Abdominal pregnancy

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Abdominal pregnancy
Intra-abdominal fetus being delivered.png
A fetus being removed from the abdomen after childbirth in abdominal pregnancy
Specialty Obstetrics

An abdominal pregnancy is a rare type of ectopic pregnancy where the embryo or fetus is growing and developing outside the uterus, in the abdomen, and not in a fallopian tube (usual location), an ovary, or the broad ligament. [1] [2] [3]

Contents

Because tubal, ovarian and broad ligament pregnancies are as difficult to diagnose and treat as abdominal pregnancies, their exclusion from the most common definition of abdominal pregnancy has been debated. [4]

Others—in the minority—are of the view that abdominal pregnancy should be defined by a placenta implanted into the peritoneum. [5]

Signs and symptoms

Symptoms may include abdominal pain or vaginal bleeding during pregnancy. [1] As this is nonspecific in areas where ultrasound is not available the diagnosis was often only discovered during surgery to investigate the abnormal symptoms. [1] They are typically diagnosed later in the developing world than the developed. [6] In about half of cases from a center in the developing world the diagnosis was initially missed. [7]

It is a dangerous condition as there can be bleeding into the abdomen that results in low blood pressure and can be fatal. Other causes of death in women with an abdominal pregnancy include anemia, pulmonary embolus, coagulopathy, and infection. [8]

Risk factors

Risk factors are similar to tubal pregnancy with sexually transmitted disease playing a major role; [8] however about half of those with ectopic pregnancy have no known risk factors (which include damage to the fallopian tubes from previous surgery or from previous ectopic pregnancy, and tobacco smoking). [9]

Mechanism

Implantation sites can be anywhere in the abdomen but can include the peritoneum outside of the uterus, the rectouterine pouch (culdesac of Douglas), omentum, bowel and its mesentery, mesosalpinx, and the peritoneum of the pelvic wall and the abdominal wall. [10] [11] The growing placenta may be attached to several organs including tube and ovary. Rare other sites have been the liver and spleen, [12] giving rise to a hepatic pregnancy [13] or splenic pregnancy, respectively. [14] Even an early diaphragmatic pregnancy has been described in a patient where an embryo began growing on the underside of the diaphragm. [15]

Primary versus secondary implantation

A primary abdominal pregnancy refers to a pregnancy that first implanted directly in the peritoneum, save for the tubes and ovaries; such pregnancies are very rare, only 24 cases having been reported by 2007. [16] Typically an abdominal pregnancy is a secondary implantation which means that it originated from a tubal (less common an ovarian) pregnancy and re-implanted. [11] Other mechanisms for secondary abdominal pregnancy include uterine rupture, rupture of a uterine rudimentary horn and fimbrial abortion. [17]

Diagnosis

Suspicion of an abdominal pregnancy is raised when the fetal anatomy can be easily felt, or the lie is abnormal, the cervix is displaced, or there is failed induction of labor. [1] X-rays can be used to aid diagnosis. [11] Sonography can demonstrate that the pregnancy is outside an empty uterus, there is reduced to no amniotic fluid between the placenta and the fetus, no uterine wall surrounding the fetus, fetal parts are close to the abdominal wall, the fetus has an abnormal lie, the placenta looks abnormal and there is free fluid in the abdomen. [8] [18] MRI has also been used with success to diagnose abdominal pregnancy and plan for surgery. [16] [19] Elevated alpha-fetoprotein levels are another clue of the presence of an abdominal pregnancy. [20]

Ultrasound

A 23-week abdominal pregnancy on ultrasound showing a normal fetus and amniotic fluid. Ultrasonography of abdominal pregnancy.jpg
A 23-week abdominal pregnancy on ultrasound showing a normal fetus and amniotic fluid.

Most cases can be diagnosed by ultrasound. [21] The diagnosis however may be missed with ultrasound depending on the operator's skill. [7] [22]

Criteria

To diagnose the rare primary abdominal pregnancy, Studdiford's criteria need to be fulfilled: tubes and ovaries should be normal, there is no abnormal connection (fistula) between the uterus and the abdominal cavity, and the pregnancy is related solely to the peritoneal surface without signs that there was a tubal pregnancy first. [23] [24] Studdiford's criteria were refined in 1968 by Friedrich and Rankin to include microscopic findings. [25]

Differential diagnosis

Depending on gestational age the differential diagnoses for abdominal pregnancy include miscarriage, intrauterine fetal death, placental abruption, an acute abdomen with an intrauterine pregnancy and a fibroid uterus with an intrauterine pregnancy . [6]

