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Int J Clin Exp Pathol 2014;7(9):5461-5472 www.ijcep.com /ISSN:1936-2625/IJCEP0001373

Original Article Advanced abdominal : an increasingly challenging clinical concern for obstetricians

Ke Huang1, Lei Song1, Longxia Wang2, Zhiying Gao1, Yuanguang Meng1, Yanping Lu1

Departments of 1Gynecology and , 2Ultrasonography, The PLA General Hospital, Beijing City, China Received July 9, 2014; Accepted August 21, 2014; Epub August 15, 2014; Published September 1, 2014

Abstract: Advanced is rare. The low incidence, high misdiagnosis rate, and lack of specific clinical signs and symptoms explain the fact that there are no standard diagnostic and treatment options available for advanced abdominal pregnancy. We managed a case of abdominal pregnancy in a woman who was pregnant for the first time. This case was further complicated by a concurrent singleton intrauterine pregnancy; the twin preg- nancy was not detected until 20 weeks of pregnancy. The case was confirmed at 26 weeks using MRI to be an abdominal combined with intrauterine pregnancy. The pregnancy was terminated by cesarean section at 33 + 5 weeks . We collected the relevant data of the case while reviewing the advanced abdominal pregnancy-related English literature in the Pubmed, Proquest, and OVID databases. We compared and analyzed the pregnancy history, gestational age when the diagnosis was confirmed, the placental colonization position, the course of treatment and surgical processes, related concurrency rate, post-operative drug treatment programs, and follow-up results with the expectation to provide guidance for other physicians who might encounter similar cases.

Keywords: Advanced abdominal pregnancy, obstetricians, clinical

Introduction abdominal [8-10]. Only two cases of an abdominal pregnancy combined with an Advanced abdominal pregnancy is rare and intrauterine pregnancy has been reported [11, often misdiagnosed [1]. Currently, among third 12]. In one of the cases, the patient underwent trimester pregnancies, secondary abdominal pr- in vitro IVF and embryo transfer. Three months egnancies are relatively common. Many pati- before the embryo transfer, the patient had a ents with advanced abdominal pregnancies hysteroscopy. Neither of the survived. have undergone uterine or dilation Primary abdominal pregnancy or primary abd- and curettage, a history of tubal or uterine horn ominal and intrauterine pregnancies without a pregnancies, or a history of artificial insemina- history of uterine or assisted reproduc- tion [2, 3]. In vitro fertilization (IVF)-induced tion are very rare [13]. consecutive abdominal pregnancies has occa- sionally been reported [4]. Some scholars There is no standard diagnosis and treatment believe that there is a correlation between procedure for abdominal pregnancy. Standardiz- ation of the treatment principles for advanced cocaine use and abdominal pregnancy; howev- abdominal pregnancy, peri-operative treatment er, because the results are based on a 55-case options, and post-operative management mea- abdominal pregnancy study, the credibility of sures would improve newborn survival, reduce this connection is limited [5]. The clinical mani- complications, and mortality. festation of advanced abdominal pregnancy is most often hemorrhage, which is caused by In addition, uterine malformations cause uter- rupture of the or the absence of ine horn rupture, a gestational sac located out- labor at term. Advanced abdominal pregnancy side the , and a inside the uter- can also be discovered in the process of elec- ine cavity are not classified as abdominal preg- tive cesarean section [6, 7]. While infrequent, nancies because the pathogenesis involves there are reports of fetal survival from advanced rupture of the uterine horn. Advanced abdominal pregnancy

Figure 1. Transvaginal results of a 26-week pregnancy (longitudinal). The abdominal pregnancy is posterior to the . The surface did not reach the muscular layer of the uterus.

