Peri-mortem laparotomy in a patient with a ruptured

intra-abdominal pregnancy
Ce sarienne pe rimortem chez une patiente pre sentant une
grossesse extra-ute rine rompue
A.E. Laher
*
, L.N. Goldstein, M.D. Wells, Z. Mahomed, R. Gihwala, P. Moodley
Division of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road,
Parktown Johannesburg, South Africa
Received 19 November 2012; revised 26 March 2013; accepted 27 March 2013
Available online 28 May 2013
KEYWORDS
Peri-mortem laparotomy;
Pregnancy related
complications;
Ruptured ectopic pregnancy;
abdominal decompression;
Return of spontaneous
circulation (ROSC)
Abstract Introduction: Intra-abdominal pregnancies can present at an advanced stage of preg-
nancy and can have the potential for life-threatening rupture and haemorrhage. The purpose of this
case report was to discuss the early recognition and prompt management options of a patient with a
life threatening ruptured intra-abdominal pregnancy.
Case report: We report what we believe to be the rst case of a patient who presented with an intra-
abdominal pregnancy who underwent a peri-mortem laparotomy in the Emergency Centre
following a cardiac arrest, and who exhibited a return to spontaneous circulation (ROSC).
Conclusion: Peri-mortem laparotomy/thoracotomy coupled with high quality CPR and resuscita-
tion may be lifesaving in a patient with a life threatening ruptured intra-abdominal pregnancy.
2013 Production and hosting by Elsevier on behalf of African Federation for Emergency Medicine.
*
Corresponding author. Tel.: +27 848402508; fax: +27 118340646.
E-mail address: abdullahlaher@msn.com (A.E. Laher).
Peer review under responsibility of African Federation for Emergency
Medicine.
Production and hosting by Elsevier
African Journal of Emergency Medicine (2013) 3, 178181
African Federation for Emergency Medicine
African Journal of Emergency Medicine
www.afjem.com
www.sciencedirect.com
2211-419X 2013 Production and hosting by Elsevier on behalf of African Federation for Emergency Medicine.
http://dx.doi.org/10.1016/j.afjem.2013.03.003
KEYWORDS
Peri-mortem laparotomy;
Pregnancy related
complications;
Ruptured ectopic pregnancy;
abdominal decompression;
Return of spontaneous
circulation (ROSC)
Abstract Introduction: Les grossesses extra-ute rines peuvent se pre senter a` un stade avance de la
grossesse et peuvent entraner une rupture mortelle et une he morragie. Lobjet de cette observation
e tait de discuter de lidentication pre coce et des options de prise en charge rapide dune patiente
pre sentant une grossesse extra-ute rine rompue mortelle.
Observation: Nous faisons e tat de ce qui semble e tre le premier cas de patiente se pre sentant avec
une grossesse extra-ute rine et ayant subi une ce sarienne pe rimortem au service des urgences suite a`
un arre t cardiaque, avec retour spontane de la circulation.
Conclusion: Une ce sarienne/thoracotomie pe rimortem, associe e a` une re animation cardio-respira-
toire de qualite et aux techniques de re animation, peut sauver la vie dune patiente pre sentant une
grossesse extra-ute rine rompue mortelle.
2013 Production and hosting by Elsevier on behalf of African Federation for Emergency Medicine.
African relevance
Advanced intra-abdominal pregnancies and their complica-
tions are more likely to present in the resource limited
developing world due to sub optimal antenatal screening.
Peri-mortem laparotomy/thoracotomy may be a lifesaving
procedure and must be considered by the appropriately
trained physician when indicated.
Continual post resuscitation monitoring and support in a
critical care setting are necessary for improved outcomes.
Whats new?
Abdominal pregnancies can present at an advanced stage of
pregnancy and can have the potential for life-threatening
rupture and haemorrhage.
A peri-mortem laparotomy/thoracotomy must be consid-
ered early in the ED by the appropriately trained physician.
Vigilant post-resuscitation management in theatre and the
intensive care unit are paramount to improve outcomes.
Introduction
Ruptured ectopic pregnancy is a common pregnancy related
complication and is one of the leading causes of rst trimester
maternal mortality. Ninety-ve percent of ectopic pregnancies
occur in the fallopian tube and usually present at less than
9 weeks gestation. Only 1.3% of ectopic pregnancies occur in
the abdominal cavity.
