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Successful Management of An Abdominal Pregnancy
Abstract Number: SU-16
Abstract Type: Case Report/Case Series
INTRODUCTION: Abdominal pregnancy is rare, occurring in 1/10,000-30,000 pregnancies, and is associated with high morbidity and mortality for both mother and fetus.[1,2] Often, this condition is not diagnosed until complications ensue. Neonatal survival is uncommon. We present our successful management of an abdominal pregnancy resulting in delivery of a live healthy neonate.
CASE: A 24 year-old G7P5 at 23 weeks gestational age (GA) presented with abdominal pain and tenderness to palpation. Ultrasound revealed an empty uterus, an echogenic mass representing placenta in the right lower abdominal quadrant, free fluid in the cul-de-sac, and an extra-uterine fetus in the left upper quadrant. GA was determined as 21 4/7. Fetal heart tones were present. Magnetic resonance imaging revealed minimal amniotic fluid around the fetus, adherence of the placenta to the uterus anteriorly, with abutment of the ureters, anterior abdominal wall, right rectus abdominis, and bladder, and coursing of umbilical vessels through mesentery.
Given uncertain fetal survival and risk of maternal hemorrhage, a multi-disciplinary team of maternal-fetal medicine specialists, neonatologists, obstetric anesthesiologists, and gynecologists was formed. The fetus was deemed peri-viable, thus we developed a plan to promote fetal development without compromising maternal well-being.
On presentation, the patient received betamethasone for fetal lung maturity and magnesium for neuroprotection. Given increased perinatal risk to both mother and fetus, and patient preference to avoid emergent intervention, fetal heart tone monitoring was not performed. Bi-weekly ultrasound assessed fetal growth. In absence of maternal hemorrhage, fetal indications for delivery included attainment of 34 weeks GA, or growth restriction.
Fetal growth restriction was identified at 29 weeks GA. In preparation for delivery, the patient received steroids and bowel preparation. As the surgical plan consisted of a small supra-umbilical midline incision, a thoracic epidural for post-operative pain control was placed pre-operatively. Prior to incision, ultrasound confirmed fetal positioning. Subsequently, general anesthesia was induced. Upon tracheal intubation, incision was made and fetus delivered. Umbilical cord was cut and sutured, then returned to the abdomen. To minimize maternal hemorrhage risk, the placenta was not delivered and post-operative subcutaneous heparin was not administered. Estimated blood loss was 50 mL. Neonatal Apgar scores were 6 and 8. The patient’s subsequent course was uneventful.
DISCUSSION: With multi-disciplinary input, abdominal pregnancy can be successfully managed. In the case of extensive intra-abdominal placentation, returning the umbilical cord to the abdomen and avoiding placental removal can minimize the risk of maternal peri-partum hemorrhage.
1. Nwobodo E. Ann Afr Med.2004.
2. Amritha B. et. al. J Med Case Reports.2009.
3. Baffoe et al. Ghana Med Journal.2011.