Case report surgery. She also denied a history of pelvic inflammatory disease (PID), , cig- A 30-year-old female conceived spontaneously arette use, and alcohol consumption. and had no vaginal during early preg- nancy. She was diagnosed at 12 weeks gesta- This woman was admitted to the hospital at 26 tion with a singleton intrauterine pregnancy weeks gestation. We restricted the movement using B-ultrasound. During a routine obstetric of the patient after admission, adjusted the ultrasound examination at 20 weeks of preg- diet with high fiber foods to prevent constipa- nancy, it was shown that she has twins and a tion and resulting abdominal pressure, and chorionic membrane was not identified. At 26 required the patient to wear anti-thrombosis weeks of pregnancy, it was suspected that stockings to prevent clots. Weekly moni- there was an intrauterine pregnancy combined toring of blood pressure, hemogram panels, with an abdominal pregnancy based on sono- urine testing, and biochemical indicators were graphic findings. Intrauterine fetal development carried out. After communicating with the was consistent with the number of weeks of patient and her family, to the decision was pregnancy, while abdominal pregnancy fetal made to continue the pregnancy. At 28 weeks growth was slightly behind (similar to 24 weeks gestation, the development of the fetus outside of pregnancy; Figure 1). The patient was diag- of the uterus was 2 weeks behind that of the nosed with an abdominal pregnancy and intra- fetus in the uterine cavity with no other obvious uterine pregnancy by MRI. The abdominal preg- abnormalities, based on an ultrasonographic nancy placenta was attached to the lower end examination. This observation was followed by of the uterine wall (Figure 2). The patient denied weekly monitoring of fetal development. During a history of assisted reproduction and uterine treatment, the patient had no complaints of

5462 Int J Clin Exp Pathol 2014;7(9):5461-5472 Advanced abdominal pregnancy

ultrasonographic examination indi- cated that the abdominal pregnan- cy fetus was suspected to have cardiac malformations. At 33 + 5 weeks of pregnancy, an ultrasono- graphic examination showed that fetal diastolic blood flow to the abdominal fetus had disappeared and the development was 5 weeks behind. Thus, an emergent abdom- inal delivery was arranged.

General anesthesia was used. Aft- er the incision was ma- de, the intrauterine fetus (in the breech position) and the placenta were removed first. The newborn was given an Apgar score of 9 at 1 minute and 10 at 5 minutes, and weighed 1990 g without deformi- ties. After closing the uterine inci- sion, the was explored to Figure 2. Pre-operative MRI results. Pre-operative magnetic resonance expose the abdominal gestational imaging indicated a breech fetus in the uterus. Posterior to the uterus, sac behind the uterus (Figure 3). an abdominal pregnancy with a single breech fetus can be seen. The The gestational sac surface was abdominal pregnancy placenta is located inferior to the uterine wall. adhesed to the omentum, and was separated and ligated, followed by incision of the sac wall along an av- ascular zone. With gradual expan- sion of the incision, it was noted that the was stained (third degree) and the fetus sat with a single hip inside the sac. The newborn was taken out of the sac carefully and given an Apgar score of 0 at 1 minute and 0 at 5 min- utes, and weighed 1600 g. Explo- ration of the abdomen revealed that the placenta was posterior to the uterine wall, covering the upper anterior sigmoid colon and the rec- tum, and the uterorectal fossa cou- ld not be exposed. Because the pla- cental attachment had no active bleeding, the umbilical cord was cut close to the base, excluding the placenta. The uterine horn and fal- Figure 3. Intra-operative photograph. A is the uterine pregnancy; the lopian tube were not defective or anterior incision was completely sutured. B is the abdominal pregnan- damaged. There were two indwell- cy sac with an intact surface and visibly abundant blood vessels. ing abdominal drainage tubes; one of the tubes was placed in the discomfort. The ultrasound results suggested abdominal gestational sac and the other was that starting from 28 weeks of pregnancy, fetal placed in the pelvic cavity. The abdomen was growth differences between the 2 fetuses grad- then closed layer-by-layer. The surgical blood ually increased. At 32 weeks of pregnancy, an loss was approximately 600 ml and no blood