Treatment

Ideally the management of abdominal pregnancy should be done by a team that has medical personnel from multiple specialties. [26] Potential treatments consist of surgery with termination of the pregnancy (removal of the fetus) via laparoscopy or laparotomy, use of methotrexate, embolization, and combinations of these. Sapuri and Klufio indicate that conservative treatment is also possible if the following criteria are met: 1. there are no major congenital malformations; 2. the fetus is alive; 3. there is continuous hospitalization in a well-equipped and well-staffed maternity unit which has immediate blood transfusion facilities; 4. there is careful monitoring of maternal and fetal well-being; and 5. placental implantation is in the lower abdomen away from the liver and spleen. [27] The choice is largely dictated by the clinical situation. Generally, treatment is indicated when the diagnosis is made; however, the situation of the advanced abdominal pregnancy is more complicated.

Advanced abdominal pregnancy

Advanced abdominal pregnancy refers to situations where the pregnancy continues past 20 weeks of gestation (versus early abdominal pregnancy < 20 weeks). [2] [28] In those situations, live births have been reported in the lay press where the babies are not uncommonly referred to as 'miracle babies'. [29] [30] A patient may carry a dead fetus but will not go into labor. Over time, the fetus calcifies and becomes a lithopedion. [31]

It is generally recommended to perform a laparotomy when the diagnosis of an abdominal pregnancy is made. [11] However, if the baby is alive and medical support systems are in place, careful watching could be considered to bring the baby to viability. [11] Women with an abdominal pregnancy will not go into labor. Delivery in a case of an advanced abdominal pregnancy will have to be via laparotomy. The survival of the baby is reduced and high perinatal mortality rates between 40% and 95% have been reported. [32]

Babies of abdominal pregnancies are prone to birth defects due to compression in the absence of the uterine wall and the often reduced amount of amniotic fluid surrounding the unborn baby. [33] The rate of malformations and deformations is estimated to be about 21%; typical deformations are facial and cranial asymmetries and joint abnormalities and the most common malformations are limb defects and central nervous malformations. [33]

Once the baby has been delivered placental management becomes an issue. In normal deliveries the contraction of uterus provides a powerful mechanism to control blood loss, however, in an abdominal pregnancy the placenta is located over tissue that cannot contract and attempts of its removal may lead to life-threatening blood loss. Thus blood transfusion is frequent in the management of patients with this kind of pregnancy, with others even using tranexamic acid and recombinant factor VIIa, which both minimize blood loss. [1] [34]

Generally, unless the placenta can be easily tied off or removed, it may be preferable to leave it in place and allow for a natural regression. [8] [11] This process may take several months and can be monitored by clinical examination, checking human chorionic gonadotropin levels and by ultrasound scanning (in particular using doppler ultrasonography. [22] Use of methotrexate to accelerate placental regression is controversial as the large amount of necrotic tissue is a potential site for infection, [8] mifepristone has also be used to promote placental regression. [35] Placental vessels have also been blocked by angiographic embolization. [36] Complications of leaving the placenta can include residual bleeding, infection, bowel obstruction, pre-eclampsia (which may all necessitate further surgery) [21] [35] and failure to breast feed due to placental hormones. [37]

Outcome with abdominal pregnancy can be good for the baby and mother; Lampe described an abdominal pregnancy baby and her mother who were well more than 22 years after surgery. [38]

Epidemiology

About 1.4% of ectopic pregnancies are abdominal, or about 1 out of every 8,000 pregnancies. [21] A report from Nigeria places the frequency in that country at 34 per 100,000 deliveries and a report from Zimbabwe, 11 per 100,000 deliveries. [7] [28] The maternal mortality rate is estimated to be about 5 per 1,000 cases, about seven times the rate for ectopics in general, and about 90 times the rate for a "normal" delivery (1987 US data). [10]

History

Al-Zahrawi (936–1013) is credited with first recognizing abdominal pregnancy which was apparently unknown to Greek and Roman physicians and was not mentioned in the writings of Hippocrates; Jacopo Berengario da Carpi (1460–1530) the Italian physician is credited with the first detailed anatomical description of abdominal pregnancy. [39]

Natural experiment

Because pregnancy is outside the uterus, abdominal pregnancy serves as a model of human male pregnancy or for females who lack a uterus, although such pregnancy would be dangerous. [40] [41] Abdominal pregnancy has served to further clarify the disease pre-eclampsia which was previously thought (1980s) to require a uterus for it to occur, however pre-eclampsia's occurrence in abdominal pregnancy (with the conceptus outside the uterus) helped throw light on pre-eclampsia's etiology. [42] Cases of combined simultaneous abdominal and intrauterine pregnancy have been reported. [35] [43]

Related Research Articles

Dilationand curettage (D&C) refers to the dilation of the cervix and surgical removal of sections and or layers of the lining of the uterus and or contents of the uterus such as an unwanted fetus, remains of a non viable fetus, retained placenta after birth or abortion as well as any abnormal tissue which may be in the uterus causing abnormal cycles by scraping and scooping (curettage). It is a gynecologic procedure used for treatment and removal as well as diagnostic and therapeutic purposes, and is the most commonly used method for first trimester abortion or miscarriage.

