Journal of Womens Health, Issues and Care ISSN: 2325-9795

All submissions of the EM system will be redirected to Online Manuscript Submission System. Authors are requested to submit articles directly to Online Manuscript Submission System of respective journal.

Case Report, J Womens Health Issues Care Vol: 2 Issue: 6

Post-Date Extrauterine Abdominal Pregnancy in a Rhesus Negative Nullipara with Successful Outcome: A Case Report

George Uchenna Eleje*, Oluwagbemiga Adewale, Ihechinyerem Kelechi Osuagwu, Abiodun Oyewole, Chibuzor Emeka Obianika, Ikechukwu Innocent Mbachu and Emmanuel Anayo Nwanze
Department of Obstetrics And Gynaecology, Madonna University Teaching Hospital, Pmb 48, Elele, Rivers State, Nigeria
Corresponding author : Dr. George Uchenna Eleje
Department of Obstetrics and Gynaecology, College of Health Sciences, Madonna University, P.M.B. 48, Elele, Rivers State, Nigeria
Tel: +2348068117444
E-mail: [email protected]
Received: August 12, 2013 Accepted: November 04, 2013 Published: November 08, 2013
Citation: Eleje GU, Adewale O, Osuagwu IK, Oyewole A, Obianika CE, et al. (2013) Post-Date Extrauterine Abdominal Pregnancy in a Rhesus Negative Nullipara with Successful Outcome: A Case Report. J Womens Health, Issues Care 2:6. doi:10.4172/2325-9795.1000127

Abstract

Post-Date Extrauterine Abdominal Pregnancy in a Rhesus Negative Nullipara with Successful Outcome: A Case Report

Abdominal pregnancy is becoming a nightmare to many obstetricians and it represents just about 1% of ectopic pregnancies. Since its first report in 1708, copious cases have been published subsequently. The diagnosis is usually intricate except if there are complications such as abdominal pain and haemorrhage. Maternal mortality and morbidity are also very high principally if the condition is not diagnosed and managed appropriately. By and large, abdominal pregnancies do not attain to or go beyond 37 weeks of gestation.

Keywords: Nulliparous; Abdominal; Pregnancy

Keywords

Nulliparous; Abdominal; Pregnancy

Introduction

Abdominal pregnancy is becoming a nightmare to many obstetricians and it represents just about 1% of ectopic pregnancies [1]. Since its first report in 1708, copious cases have been published subsequently [1]. The diagnosis is usually intricate except if there are complications such as abdominal pain and haemorrhage. Maternal mortality and morbidity are also very high principally if the condition is not diagnosed and managed appropriately. By and large, abdominal pregnancies do not attain to or go beyond 37 weeks of gestation. Usually, the outcome is the delivery of a dead fetus but in the surviving babies, there is the exceedingly high frequency of congenital malformations.
Therefore, abdominal pregnancy at term (37 to 42 completed weeks of gestation) with a healthy viable fetus is therefore an extremely rare situation with very few reports such as from Jordan [2], China [3], Thailand [4], Nigeria [5,6] and Saudi Arabia [7] seen in the literature. We describe here a 28-year-old Rhesus D Negative patient with post-date secondary abdominal pregnancy which was not diagnosed until laparotomy with a resultant live baby without malformations, which to the best of our knowledge is the first of such a case in the reporting hospital.