1
We report what we believe to be the rst case of a patient
who presented with an intra-abdominal pregnancy who under-
went a peri-mortem laparotomy in the Emergency Centre (EC)
following a cardiac arrest, and who exhibited a return to spon-
taneous circulation.
Case report
A 33-year-old female presented to the EC with a history of
syncope preceded by severe abdominal pain. No other history
was available at the time of presentation. On arrival she was
obtunded, a manual blood pressure reading was unobtainable
and she had a pulse rate of 122 bpm. Her abdomen was mildly
distended. Resuscitation with intravenous uids was com-
menced. As a result of further physiologic deterioration, rapid
sequence intubation followed. Arterial blood gas analysis re-
vealed a severe metabolic acidosis (pH 6.90), ScvO2 of 46%
and a haemoglobin of 4 g/dl. An emergency ultrasound proto-
col for hypotension was performed which revealed large
amounts of intra-abdominal uid and a at inferior vena cava
(IVC). Further ultrasound examination revealed an empty
uterus and an intra-abdominal foetus with a visible heartbeat.
An urgent blood transfusion was initiated. The obstetrics and
gynaecology specialist registrar from the satellite women and
childrens hospital and the on-site surgical specialist registrar
were urgently notied. Prior to their arrival, the patient deteri-
orated and went into cardiac arrest. The arrest rhythm proved
to be a pulse less ventricular tachycardia. She was promptly
debrillated and cardiopulmonary resuscitation (CPR) was
commenced as per advanced cardiac life support guidelines.
On repeat examination during CPR, the abdomen was tensely
distended. A decision was made to perform an ED laparot-
omy. The abdomen was opened up via a midline incision from
xiphisternum to pubic symphysis during CPR. Approximately
5 L of blood was suctioned from the abdominal cavity. An ex-
tra-uterine gestational sac, which was attached to the fundus of
the uterus via a pedicle, was ligated. A 12 cm long foetus was
found amongst loops of small bowel. CPR was continued for a
further 15 min before a return of spontaneous circulation
(ROSC) was achieved. Post ROSC red blood cell, fresh frozen
plasma and platelet transfusion were continued and an adren-
aline infusion (0.8 mcg/kg/min) was commenced. One gram of
tranexamic acid was administered and an infusion of 1 g to run
over 8 h was commenced. The abdomen was packed and the
patient transferred to theatre. Thirty minutes post ROSC,
the following parameters were recorded: SBP 96 mmHg,
HR 113 bpm, ScvO2 66%, pH 7.04. Post theatre the pa-
tient was sent to ICU with the abdomen surgically closed. SBP
was recorded as 110 mmHg and the adrenaline infusion, now
running at 0.4 mcg/kg/min was continued. The patient died
in ICU three days later secondary to multi-organ failure and
DIC.
Discussion
An extra-uterine/ectopic pregnancy is any implantation of the
fertilised ovum outside the endometrium of the uterus.
2
Causes
of ectopic pregnancy include previous pelvic infection, prior
ectopic pregnancy, tubal surgery/ligation, assisted reproduc-
Peri-mortem laparotomy in a patient with a ruptured intra-abdominal pregnancy 179
tion, use of intrauterine devices, advanced age and smoking.
3
The incidence of abdominal pregnancy has been reported as
1 per 33727931 births.
4
The mortality rate of abdominal preg-
nancy is seven times higher than fallopian tube pregnancies.
5
Most abdominal pregnancies originate as tubal or ovarian
pregnancies and then rupture into the peritoneal cavity where
they then implant for a second time (secondary abdominal
pregnancy).
4,6
Abdominal pregnancies can present at an ad-
vanced stage (>24 weeks) and may have the potential for
life-threatening rupture and haemorrhage.
1
The above- mentioned patient presented at >14 weeks ges-
tation (based on the size of the foetus). Later investigation of
the patients background history revealed that she had un-
der-went a previous tubal ligation, placing her at a higher risk
of developing an ectopic pregnancy.
With recent advances in the use of ultrasonography in the
EC, focused EC ultrasound can be used to better dene the
cause of shock when it is not immediately apparent (especially
hypovolaemic and cardiogenic causes). Free uid in the abdo-
men together with a small IVC diameter is suggestive of
hypovolaemic/haemorrhagic shock.
