Reminder of important clinical lesson BMJ Case Reports: first published as 10.1136/bcr-2017-221433 on 1 September 2017. Downloaded from CASE REPORT Delayed diagnosis and management of second trimester abdominal pregnancy Katherine Tucker,1 Neha Rani Bhardwaj,2,3 Elizabeth Clark,4 Eve Espey4 1Department of Obstetrics SUMMARY by maternal fetal medicine (MFM) specialists. and Gynecology, Division of Second trimester abdominal ectopic pregnancies are rare Abortion restrictions in the patient’s home state, Gynecologic Oncology, The and life threatening. Early diagnosis and treatment are compounded by the patient’s perception of her University of North Carolina, paramount in reducing maternal morbidity and mortality. home state physicians’ ethical objections to abor- Chapel Hill, North Carolina, USA 2 tion, had an impact on the patient’s care. Department of Obstetrics and We describe an unusually late diagnosis of abdominal Gynecology, Mount Sinai St. pregnancy despite multiple ultrasounds beginning Luke’s and Mount Sinai West, in early pregnancy. A 28-year-old G2P1001 sought CASE PRESENTATION New York, USA pregnancy termination at 22 weeks’ gestation after fetal A 28-year-old G2P1001 at 22 weeks 3 days’ gesta- 3Department of Obstetrics and anomalies were noted on an 18-week ultrasound during tion travelled out of state for pregnancy termination Gynecology, Icahn School of evaluation for elevated maternal serum alfa-fetoprotein. 4 weeks after diagnosis of multiple fetal anomalies. Medicine at Mount Sinai, New Due to abortion restrictions in her home state, she She was healthy, had no medical or surgical history York, USA 4 travelled over 500 miles for abortion care. During dilation and had one prior uncomplicated vaginal delivery Department of Obstetrics and and evacuation, suspected uterine perforation led to Gynecology, University of New at term; she received early prenatal care for this Mexico School of Medicine, the finding of a previously undiagnosed abdominal highly desired pregnancy. Albuquerque, New Mexico, USA pregnancy. At laparotomy, she underwent left salpingo- Initial abdominal ultrasound at 12 weeks demon- oophorectomy and removal of abdominal pregnancy strated an intrauterine pregnancy with fetal heart Correspondence to and placenta. A multidisciplinary team approach was motion present. Early genetic screening demon- Dr Katherine Tucker, paramount in optimising the patient’s outcome. Abortion strated elevated MSAFP at 9.2 multiples of the ktucker77@ gmail. com restrictions requiring travel away from the patient’s home mean. The patient was referred to a MFM specialist copyright. community interrupted her continuity of care and created where she underwent comprehensive level II abdom- Accepted 23 August 2017 additional hardships, complicating management of an inal ultrasound and amniocentesis at 18 weeks and unexpected, rare and life-threatening condition. 5 days. Ultrasonography revealed appropriate fetal growth but a thickened posterior placenta previa with ‘multiple venous placental lakes’ and multiple BACKGROUND structural fetal anomalies including an abnormally Abdominal ectopic pregnancy is rare and life threat- shaped spine and head, small chest, echogenic http://casereports.bmj.com/ ening with an estimated frequency of 9–11 per cardiac focus and clubbed feet. Amniocentesis 1000 ectopic pregnancies and a mortality rate revealed grossly bloody amniotic fluid with normal ranging from 0.5% to 20%.1 2 While uncommon, AFP level, normal fluorescence in situ hybridisation it is important to understand the diagnostic criteria and slightly elevated acetyl cholinesterase level. and management. MFM ultrasound was repeated at 20 weeks and 5 Classic diagnostic criteria include ultrasound days with similar findings. The extrauterine loca- findings of normal fallopian tubes and ovaries, lack tion of the pregnancy was not detected on either of an intrauterine gestation and pregnancy adjacent ultrasound or during amniocentesis. to the peritoneal surface.3 4 Typically, abdominal The patient received counselling about poor fetal prognosis due to multiple fetal anomalies and ectopic pregnancy is recognised on early first-tri- on 25 September 2021 by guest. Protected mester ultrasound. Late presentation to care or abnormal MSAFP. She opted for pregnancy termi- inadequate ultrasound may result in failure to make nation via dilation and evacuation. Legal restric- the correct diagnosis. Although unusual, increased tions in her home state banned abortion after 20 clinical suspicion may be warranted in the setting of weeks unless maternal health was compromised. elevated maternal serum alfa-fetoprotein (MSAFP), She self-referred to the closest facility providing placental and/or fetal abnormalities, and a deviated abortion services, over 