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That extrauterine pregnancy is WHERE?
Abstract Number: T2C-4
Abstract Type: Case Report/Case Series
An advanced extrauterine pregnancy has been described as any pregnancy after 18 weeks in which the majority of the fetus is outside of the uterus, or implantation of the placenta in the peritoneal cavity. We present the case of a 35 year old G2P1 female at 20 weeks and 4 days gestational age who was found to have an extrauterine pregnancy on her routine anatomy ultrasound. Fetal heart tones were in the 150s at the time of discovery. She had no past medical or surgical history, and was currently asymptomatic. She was sent for an urgent MRI which revealed a left adnexal ectopic pregnancy with an anterior placenta attached to the pelvic sidewall without any clear attachment to the uterus. The vascular supply to the placenta appeared to be via the left internal iliac vessels.
The patient was admitted the following day, at which point fetal heart tones were absent. She was brought to the IR suite for bilateral uterine artery embolization and remained hospitalized to trend serial HCGs for involution. No change in size of the gestational sac was noted after 10 days, and the dominant feeding vessel remained from the left internal iliac. The patient was discharged home with plans for definitive surgical evacuation in two weeks, with the primary intent of further involution during this time period.
After discharge, the patient was lost to followup for over three months. When she was finally able to return to the hospital, abdominal ultrasound revealed an intact fetus with no considerable regression, although the placenta had involuted with no doppler flow noted to it. She underwent an exploratory laparotomy under general anesthesia with removal of the fetus and gestational sac, leaving the placenta in situ. The procedure was without complications and she was ultimately discharged on post-operative day 7.
Extrauterine pregnancies confer high fetal and maternal mortality rates, requiring vigilance and therapeutic interventions upon discovery. This case highlights the importance of social concerns, as well as medical concerns in these cases. While the decision to discharge her from the hospital for a staged surgical intervention may have been clinically valid, the patient did not return due to her inability to miss work for financial reasons. This part of her social history was unknown to the team treating her, which could have caused potentially devastating consequences. As such, a more proactive approach to followup in patients undergoing staged operations could not only enhance patient satisfaction, but also improve patient outcomes in socially challenging cases.