Case Presentation

A 28-year old woman, gravida 3, para 0+2, none alive, Rhesus D negative, came to our antenatal clinic and had been pregnant for 40 weeks plus 6 days dated from the first day of her last normal menstrual period. She had two previous first trimester miscarriages with no post abortion complications. She was investigated and treated earlier for a 5-year history of infertility in another hospital, and was already receiving antenatal care at a maternity home which is about 100 kilometers from our hospital. She presented to our antenatal clinic on herself referral. She only knew that she was Rhesus D negative at the index pregnancy on presentation at our hospital.
She came with an ultrasound report that showed type 2 placenta previa with a viable intrauterine singleton in oblique lie and normal liquor volume. There was no fetal anomaly and there was no coexisting fibroid mass. She had no pelvic pain, vaginal spotting/bleeding throughout the pregnancy and so the pregnancy had been hitherto uneventful. She reported that she had not had any contractions but had felt a lot of fetal movement.
Physical examination revealed a young healthy-looking gravid woman in no obvious distress. She was afebrile, not pale and anicteric. She was neither dehydrated nor pedal edema. Blood pressure was 110/60 mmHg and pulse rate was 72 beats per minute. Symphysiofundal height was 40 cm and the “uterus” contained a viable singleton in oblique lie. The vaginal examination revealed a closed and uneffaced cervical os.
The hemoglobin and hematocrit values were 10 g/dl and 31%, respectively. She was admitted for elective “cesarean section” the next day. Her urine analysis showed no significant protein or glucose; blood group was B Rhesus D negative (husband was O Rhesus D positive); genotype AA; venereal disease research laboratory test was non-reactive. Four units of Rhesus negative whole blood were grouped and cross-matched.
She eventually had surgery (at the 41st week of gestation) using a pfannenstiel incision under spinal anesthesia. An intraoperative findings included: abdominal pregnancy on the right cornual pouch, a bulky uterus with diffuse adhesion around it, a live female baby with no gross abnormality (APGAR 10/1, 10/5), birth weight of 2.95 kg, placenta that was massively adhered to omentum, intestinal and uterine cornua (right broad ligament and adnexa) with some feeding vessels arising from posterior peritoneum. The right fallopian tube was incorporated into the placental attachment and the ovary on that side was visualized. The left fallopian tube and ovary were not visualized. The baby was delivered through an incision on thickened fetal membranes and the placental attachment was only identified after some attempt at delivering it. There was severe hemorrhage from the placenta with hemodynamic instability on delivering the baby during which time the blood transfusion was commenced. The bleeding was controlled by clamping with hemostat the feeding vessels arising from the right adnexa and its structures, following which the placenta was removed as much as could be safely done, along with the right tube, right ovary and right broad ligament. Omentectomy and inadvertent appendicectomy were done. Although most of the placenta was removed, placental tissues adherent to surrounding structures was left in place.
The anterior abdominal wall was closed in layers. The estimated blood loss was 2.5 litres. She successfully received one unit of whole blood intra-operatively, and two units post-operatively. She was also placed on intra-nasal oxygen therapy. There was no active bleeding at the end of the procedure. The immediate post-operative condition was satisfactory. She remained hemodynamically stable post operatively.
Her urinary output was adequate throughout this period. Thereafter she had steady recovery on the post-operative prescription: intravenous antibiotics (ceftriaxone 1 g daily for 72 hours, metronidazole 500 mg 8 hourly for 72 hours, gentamicin 80 mg 8 hourly for 72 hours; intravenous fluid 0.9% normal saline one litre to alternate with 5% dextrose in water one litre 8 hourly for 48 hours. During this time she was to be on nil per orum until bowel sounds returned. She also had adequate parenteral analgesia and fluid input and output was monitored. Methotrexate was not required in the postoperative period. By the third post-operative day, her bowel activity had fully returned. Subsequently, she was commenced on graded oral sips. Her hemoglobin concentration and hematocrit at the time were 6.7 g/dl and 20%, respectively. She also received 1500 iu of Rhesus anti D immunogloblun three days post-operatively since the blood group of the baby was O rhesus D positive. Early ambulation was encouraged. Her parenteral drugs were converted to oral antibiotics, analgesics and hematinics. She was discharged on 7th post-operative day in satisfactory condition. At discharge, the patient has established optimal lactation. She was given oral hematinics for 6 weeks on discharge. Her post natal visit two weeks after discharge revealed a hematocrit of 34%.
Six weeks following surgery, the patient and her baby were apparently doing well. At about three months after delivery, the mother had no complaints and her physical examination was unremarkable. However, the infant’s growth and development were seemingly normal. The infant’s head circumference was 37.5 cm and there is no cranial asymmetry.