500 miles away in another cervix on pelvic examination. When abdominal state. The patient described emotional distress, ectopic pregnancy is suspected, coordination of feeling judged by the obstetric providers in her care with a multidisciplinary team of experienced home community for her decision to terminate the physicians may improve patient outcomes. pregnancy. T o cite: Tucker K, This case describes the rare event of a second Bhardwaj NR, Clark E, et al. trimester abdominal ectopic pregnancy diagnosed TREATMENT BMJ Case Rep Published After extensive counselling at the out-of-state Online First: [please during dilation and evacuation for a presumed anom- include Day Month Year]. alous intrauterine pregnancy. Our case is unique in facility, she received 200 mg of oral mifepris- doi:10.1136/bcr-2017- that the patient desired termination of pregnancy tone and 2 mg of transabdominally administered 221433 for fetal anomalies seen on ultrasound completed intrafetal digoxin. Fetal demise was confirmed by Tucker K, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2017-221433 1 Reminder of important clinical lesson BMJ Case Reports: first published as 10.1136/bcr-2017-221433 on 1 September 2017. Downloaded from ultrasound the following day. On attempted laminaria insertion received postoperative care from a local MFM specialist for cervical preparation, the provider was unable to adequately uninvolved in her prior care. During her unexpected 11-day visualise the cervix. Given the advanced gestational age, poste- out-of-state hospital stay, she described the constant stress of rior placenta previa and difficulty visualising the cervix, the coordinating childcare with family in her home state, missed provider transferred the patient to a local tertiary-care university employment for her spouse who remained with her in the teaching hospital with specialists in family planning. hospital and the psychological burden of uncertainty about At the university hospital, pelvic examination demonstrated a insurance coverage for her hospitalisation given exclusion of posterior and left-deviated cervix. Bedside transabdominal ultra- abortion care as a covered benefit. The patient was also grieving sound confirmed fetal demise and gestational age of 22 weeks. the loss of a highly desired pregnancy. Additionally, the patient The patient reaffirmed her choice for dilation and evacuation, expressed ongoing distress that obstetric providers in her home and synthetic cervical dilators were placed under intravenous state had allowed their ethical objections to abortion to influ- and local anaesthesia. ence the timeline for diagnosis of the ‘fetal anomalies’ such that Attempt at dilation and evacuation under general anaesthesia she was beyond the legal gestational age limit for abortion in commenced 12 hours later. Synthetic cervical dilators were that state. removed; the cervix was serially dilated to accommodate Bierer The patient has now made a full physical recovery and is doing forceps. Under continuous real-time bedside abdominal ultra- well with her family at home. sound guidance, a pass of the Bierer forceps yielded a small piece of yellow tissue consistent with omentum, prompting suspicion DISCUSSION of uterine perforation. An attending radiologist was called to With hindsight, the patient exhibited several findings suspicious perform real-time ultrasonography and apparent intrauterine for abdominal ectopic pregnancy, but the diagnosis was missed position of the forceps was verified. Given high clinical suspicion on at least three ultrasound examinations, including an intra- for uterine perforation, diagnostic laparoscopy was performed operative ultrasound performed by an attending radiologist with finding of a large cystic abdominopelvic mass with densely when a pregnancy-related procedural complication was strongly adherent sigmoid colon. Laparotomy was performed with the suspected. The ‘structural fetal anomalies’ on second trimester assistance of gynaecological oncology and general surgery. After ultrasound were most likely misdiagnosed images of a fetus extensive adhesiolysis, the uterus was found to be 8 weeks’ size constricted by its extrauterine location. A paediatric dysmorphol- with lateral and posterior perforations from the Bierer forceps. ogist and pathologist examined the fetus immediately following On initial examination, the pregnancy appeared to originate abdominal removal and found no gross structural abnormalities. from the left adnexa. However, on closer inspection, and later Abdominal pain, vaginal bleeding, nausea and emesis, and pathological confirmation, the pregnancy and placenta were copyright. decreased or absent fetal movement are symptoms of abdominal located within a dense capsule in the abdomen-pelvis