5463 Int J Clin Exp Pathol 2014;7(9):5461-5472 Advanced abdominal pregnancy

Figure 4. Fourteen days after surgery, a post-operative ultrasound indicated rich blood flow signals of the residual abdominal pregnancy placenta. transfusion was indicated. The patient was up, the patient had no complaints of discomfort transferred back to the maternity ward. After 5 and reported no impact on her sexual life. No days, no bloody drainage outflow was observed intestinal obstruction symptoms developed and the drainage tubes were removed. and elevation of the serum β-HCG was not observed. A MRI 1 and 2 years later suggested The patient was given cefazolin (2 g bid) to pre- that the abdominal pregnancy placenta was vent . She was given (50 still in the same site and there were no blood mg bid) the next day and the β-HCG level flow signals Figures( 6, 7). dropped from 19033 mIU/mL to 16078 mIU/ mL 12 days later. An ultrasonographic examina- Characteristics and diagnostic key points of tion showed an abundance of abdominal pla- advanced abdominal pregnancy cental blood flow signalsFigure ( 4). After 12 days, the oral mifepristone was discontinued An abdominal pregnancy is a special type of and (75 mg intramuscular) was , accounting for approximate- administered. When the patient was discharged ly 1% of the total number of ectopic pregnan- 2 days later, the β-HCG level had dropped to cies. Abdominal pregnancy is easily missed and 4411.5 mIU/mL. Fifty days after the surgery, an mostly diagnosed after substantial emergency ultrasonographic examination suggested that bleeding, which is caused by an insecure the blood flow in the abdominal pregnancy pla- abdominal pregnancy placenta, a weak gesta- cental had decreased significantly Figure ( 5). tional sac, and the lack of protection of the Three months after surgery, the β-HCG dropped myometrium [14]. The etiology of this disease is to the normal range. The patient was followed unknown and early detection is difficult. There up once a year after surgery. During the follow- are no widely accepted diagnostic criteria for

5464 Int J Clin Exp Pathol 2014;7(9):5461-5472 Advanced abdominal pregnancy

Figure 5. After 50 days of surgery, the ultrasound results suggested a small amount of placental blood flow signals at the edge of the abdominal pregnancy residual placenta. abdominal pregnancies and the current diag- sound diagnosis is of lesser value [9, 16, 17]. nostic criteria for primary abdominal pregnancy With nine cases of abdominal pregnancy, are based on 1942 Studdiford standards. Lockhat et al. [18] confirmed the value of MRI Abdominal pregnancy often leads to early spon- in the diagnosis of abdominal pregnancy. MRI taneous , causing abdominal bleeding. can be used to diagnose an abdominal preg- In rare cases, the pregnancy can develop to nancy, and more importantly, MRI can help late stages. locate and identify the relationship between the placenta and the adjacent organs and tis- For advanced abdominal pregnancy, placental sues. The location of the placental site can help location tends to be relatively stable. The major- decide whether or not to continue the pregnan- ity of the are located near the uterine cy, and help develop a relatively safe and rea- wall and the placenta has a relatively abundant sonable treatment option and surgical plan- blood supply to maintain fetal development ning. This patient was misdiagnosed with a [15]. There are different degrees of fetal growth singleton pregnancy before the twin pregnancy retardation with advanced abdominal pregnan- was diagnosed at 20 weeks of pregnancy. cies, but no increase in the fetal malformation Because careful analysis of the reasons for rate has been reported with advanced abdomi- misdiagnosis of twin pregnancies was not per- nal pregnancies. formed, the abdominal pregnancy was not dis- covered. At 26 weeks of pregnancy, however, Abdominal pregnancy can be easily missed or the patient was suspected to have an intrauter- misdiagnosed. The diagnostic value of ultraso- ine pregnancy combined with an abdominal nography alone is limited. When the intestines pregnancy. The relatively low sensitivity and are close to the abdominal pregnancy, ultra- specificity of ultrasound diagnosis was the

5465 Int J Clin Exp Pathol 2014;7(9):5461-5472 Advanced abdominal pregnancy

main reason for the late diagnosis in the current case. At 26 weeks of pregnancy, the patient was diag- nosed by MRI with an abdominal pregnancy and an intrauterine pre- gnancy. The abdominal pregnancy placenta, which was located below the uterine wall, can maintain fetal development in an abdominal preg- nancy. Gestational fetal reduction at this stage is associated with a risk for intra-abdominal infection, bleeding, and intestinal perfora- tion, thus endangering the safety of the fetus in utero. When consid- ering the gestational age with the development of the twin gestation, and after thorough communication with the patient and her family, the decision was made to continue the tocolytic therapy.

Treatment principles for advanced Figure 6. MRI results of the follow-up after 1 year. Placenta located abdominal pregnancy at the uterorectal fossa did not significantly shrink in size. The border with the anterior uterus was not clear. No obvious bowel oppression symptoms were noted. With the early detection of an abd- ominal pregnancy, artificial termi- nation of pregnancy is safe. Depe- nding on the number of weeks of pregnancy and the physical condi- tion of the gravida, different preg- nancy termination options, includ- ing laparoscopic or open surgery, arterial embolization, and intracap- sular injection of potassium chlo- ride into the abdominal pregnancy sac are available; however, differ- ent complications occur to various degrees, with bleeding being the more common problem.

