary woman diagnosed as repeated implantation failure in previous in vitro fertilization with her ex-husband ever presented in surgery department with a history of 15-day abdominal pain, nausea, and vomiting and 3-h worsening abdominal pain. The serum beta-human chorionic gonadotropin value was more than 10,000 m-international units per milliliter. Sonogram findings were significant for the absence of intrauterine gestation; a placenta and well-formed living fetus of second-trimester gestation were seen in the abdomen, accompanied by hemoperitoneum. A unique spontaneously second-trimester tubo-abdominal pregnancy was confirmed in emergent laparotomy by gynecologists, she received a removing of the living fetus, a right total salpingectomy, resection of partial omentum and blood transfusion. The patient recovered uneventfully and her serum beta-human chorionic gonadotropin returned to normal range on the 30th postoperative day, till now, she has weak fertility awareness because of her catastrophic experiences in the unexpected abdominal pregnancy. CONCLUSIONS: This case highlights woman with a previous in vitro fertilization history may be in is a high risk to be delayed or missed in diagnosis in an intended ectopic pregnancy due to a fixed belief in infertility. Educational interventions and contraceptive care should be provided by fertility and healthcare practitioner. The possibility of abdominal pregnancy must always be suspected and dealt with promptly and appropriately by the astute clinician.

Asymptomatic 39 Weeks Abdominal Pregnancy - Video Report of a Case Occurred in Ivory Coast Resulting in a Live Birth.

BACKGROUND: Despite the current advances in antenatal care and imaging methodologies in obstetrics, cases of advanced abdominal pregnancies are still reported, mostly in low- and middle-income countries where frequently only a few perinatal checks are performed and where these methodologies are sometimes not adopted in obstetrical outpatient settings. CASE PRESENTATION: We report the video of a case of a 20-year-old I gravida Ivorian patient, sent to CHU de T reichville in Abidjan, Ivory Coast, for management of abdominal 39 weeks pregnancy after routine antenatal care. She was asymptomatic with a live foetus in transverse lie position. The anamnesis revealed four prenatal checks without ultrasound evaluation, the first one at 24 weeks of pregnancy. Emergency median longitudinal sub-umbilical laparotomy incision was performed. Foetal extraction was realized by transplacental incision due to omental placental implantation. A live female baby weighting 3350 grams was delivered, presenting bilateral clubfeet and an enlarged neck. The release of the adherent placenta required a partial omentectomy and left adnexectomy and was carefully removed following active bleeding from its detached margins. The newborn died of respiratory distress on the first day after birth. No autopsy was performed. Postoperative morbidity for the woman was minimal and she was discharged on the seventh post-operative day in good general condition. CONCLUSION: Abdominal pregnancies with a normal live foetus at such an advanced gestational age are extremely rare, and there are no available videos in the extant literature of the surgical procedure performed. Standardization of treatment principles, pre-operative preparation with imaging techniques (MRI, embolization of placental vessels) and adequately equipped and staffed neonatal units are necessary to optimize the foetus-maternal outcomes.