2006-01-24-09 Abdominal pregnancy © Galluzzo www.thefetus.net/
Roberto Noya Galluzzo, MD , Georgina de Melo Cardoso, MD, Marcos Leite Santos, MD
Instituto Fernandes Figueira, Florianopolis, Brazil
The woman was admitted in our unit with severe abdominal pain and alteration of the bowel function. The ultrasonographic examination revealed a 20 weeks and 4 days gestation, with placental mass extending from the right iliac fossa to the right hypochondrium and marked oligodramnios. In the transvaginal exam a heterogeneous image was observed in the pelvis suggesting the uterus.
An MRI exam confirmed the presumptive diagnosis of abdominal pregnancy. The surgery was performed, without complications. The placenta was adhered to the uterine bottom, with prolongation to the epiploon. The placenta was successfully removed. A uterine suture was necessary. The anatomopathological study diagnosed a fetus of 450g, with 30,5 cm, without malformations, compatible with gestational age between 28 and 32 weeks. After 3 days, the patient left the hospital in good conditions.
Note the empty uterine cavity with an abdominal mass on the right.
Definition: Abdominal pregnancy is a form ectopic pregnancy, located in the peritoneal cavity, excluding the ovarian and intraligamentary pregnancy. The placenta is frequently inserted on the bowel, omentum, utero-vesical recess and pelvic wall. Rare places including the mesenteric, bladder wall, appendices and liver may occur.
Incidence: 1:10.000 births and 1:100 of the ectopic pregnancies.
Etiology: It is a rare complication of ectopic pregnancy, usually due to an abnormal implantation or a rupture of an ectopic pregnancy in the abdominal cavity.
Risk factors: Pelvic infection disease (Chlamydia trachomatis), smoke, previous pelvic surgery, previous ectopic gestation, intrauterine device.
Clinical presentation: Clinical history of recurrent episodes of abdominal pain, vaginal bleeding and gastrointestinal symptoms are the first clue for the correct diagnosis, associated with abnormal fetal presentation.
Complications: The most serious complications include severe hemorrhage due to intravascular disseminated coagulation and infection with abscess formation.
Diagnosis: Ultrasound and more recently MRI have facilitated the early and correct identification of the ectopic pregnancy. The visualization of an empty uterine cavity with an abdominal mass that includes the fetus, but without amniotic fluid or myometrium around are the most suggestive signs. Besides the capability to differentiate organs and structures based on their characteristic signs, MRI allows a correct diagnosis and the right location of the fetus and placenta.
Prognostic: The abdominal pregnancy is associated with high maternal (0-20%) and perinatal (40-95%) mortality. Maternal mortality is about 5.1:1.000 compared with 0.7:1.000 in other ectopic gestation"s. The perinatal mortality has been traditionally high. However recent progresses have result in a 70-80% increase in the survival in fetuses older then 30 weeks. More than 90% of the survivors have serious malformations.
Conclusions: Mortality and maternal morbidity are directly related to the removal of the placenta during childbirth. The remove of the placenta depends on the degree of invasion, the location of insertion, the involvement of the other organs and the surgical access to the placental blood supply. If it is possible, the complete placental extraction should be done. If not, the placenta should be left at the place, following by occlusion of the umbilical cord. The subsequent management is expectant. The placental reabsorption can be accelerated with methotrexate, selective arterial embolization and secondary laparotomy.
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