AN ADVANCED EXTRAUTERINE ABDOMINAL PREGNANCY A CASE REPORT MAMOONA MUSHTAQ, FARIHA ALTAF ABS1RACT This paper reports on a 30 years old multigravida with a full term abdominal extrauterine pregnancy. KEY WORDS: - Extrauterine Pregnancy, Multigravida, INTRODUCTION movements 15 days letter which she failed to report. On Abdominal pregnancy' is an ectopic pregnancy that is clinical examination fetal heart was found to be absent implanted outside the uterine cavity. It may be primary or and it was confirmed on ultrasound. To our surprise fourth secondary following tubal abortion or rupture", Incidence sonogram revealed major placenta praevia. With a varies from 1:3000 to 1:10000 deliveries and accounts for working diagnosis of major placenta praevia and breech 1-4% of all ectopic pregnancies. Even more uncommonly LSCS was done. 3 does it reach an advanced stage of gestation • Diagnosis is difficult and often missed". Signs and symptoms such At laparotomy, upon entering the abdomen via a as abdominal pain. Gastrointestinal symptoms. Painful pfannenstiel's incision a term-size dead fetus was found fetal movements, abnormal presentation are considered inside an intact amniotic sac within the abdominal cavity. suggestive of abdominal pregnancy. It is a potentially life- threatening eondition", No haemoperitoneum was present but multiple adhesions were encountered. The uterus was 12 weeks gestational CASE REPORT size. Left tube and ovary was normal in size and shape. The 30 years old G6 P4 was admitted with history of pain The placenta along with the sac had spread all over abdomen in left upper quadrant. Her only prenatal care omentum. The right fallopian tube was distorted. After consisted of two sonograms in which radiologists were extraction of the fetus, there was rnassive :obstetric unable to detect abdominal pregnancy. Both sonograms haemorrhage from the fetal surface of the placenta which had shown a single viable fetus with gestational ages of continued throughout, attempts performed at hemostasis. 16 and 28 weeks, adequate amniotic fluid and a placenta The right ovary was tennis ball size with bleeding from the that was described as low lying and placenta previa type surface and pedicle. Compression and intraabdominal I respectively. An urgent ultrasound after hospitalization packing were used but to no avail. Ultimately, the placenta was carried out to rule out placental abruption and was removed after right adnexectomy. Mvst of the portion revealed viable single pregnancy with breech of amniotic sac removed partial omentectomy done, presentation at 35 weeks, adequate amniotic fluid. And hemostasis secured and peritoneal toilet done. Gut was right lateral placenta away from cervical os. She had been found to be normal. During the procedure there was an adequately managed conservatively as she was unsure of estimated blood loss of 3000 ml. Patient received four dates. Pain abdomen was intermittent dull in nature, with units of whole blood, and six units of fresh frozen plasma. no localizing sign; there was no tenderness or abdominal Drain in pouch of Douglas and abdomen closed in layers. distension. Unfortunately patient developed less fetal The patient's postoperative course was uneventful. She was given MTX therapy, 50 mg/m2 11Mstat. Her post-op Correspondence: hemoglopbin, platelet count, coagulation profile, liver & Col. Mamoona Mushtaq renal function test were normal. On the second Department of Obestetrics & Gynecology postoperative day, the patient resumed normal Military Hospital gastrointestinal fuction, starting diet on the third day. Drain Rawalpindi Journal of Surgery Pakistan (International) Vol. 9 (2) April - June 2004 53 An Advanced Extrauterine Abdominal Pregnancy removed on 3rd post-op day & intake output was normal. maternal vessels supplying the placenta. This reduces She was discharged after two weeks with advice for follow hospital stay and morbidity. MTX4 is given for any retained up. On follow up her condition was unremarkable. products. This was done successfully in the present case. The patients should then be followed with sonograms and DISCUSSION clinically. Viable advanced abdominal pregnancies are rare, and only a few sporadic cases have been reported in the past REFERENCES 10-15 years1.2·3.it compels every clinician to have a high 1. Badria L, Amarin Z Jaradat A, Zahawi H, Gharaibeh A, index of suspicion for this condition, and be familiar with Zobi A, Full-term viable abdominal pregnancy: a case its challenging diagnostic and management features', The reportand review. Arch Gynecol Obstet. 2003: case presented here was probably missed because this 268:340-2 rare entity was not thought of. The fact that, in spite of 4 2. Hussain M, Yasmeen H, Noorani K, Ruptured corneal sonograms, the diagnosis was missed preoperatively, is pregnancy J. Coli Physician Surgeon Pakistan 2003 : disturbing but not unusual. The signs and syumptoms 13, suggestive of abdominal pregnancy were non-specific. Even under the best circumstances, and using 3. Mahi M. Boumdin H, Chauir S, Salaheddine T, Attioui sonography, the diagnosis is often missed. However, CT D, Amil T, Hanine A, Benameur M. A new case of scan and magnetic resonance imaging have been used abdominal pregnancy. J Radiol. 2002: 83 : 989-92. successfully. Once the diagnosis is made optimal 4. veerareddy S, Sriemevan A, Cockburn Jf, Overton Tg. management requires immediate operative interventions. Non-Surgical Management of a. midtrimester Management of advanced abdominal pregnancy poses a abdominal pregnancy Br J Obstet Gynaecol great challenge to even the best of clinician. It is often 2004;111 :281-3. associated with sever blood loss. For which one should be prepared. 5. beddock R, Naepels P, Gondry C, Besserve P,Camier B,Boulanger Jc, Gondry J. Diagnosis and current The other significant problem at operation is whether or concepts of management of advanced abdominal not to remove the placenta. Massive hernorrhaqe" occurs pregnancy. Gynecol Obstet Fertill. 2004,32:55-61. more frequently when attempts are made to remove the 6. Ramachandran K, Kirk P. Massive Haemorrhage in a placenta. If left in situ, though it is usually the procedure previously undiagnosed abdominal pregnancy of choice, the morbidity from abscess formation is high. presenting for elective for cesarean delivery. Can J Removal of the placenta should be undertaken if it is safe, Anaesth. 2004;51 :57-61 depending upon the accessibility of ligation of the 54 Journal of Surgery Pakistan (International) Vol. 9 (2) April- June 2004.