Obstetrics is the field of study concentrated on pregnancy, childbirth and the postpartum period. As a medical specialty, obstetrics is combined with gynecology under the discipline known as obstetrics and gynecology (OB/GYN), which is a surgical field.

<span class="mw-page-title-main">Ectopic pregnancy</span> Female reproductive system health issue

Ectopic pregnancy is a complication of pregnancy in which the embryo attaches outside the uterus. Signs and symptoms classically include abdominal pain and vaginal bleeding, but fewer than 50 percent of affected women have both of these symptoms. The pain may be described as sharp, dull, or crampy. Pain may also spread to the shoulder if bleeding into the abdomen has occurred. Severe bleeding may result in a fast heart rate, fainting, or shock. With very rare exceptions, the fetus is unable to survive.

<span class="mw-page-title-main">Placenta praevia</span> Medical condition

Placenta praevia is when the placenta attaches inside the uterus but in a position near or over the cervical opening. Symptoms include vaginal bleeding in the second half of pregnancy. The bleeding is bright red and tends not to be associated with pain. Complications may include placenta accreta, dangerously low blood pressure, or bleeding after delivery. Complications for the baby may include fetal growth restriction.

A hysterotomy is an incision made in the uterus. This surgical incision is used in several medical procedures, including during termination of pregnancy in the second trimester and delivering the fetus during caesarean section. It is also used to gain access and perform surgery on a fetus during pregnancy to correct birth defects, and it is an option to achieve resuscitation if cardiac arrest occurs during pregnancy and it is necessary to remove the fetus from the uterus.

<span class="mw-page-title-main">Asherman's syndrome</span> Medical condition

Asherman's syndrome (AS) is an acquired uterine condition that occurs when scar tissue (adhesions) forms inside the uterus and/or the cervix. It is characterized by variable scarring inside the uterine cavity, where in many cases the front and back walls of the uterus stick to one another. AS can be the cause of menstrual disturbances, infertility, and placental abnormalities. Although the first case of intrauterine adhesion was published in 1894 by Heinrich Fritsch, it was only after 54 years that a full description of Asherman syndrome was carried out by Joseph Asherman. A number of other terms have been used to describe the condition and related conditions including: uterine/cervical atresia, traumatic uterine atrophy, sclerotic endometrium, and endometrial sclerosis.

<span class="mw-page-title-main">Placental abruption</span> Medical condition

Placental abruption is when the placenta separates early from the uterus, in other words separates before childbirth. It occurs most commonly around 25 weeks of pregnancy. Symptoms may include vaginal bleeding, lower abdominal pain, and dangerously low blood pressure. Complications for the mother can include disseminated intravascular coagulopathy and kidney failure. Complications for the baby can include fetal distress, low birthweight, preterm delivery, and stillbirth.

<span class="mw-page-title-main">Uterine rupture</span> Medical condition

Uterine rupture is when the muscular wall of the uterus tears during pregnancy or childbirth. Symptoms, while classically including increased pain, vaginal bleeding, or a change in contractions, are not always present. Disability or death of the mother or baby may result.

<span class="mw-page-title-main">Complications of pregnancy</span> Medical condition

Complications of pregnancy are health problems that are related to, or arise during pregnancy. Complications that occur primarily during childbirth are termed obstetric labor complications, and problems that occur primarily after childbirth are termed puerperal disorders. While some complications improve or are fully resolved after pregnancy, some may lead to lasting effects, morbidity, or in the most severe cases, maternal or fetal mortality.

<span class="mw-page-title-main">Intrauterine hypoxia</span> Medical condition when the fetus is deprived of sufficient oxygen

Intrauterine hypoxia occurs when the fetus is deprived of an adequate supply of oxygen. It may be due to a variety of reasons such as prolapse or occlusion of the umbilical cord, placental infarction, maternal diabetes and maternal smoking. Intrauterine growth restriction may cause or be the result of hypoxia. Intrauterine hypoxia can cause cellular damage that occurs within the central nervous system. This results in an increased mortality rate, including an increased risk of sudden infant death syndrome (SIDS). Oxygen deprivation in the fetus and neonate have been implicated as either a primary or as a contributing risk factor in numerous neurological and neuropsychiatric disorders such as epilepsy, attention deficit hyperactivity disorder, eating disorders and cerebral palsy.