Discussion

Abdominal pregnancy is now becoming frequently encountered entity in our practice but its advanced form is extremely rare. The diagnosis and management can pose some difficulties especially in low-resource settings like ours. High index of suspicion is vital in making prompt diagnosis in such situations. Nevertheless, medical practitioners in Nigeria will at some point encounter these patients and should be primed to manage them under various circumstances. Most of the cases of abdominal pregnancies are secondary from aborted or ruptured tubal pregnancy [8]. In our case it was obvious that the abdominal implantation was secondary to undiagnosed ruptured right tubal ectopic pregnancy and subfertility was a possible risk factor for our patient leading to an ectopic pregnancy [9]. This is obvious because the patient had five years history of infertility. Clinical diagnosis can be very difficult and ultrasound is very helpful during the early stages of gestation but can also be disappointing in the later stages as was seen in this case where the case was misdiagnosed as placenta previa.
Most abdominal pregnancies implant in the posterior cul de sac, on the posterior aspect of the uterus and on the fundus as in our present case [10]. On rare occasions, more dangerous implantations have been reported on the liver, spleen, and diaphragm [10]. The management of advanced abdominal pregnancy as in our case includes the vehement concern of removal or leaving in-situ placenta which may have implanted into a major intrabdominal blood vessel which may entail extensive amount of placenta separation. With this, the resultant blood loss can be quite significant.
On critical review of the sonographic image obtained in the pregnancy under discussion, it was apparent that at no stage was there an image demonstrating intra-abdominal pregnancy. It only revealed placenta previa. This failure of prenatal ultrasound diagnosis is upsetting. This case serves as a timely reminder to sonographers to remain heedful of the fundamental ultrasound techniques in a world bemused by fabulous advances in imaging technology.
Contrariwise, as the obstetric care providers for this woman, we also are mindful that the failure of an early diagnosis did enable the achievement of her lifetime desire of a live healthy infant following her prolonged infertility. This is because early diagnosis could have obliged early intervention that may have compromised the survival of the baby following delivery, with the “end justifying the means”.
In our opinion, bleeding from site of implantation of placenta is the most life-threatening complication during laparotomy. The decision to remove the placenta or not can be a determining factor for the survival or otherwise of the woman and this judgment is subject to the surgeon’s expertise and the particular case in question. It is usually recommended to leave the placenta in situ and make a follow up with human chorionic gonadotropin levels [11]. In this case there was significant bleeding from some detached portions of the placenta that prompted removal of these portions to secure hemostasis albeit painstakingly. The patient was transfused with one unit of blood during the operation and two postoperatively and that was enough.
Similarly, in a previous case report of advanced viable abdominal pregnancy in Nigeria, placenta was removed intra-operatively with satisfactory outcome even when the patient did not receive blood transfusion on religious ground [12]. Nevertheless, leaving the placenta in situ is not, however, without potential maternal risks, including a protracted resorption time, delayed placental hemorrhage, peritonitis and bowel obstruction [13,14]. In view of the huge placental mass in the case under discussion, we elected to take out the placenta as much as possible without the need for methotrexate while waiting for the dawdling spontaneous absorption of the residual placental mass.
Another interesting aspect of our case was the rhesus negative blood typing. Although we usually had ready access to immediate blood transfusion which most patients undergoing emergency surgery receive, it may become very difficult to get as many units of rhesus negative blood as possible in emergency situation. This was possible because four units of whole blood were already crossmatched as the case was initially diagnosed of placenta previa. Where blood transfusion is not readily available (as in rhesus negative blood donors), leaving the placenta in situ has been recommended [15]. In our case, placental removal is done after assessing for safety including the practicability of its removal and only one unit of whole blood was transfused intraoperatively.
Nor is it all. As in our case, ruptured ectopic pregnancy is an established event that can potentially sensitize a Rhesus negative woman early in pregnancy [16,17]. This could actually negate the beneficial effect of the Rhesus anti-D immunoglobulin given three days post-operatively. Additionally, the fact that she had two previous first trimester miscarriages without receiving Rhesus anti-D immunoglobulin was also noteworthy, although the outcome of the index case suggests that she could not have been previously sensitized.
Of the antibiotics used post-operatively in this patient, parenteral gentamicin was inclusive. Since gentamicin is potentially nephrotoxic, it would be advisable to be extremely cautious in using it especially in a patient who is already at risk of acute kidney injury from obstetric hemorrhage. However, in our case, even though she lost up to 2.5 litres of blood, she remained hemodynamically stable post-operatively and her urinary output was adequate throughout this period (intra-operatively and post-operatively).
By and large, abdominal pregnancies do not attain to or go beyond 37 weeks of gestation. Usually, the outcome is the delivery of a dead fetus but in the surviving babies, there is the exceedingly high frequency of congenital malformations. In our case, the pregnancy extended to post-date period since the pregnancy was already at the 41st week of gestation before delivery. The resulting excellent maternal and fetal outcome was intriguing.
For the newborn, it is very important to rule out congenital malformations. There are several reports of fetal malformations as high as 40% associated with abdominal pregnancies and only 50% of these babies survive up to one week of life [18]. In his extensive review, Stevens [19] found some varying degrees of deformations and malformations in 21.4% of infants of mothers with abdominal pregnancy. In this case that has been presented; the baby had good APGAR score on delivery without need for resuscitation or intervention and more so, no malformation has so far been found on the child after three months. Nevertheless, we ascribe this successful outcome despite unavailability of myometrial wall protection due to normal amniotic fluid volume noted on sonography which is dissimilar in a previous report of post date abdominal pregnancy [20].
Since our patient has history of infertility coupled with abdominal pregnancy of the index case, the patient is almost certainly at higher risk of having ectopic pregnancy in future conception [9,20]. Therefore, in order to optimize the patient in her next pregnancy, she was advised to be present at pre-conception counseling. She was also advised of the need to have close follow-up of her current baby since other possible congenital anomaly may become obvious later.

Conclusion

Abdominal pregnancy with resultant healthy newborn is very rare and its occurrence at postdate is a rarity. Diagnosis of the condition can be difficult especially if the pregnancy is advanced. High level of suspicion, careful clinical and ultrasound examinations are the routine means of diagnosis though Computed Tomography scan and Magnetic Resonance Imaging can be useful. Bleeding is the single most important grave complication for the mother whilst fetal malformation is one of the numerous challenges that can meet head-on with the newborn. It is second-rate that despite a pregnancy secondary to prolonged infertility, the diagnosis was not made in a well-timed manner, although there was successful outcome for the mother and the child. Attention to the basic principles of pregnancy imaging is fundamental to the prenatal detection of this potentially lethal condition, and the distraction of scanning the intrauterine contents should not prevent determination of the particular location of pregnancy.

Competing Interests

The authors declare that they have no competing interests.

Acknowledgment

The woman whose story is told in this case report signed permission for its publication.

Authors’ Contributions

OA, OIK and NEA performed the surgery. AO, OIK, OCE and MII were also involved in patient care. EGU, NEA, OIK and OCE assisted in the drafting of the manuscript, performed PubMed research, and helped to critically revise the manuscript. OA, AO, EGU and MII performed the obstetrics workup of the patient, assisted in the writing of the manuscript, and performed PubMed research. All authors read and approved the final manuscript.

References





















Track Your Manuscript

Media Partners

Associations