Whether or not fetal survival is the goal in an abdominal pregnancy, open surgery is the main means of treatment for advanced abdominal pregnancies. Previous experience suggests that uterine artery embo- lization, injection of potassium ch- loride into the abdominal pregnan- cy sac, and other conservative tre- atments can lead to a higher inci- dence of infection and late bleed- Figure 7. MRI results of the follow-up after 2 years. After 2 years, a MRI still indicated that the placenta was at the uterorectal fossa and was ing during the fetus ossification pr- not significantly reduced in size. The border with the anterior uterus ocess because the dead fetus can- was not clear. No obvious bowel oppression symptoms were noted. not be absorbed completely. There

5466 Int J Clin Exp Pathol 2014;7(9):5461-5472 Advanced abdominal pregnancy are also reports of intestinal after fetal gically can cause serious bleeding [10]. Tshiv- ossification [19]. Thus, for the fetus in an hula et al. [21] reported an abdominal pregnan- advanced abdominal pregnancy, if the develop- cy diagnosed at 29 weeks gestation in which ment is acceptable, expectant treatment can conservative treatment was carried out until be adopted to ensure a live birth [20]. In the week 32, followed by elective laparotomy thr- case herein, because the diagnosis of twin ough which the abdominal fetus was removed pregnancy was established late, irrespective of and the placenta was manually removed. the method of treatment for abdominal preg- Because the placenta was near the uterus and nancy that was utilized, the survival for the close to the broad ligament and right peritone- fetus in the uterine cavity was at risk. Because um and some parts of the colon, there was sig- both fetuses developed reasonably well and nificant blood loss (2 L) during surgery [21]. the patient had no complaints of discomfort, Miguel Echenique-Elizondo et al. [22] reported upon full disclosure to the patient, expectant a case of placental invasion of the omentum, management was chosen. , colon, small intestine, and left ure- ter and iliac vessels (mostly the iliac vein). Timing of pregnancy termination During the surgical removal of the placenta, 8 units of whole blood and 6 units of freshly fro- This case was a twin pregnancy with the zen plasma was used for infusion. Thus, for abdominal pressure higher than in a singleton abdominal pregnancy patients in whom the pla- abdominal pregnancy. We initially planned ter- cental colonization site is relatively stable, mination at 32-34 weeks of pregnancy. There intra-operative exclusion of the placenta is were several considerations. First, a fetus after safer. We determined that the placenta was 34 weeks of gestation has a high survival rate. attached to the lower portion of the uterine wall Of note, we were concerned that with the pre-operatively by MRI. During the surgery, we increase in the number of weeks of pregnancy, selected the uterine avascular zone to perform especially after 34 weeks gestation, the size of the abdominal gestational sac incision, and the pregnancy sac increases rapidly and the after removal of the abdominal pregnancy and risk of abdominal pregnancy sac rupture was the incision of the fetal umbilical cord, no pla- significantly higher. Based on a literature revi- cental separation was observed. Further inves- ew, abdominal discomfort or tigation revealed widespread attachment of the may not be a harbinger of gestational sac rup- abdominal pregnancy placenta to the lower ture sensitivity, and MRI is still the most reliable portion of the uterine wall, the anterior aspect method to evaluate the integrity of the gesta- of the sigmoid colon, and the uterine rectal tional sac. Therefore, the original plan was after fossa, with no active bleeding. We made the 34 weeks of pregnancy, MRI would be per- decision to keep the pelvic ectopic placenta in formed weekly to assess the integrity of the situ, and inserted abdominal drainage tubes. abdominal pregnancy sac. To our surprise, at After surgery, we used mifepristone to induce 33 + 5 weeks gestation, we found that the dia- placental degeneration, followed by intramus- stolic flow of the fetal abdominal pregnancy dis- cular methotrexate (75 mg) 12 days later. No appeared based on an ultrasonographic exami- pelvic infection occurred during the treatment nation, and the decision was made to proceed period. Three weeks after surgery, the serum with an emergent abdominal delivery. HCG returned to normal and serial ultrasound examinations showed no placental blood flow. Surgical principles for advanced abdominal pregnancy Literature review