<span class="mw-page-title-main">Placenta accreta spectrum</span> Medical condition

Placenta accreta occurs when all or part of the placenta attaches abnormally to the myometrium. Three grades of abnormal placental attachment are defined according to the depth of attachment and invasion into the muscular layers of the uterus:

  1. Accreta – chorionic villi attached to the myometrium, rather than being restricted within the decidua basalis.
  2. Increta – chorionic villi invaded into the myometrium.
  3. Percreta – chorionic villi invaded through the perimetrium.
<span class="mw-page-title-main">Bicornuate uterus</span> Medical condition

A bicornuate uterus or bicornate uterus, is a type of Müllerian anomaly in the human uterus, where there is a deep indentation at the fundus (top) of the uterus.

Placental insufficiency or utero-placental insufficiency is the failure of the placenta to deliver sufficient nutrients to the fetus during pregnancy, and is often a result of insufficient blood flow to the placenta. The term is also sometimes used to designate late decelerations of fetal heart rate as measured by cardiotocography or an NST, even if there is no other evidence of reduced blood flow to the placenta, normal uterine blood flow rate being 600mL/min.

<span class="mw-page-title-main">Velamentous cord insertion</span> Velamentous placenta

Velamentous cord insertion is a complication of pregnancy where the umbilical cord is inserted in the fetal membranes. It is a major cause of antepartum hemorrhage that leads to loss of fetal blood and associated with high perinatal mortality. In normal pregnancies, the umbilical cord inserts into the middle of the placental mass and is completely encased by the amniotic sac. The vessels are hence normally protected by Wharton's jelly, which prevents rupture during pregnancy and labor. In velamentous cord insertion, the vessels of the umbilical cord are improperly inserted in the chorioamniotic membrane, and hence the vessels traverse between the amnion and the chorion towards the placenta. Without Wharton's jelly protecting the vessels, the exposed vessels are susceptible to compression and rupture.

<span class="mw-page-title-main">Heterotopic pregnancy</span> Medical condition

A heterotopic pregnancy is a complication of pregnancy in which both extrauterine (ectopic) pregnancy and intrauterine pregnancy occur simultaneously. It may also be referred to as a combined ectopic pregnancy, multiple‑sited pregnancy, or coincident pregnancy.

Amnioinfusion is a method in which isotonic fluid is instilled into the uterine cavity.

<span class="mw-page-title-main">Cervical pregnancy</span> Medical condition

A cervical pregnancy is an ectopic pregnancy that has implanted in the uterine endocervix. Such a pregnancy typically aborts within the first trimester, however, if it is implanted closer to the uterine cavity – a so-called cervico-isthmic pregnancy – it may continue longer. Placental removal in a cervical pregnancy may result in major hemorrhage.

Ovarian pregnancy refers to an ectopic pregnancy that is located in the ovary. Typically the egg cell is not released or picked up at ovulation, but fertilized within the ovary where the pregnancy implants. Such a pregnancy usually does not proceed past the first four weeks of pregnancy. An untreated ovarian pregnancy causes potentially fatal intra-abdominal bleeding and thus may become a medical emergency.

Early pregnancy bleeding is vaginal bleeding before 14 weeks of gestational age. If the bleeding is significant, hemorrhagic shock may occur. Concern for shock is increased in those who have loss of consciousness, chest pain, shortness of breath, or shoulder pain.

Pregnancy in a rudimentary horn of the uterus is a very rare type of ectopic pregnancy. This type of pregnancy can be life-threatening, as the rudimentary horn is not meant to sustain a pregnancy and is at risk of rupturing.

References

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  40. ↑ Meryl Rothstein. "Male Pregnancy: A Dangerous Proposition", Popular Science , Bonnier Corporation, 31 July 2005. Retrieved on 12 November 2014.
  41. ↑ Dick Teresi. "HOW TO GET A MAN PREGNANT", The New York Times , 27 November 1994. Retrieved on 12 November 2014.
  42. ↑ Moodley J, Subrayen KT, Sankar D, Pitsoe SB (1987). "Advanced extra-uterine pregnancy associated with eclampsia. A report of 2 cases". S Afr Med J. 71 (7): 460–1. PMID   3563800.
  43. ↑ Zacchè, M. M.; Zacchè, G.; Gaetti, L.; Vignali, M.; Busacca, M. (2011). "Combined intrauterine and abdominal pregnancy following ICSI with delivery of two healthy viable fetuses: A case report". European Journal of Obstetrics & Gynecology and Reproductive Biology. 154 (2): 232–233. doi:10.1016/j.ejogrb.2010.10.015. PMID   21093142.
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