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Successful Anesthetic Management of Parturient with Advanced Abdominal Pregnancy
Abstract Number: T5C-6
Abstract Type: Case Report/Case Series
Abdominal pregnancy is an extremely rare form of ectopic pregnancy associated with high mortality rate for both the fetus and the mother. The mortality rate is seven times higher than general ectopic pregnancy and 90 times higher than third trimester delivery. Given the rarity and lack of standard management for this condition, we present our anesthetic management of a patient diagnosed with abdominal pregnancy who underwent successful delivery of a viable neonate.
A 48-year-old G4P1022 female from Ghana was diagnosed with ectopic pregnancy at 5 weeks of gestation. She was advised to undergo elective termination given the risks, but decided to continue with the pregnancy. The MRI showed an extrauterine gestational sac in the left hemipelvis with an abnormally shaped implanted placenta located to the left. Adjacent bowel loops were displaced with no signs of invasion to other adjacent structures. The CTA showed primary placental supply by the left ovarian and uterine arteries. The patient was admitted to the hospital at 24 weeks of gestation for observation with plan for surgical delivery at 28 weeks. Trauma, vascular, interventional radiology, urology, and gynecology services were consulted for possible assistance during the operation. Our anesthetic plan was carried out successfully and consisted of general anesthesia with rapid sequence endotracheal tube intubation, arterial line, central line, two large bore peripheral catheters, and a cooler with blood products in the room before the incision. The fetus was located in the abdominal cavity behind the uterus with the placenta attached to the left ovary. The vasculature was isolated followed by the delivery of the viable neonate and the placenta. The patient lost total of 1.5L of blood which was managed with 1g of tranexamic acid, 3 units of pRBC, 3 units of FFP, and 2.7L of crystalloid. She remained hemodynamically stable throughout the procedure and was extubated immediately afterwards. The patient was discharged on postoperative day 4 with no issues while the neonate received care in the NICU.
High rate of mortality from abdominal pregnancy are mostly due to massive hemorrhage from placental separation. The placenta can implant at various sites in and its separation is highly unpredictable. It can occur at any point during pregnancy and can lead to possible exsanguination and death. Anesthesiologists must establish adequate intravenous access and be prepared to manage hemorrhage in a timely manner. It is also vital to identify the blood supply to the placenta as this can predict the severity of bleeding. Intraoperative embolization by interventional radiology may be performed to decrease postpartum hemorrhage. We present this case to demonstrate the comprehensive planning and proper anesthetic management required to ensure an optimal outcome in this patient population.
1. Baffoe P, Fofie C, Gandau BN. Term Abdominal Pregnancy with Healthy Newborn: A Case Report. Ghana Med J 2011; 45: 81-3.