The primary goal of surgery is to save the fetus. We used “advanced abdominal pregnancy or The secondary goal is to properly treat the late trimester and pregnancy or ectopic preg- abdominal pregnancy placenta. nancy” and “advanced extra-uterine pregnan- cy” as keywords to search the English literature There are no conclusive treatment procedures in the Medline database from 1989 to March for placentas in advanced abdominal pregnan- 2014, and all English literature in the Proquest cies. When the placenta is located in a blood and OVID databases from 1980 to December vessel-rich area, such as an advanced ovarian 2013. There were 47 papers meeting the study pregnancy, forcible removal of the placenta sur- requirements, which are summarized below.

5467 Int J Clin Exp Pathol 2014;7(9):5461-5472 Advanced abdominal pregnancy

Clinical characteristics Expectant treatment is suitable for abdominal pregnancies for which placenta colonization is The etiology of primary abdominal pregnancies in the uterus or at the uterine wall because is unknown. Many patients with secondary these sites can provide a relatively stable blood abdominal pregnancies have a history of uter- supply and the probability of acute bleeding is ine surgery or are IVF patients [23]. It is difficult low. Periodic review of obstetric ultrasound and to detect an abdominal pregnancy early; the monitoring of fetal development is necessary. diagnosis is usually based on abdominal pain At the beginning of 32 weeks of pregnancy, it is or emergency bleeding caused by abdominal recommended to have a weekly MRI to evalu- pregnancy rupture [24, 25]. Abdominal preg- ate the integrity of the gestational sac to detect nancies often result in early abortion; a few any early signs of abdominal gestational sac cases can develop to advanced pregnancy and rupture [21]. the use of MRI diagnosis is more reliable than ultrasound [26]. When colonization is outside the uterus, such as the omentum, bowel, , and Clinical manifestations surface, more life- threatening complica- tions occur in gravidas during the second tri- There are no specific early symptoms or signs mester. Active treatment of such cases is rec- for abdominal pregnancy; bleeding is the main ommended, and there are several treatment complication. It is believed that in advanced methods available, as below. abdominal pregnancy, bleeding is not only relat- ed to the gestational sac, but also to the site of Vascular embolization colonization. Based on the available literature, abdominal pregnancy sac colonization on the Because the arterial supply to the placenta is omentum and liver and surface are high not well-defined and may involve the surround- bleeding risk factors, and colonization in the ing blood supply to vital organs, this method uterus or other parts of the uterus surface is tends to yield poor results. In addition, after associated with a relatively low risk of bleeding. arterial embolization, fetal bone ossification- When placental colonization is on the uterine associated intestinal perforation and other wall, the likelihood of abdominal pregnancy complications are not uncommon. Therefore, fetal growth retardation is lower. vascular embolization is not preferred.

Treatment of abdominal pregnancy Gestational sac injection or umbilical intrave- nous injection of potassium chloride For advanced abdominal pregnancies diagno- sed based on acute blood loss, surgery should This technique is suitable for early pregnan- aim to completely stop the bleeding and remove cies. For advanced abdominal pregnancy, due the abdominal pregnancy fetus. Combined with to the risk of bleeding, infection, fetal ossifica- the existing literature, for abdominal pregnancy tion-associated secondary damage and the cases diagnosed in the mid-trimester, we beli- subsequent second surgery, this method is not eve that an individualized treatment approach recommended. should be adopted based on the site of placen- Laparotomy tal colonization. This is especially important for gravidas with an intrauterine pregnancy who This approach is applicable to patients at vari- also have an abdominal pregnancy. In addition ous stages of pregnancy. A thorough evaluation to protecting pregnant women, it is also neces- before surgery is required and MRI is used to sary to take into account the safety of the two determine the site of abdominal pregnancy col- fetuses. It should be noted that abdominal pain onization before surgery. is not a harbinger of gestational sac rupture. For cases in which the abdominal pregnancy is Neonatal development diagnosed during an ongoing pregnancy, MRIs must be periodically performed to assess the The current literature does not support a cor- integrity of the gestational sac and timely termi- relation between abdominal pregnancy and nation of pregnancy is performed when nece- birth defects; however, because most cases of ssary. abdominal pregnancy do not achieve full term,

5468 Int J Clin Exp Pathol 2014;7(9):5461-5472 Advanced abdominal pregnancy and because the blood supply to the placental the placenta. We administered oral mifepris- colonization site is poorer than that of a normal tone post-operatively and did not find placental intrauterine pregnancy, the S/D ratio increases separation bleeding; however, the effect on in the umbilical cord and neonatal growth retar- β-HCG reduction is poor. Although methotrex- dation is relatively common. In our case, a simi- ate can quickly reduce the HCG level, use of lar phenomenon was observed [27, 28]. methotrexate directly after surgery can lead to rapid placental lobular necrosis and likely Treatment of residual placenta and long-term cause intra-abdominal bleeding. Thus, we only outcome used a single dose of methotrexate (75 mg intramuscular) 12 days after surgery. During Placenta treatment should be individualized treatment, no infection, bleeding, and other according to the colonization site. There are complications were observed. The results are reported cases of colonization at important similar to the results reported by Cetinkaya perivascular sites, such as the iliac vessels and [34]. Valenzano et al. reported a more rapid pelvic ligament, where even when the residual reduction of the serum β-HCG level [37]. In placenta has no blood flow and the β-HCG has some cases, methotrexate is administered twi- decreased to normal, late post-operative bleed- ce daily (10 mg) to achieve a gradual decrease ing still occurs. This may be caused by the rela- in the β-HCG level. There also are reports of not tively large size of the residual placenta and the using any drugs after surgery. Rather, the adjacent blood vessels being torn during activi- serum β-HCG level is monitored until it decreas- ties. We believe that for placenta colonization es to the normal range, but > 5 weeks is typi- at the vessel-rich and mobility-poor regions cally required [38, 39]. (pelvic ligaments, iliac vessel region, the hepat- ic portal, or spleen), surgery must be gentle and Our patient was followed for 2 years. The pati- meticulous to avoid causing placental separa- ent had no complaints of discomfort. Ossified tion. Aseptic procedures must be strictly fol- placentas do not affect the patient’s daily life lowed with adequate drainage, otherwise the and sexual activities. A gynecologic examina- incidence of secondary pelvic abscesses will tion showed that the residual placenta was still be high [29, 30]. When the patient’s condition palpable within the uterorectal fossa; however, stabilizes and placental blood flow ceases an ultrasound blood flow signal was not found. (approximately 3 months after surgery) a sec- Review of the MRIs after 1 and 2 years indicat- ond surgical procedure to remove the placenta ed that the pelvic mass echo had increased, can be performed. Otherwise, there may be a the ossified placenta did not shrink significant- post-operative risk of excess residual fluid, ly, and no blood flow signals were detected. The bleeding, or infection [2, 31-33]. The placenta serum β-HCG level was undetectable. Our long- colonized at other parts does not need to be term case follow-up continues. In similar cases treated [34, 35]. For the cases of abdominal in the literature, absorption of the residual pla- pregnancy diagnosed after fetal death, arterial centa was not satisfactory either. embolization may be performed before surgery to reduce blood loss [36]. Conclusions

There is no standardized post-operative medi- Abdominal pregnancies are rare. Cases of adv- cation guide. We believe that early post-opera- anced intrauterine pregnancies with abdominal tive drug therapy for the residual placenta pregnancies are even rarer. The diagnostic cri- should not be abandoned and a potent short- teria for abdominal pregnancy, treatment meth- term drug-induced placental necrosis is not ods, treatment timing, peri-operative consider- appropriate because the latter may increase ations, and post-operative follow-up deserve the risk of placental separation and postpar- our attention. Clinicians need to be aware of tum hemorrhage. Instead, relatively mild drugs how to improve the rate of early diagnosis and should be given. When the conditions stabilize reduce the risks and complications in patients. and the placenta begins fibrosis, potent drugs With the current development of myomectomy should be used to promote placental necrosis, and other types of surgeries, cases of desired which can reduce late bleeding risks. Mife- fertility after surgery have gradually increased pristone is effective in inducing degradation of and women undergoing IVF treatment are also

5469 Int J Clin Exp Pathol 2014;7(9):5461-5472 Advanced abdominal pregnancy increasing. Consequently, the occurrence of ab- did not show any reaction to estrogen and pro- dominal pregnancy has shown a gradually in- gesterone stimulation [41]. The regular follow- creasing trend. up of our patient at 29 months showed no apparent abnormalities. Currently, the most accepted method of diag- nosing an abdominal pregnancy is MRI, while Disclosure of conflict of interest ultrasound is suitable for screening. A MRI can- not only diagnose an abdominal pregnancy, but None. also locate the position of the placenta, which will significantly contribute to the development Address correspondence to: Dr. Yanping Lu, Depart- of treatment principles and a surgical treat- ment of Gynecology and Obstetrics, The PLA General ment plan [40]. The treatment timing of abdom- Hospital, Beijing City, China. Tel: +86-10-66938147; inal pregnancy needs to be individualized Fax: +86-10-66938147; E-mail: yanpinglu569@163. according to the location of the placenta. In com cases with a relatively stable placental coloni- References zation site, expectant treatment is a conserva- tive choice. For abdominal pregnancies with [1] Sunday-Adeoye I, Twomey D, Egwuatu EV, placental colonization involving non- stable Okonta PI. A 30-year review of advanced ab- parts, an early termination of pregnancy is rec- dominal pregnancy at the Mater Misericordiae ommended. We believe that if the abdominal Hospital, Afikpo, southeastern Nigeria (1976- pregnancy placenta colonization involves the 2006). Arch Gynecol Obstet 2011; 283: 19-24. uterine wall and MRI does not indicate a threat- [2] Roberts RV, Dickinson JE, Leung Y, Charles AK. ened rupture or defects of the gestational sac, Advanced abdominal pregnancy: still an occur- pregnancy can continue under strict monitor- rence in modern medicine. Aust N Z J Obstet ing. Starting from week 32 of gestation, MRI Gynaecol 2005; 45: 518-521. [3] Hyvarinen M, Raudaskoski T, Tekay A, Herva R. should be used to assess the integrity of the [Abdominal pregnancy]. Duodecim 2009; 125: gestational sac every week and early termina- 2448-2451. tion of pregnancy should be performed when [4] Moonen-Delarue MW, Haest JW. Ectopic preg- necessary. Because the abdominal pregnancy nancy three times in line of which two ad- sac wall will thicken, the likelihood of continued vanced abdominal pregnancies. Eur J Obstet pregnancy to 34 weeks is high. For treatment of Gynecol Reprod Biol 1996; 66: 87-88. post-operative residual placenta in the pelvis, [5] Audain L, Brown WE, Smith DM, Clark JF. the consensus is to avoid the use of potent Cocaine use as a risk factor for abdominal drugs to induce placental necrosis. Relatively pregnancy. J Natl Med Assoc 1998; 90: 277- mild or slow- acting drugs can be given early on, 283. which is followed by a potent drug-induced [6] Tungshevinsirikul R, Charutragulchai P, Khun- pradit S, Herabutya Y. Advanced abdominal necrosis of the placenta or the continued use pregnancy: a case report. J Med Assoc Thai of small doses of potent drugs to cause placen- 1990; 73 Suppl 1: 107-110. tal necrosis, e.g., methotrexate (50 mg intra- [7] Matovelo D, Ng’walida N. Hemoperitoneum in muscular injection once a week for a total of 4 advanced abdominal pregnancy with a live doses; [41]. For placentas colonized at the baby: a case report. BMC Res Notes 2014; 7: major blood vessels (pelvic ligaments and iliac 106. vessel region), we recommend that when pla- [8] Huang J, Jing X, Fan S, Fufan Z, Yiling D, Pixiang cental blood flow ceases 3 months after - sur P, Xiaomeng X. Primary unruptured full term gery, a second surgery is performed to remove with live female infant: case the residua. Otherwise, there may be late post- report. Arch Gynecol Obstet 2011; 283 Suppl operative bleeding and risks of other compli- 1: 31-33. [9] Varma R, Mascarenhas L, James D. Successful cations. outcome of advanced abdominal pregnancy Current data has shown that the placenta with exclusive omental insertion. Ultrasound Obstet Gynecol 2003; 21: 192-194. remaining in the pelvis cannot be self-absorbed. [10] Meseci E, Guzel Y, Zemheri E, Eser SK, Ozkanli No cases of residual placenta growth or malig- S, Kumru P. A 34-week ovarian pregnancy: nancy have been reported. When patients case report and review of the literature. J Turk achieve pregnancy again, the residual placenta Ger Gynecol Assoc 2013; 14: 246-249.

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