7
The emergent management of any patient in haemorrhagic
shock is to stop the bleeding and concurrently optimise circu-
lating blood volume in order to maintain perfusion to vital or-
gans so as to prevent irreversible end organ ischaemia.
3
Due to
unavoidable delays in taking our patient to the operating the-
atre and on-going internal bleeding she went into cardiac
arrest.
The only interventions in cardiac arrest that have been pro-
ven to have an impact on morbidity and mortality are early
debrillation with high quality CPR and addressing the under-
lying cause.
2,8
Therefore after our patient was promptly debr-
illated and CPR commenced, a peri-arrest laparotomy was
performed in the EC in order to treat the underlying cause
of the arrest. The performance of the peri-mortem laparotomy
served a dual purpose rstly to stop the bleeding and sec-
ondly to relieve the intra-abdominal pressure, thereby improv-
ing the already compromised IVC capacitance and venous
return to the heart.
9
PubMed and Google searches using the keywords peri-
mortem and laparotomy revealed only one previous case
study of a patient who underwent a laparotomy in the EC fol-
lowing asystolic cardiac arrest secondary to a ruptured ovarian
malignant mass, resulting in massive intra-abdominal haemor-
rhage. No ROSC was achieved.
10
Perhaps not much has been
published in the literature, likely due to dismal results and high
mortality rates associated with EC laparotomy. The survival
rate from blunt trauma is less than 1% whilst the survival rate
from penetrating trauma is not much higher.
11
However rup-
tured abdominal ectopic pregnancies are rare and bleeding is
usually from an isolated site. It is assumed that the survival
rates would be better than that for blunt trauma. Therefore
every effort towards resuscitation should be attempted, bear-
ing in mind available resources.
Many case studies and protocols have been described
regarding peri-mortem caesarean section in the EC.
9,12,13
The
main objective is to relieve the pressure of the gravid uterus
on the IVC, thus improving maternal venous return. The goal
is to remove the foetus within 5 min of cardiac arrest in order
to improve maternal outcomes.
13,14
According to a recent sys-
tematic review there are very few instances where a caesarean
section had been performed within 5 min of cardiac arrest.
9
There are many reports of peri-mortem EC thoracotomy for
various indications such as internal cardiac message, pericardi-
otomy for pericardial tamponade and to clamp the descending
aorta in trauma patients with uncontrolled intra-abdominal
haemorrhage.
11,15
We chose to perform a laparotomy in our
patient since ruptured ectopic pregnancies usually have a single
source of haemorrhage and are easily controlled via the abdom-
inal approach. This also allowed us to relieve pressure off the
IVC and thus improve venous return. The thoracotomy
approach may also have been considered in this patient. This
would have allowed us to clamp the descending aorta, thereby
controlling distal haemorrhage and would have facilitated
internal cardiac message. However with this approach it would
not be possible to relieve external IVC pressure.
Conclusion
Peri-mortem laparotomy/thoracotomy coupled with high
quality CPR and resuscitation may be lifesaving in a patient
with a life threatening ruptured intra-abdominal pregnancy.
Our recommendations for intra-abdominal, non-traumatic
haemorrhage in the peri-arrest patient in the EC:
Use emergency ultrasound techniques early in the resuscita-
tive phase of management to aid diagnosis and management
Maintain a high index of suspicion of pregnancy and its
complications in any female of childbearing age.
Contact gynaecologist/surgeon promptly.
Employ early uid resuscitation whilst keeping in mind the
principles of permissive hypotension.
Consider early blood/blood product administration with
packed red blood cells: fresh frozen plasma: platelets in a
ratio of 1:1:1.
Consider Anti Shock Garment (PASG/MASG) if available
(Class II b evidence).
16
Consider inotropic support if the patient remains hypoten-
sive despite demonstrably sufcient uid resuscitation.
If the patient develops cardiac arrest in the EC:
Perform early debrillation (when appropriate) with high
quality CPR.
Perform peri-mortem laparotomy/thoracotomy in the EC
as soon as possible after CPR is initiated so as to achieve
homoeostasis. A laparotomy/thoracotomy set should be
available in the EC.
Provide vigilant post-resuscitation management in theatre
and the intensive care unit.
Appendix A. Short answer questions
Test your understanding of the contents of this case report (an-
swers can be found at the end of the regular features section)
1. Regarding peri-mortem caesarean section:
a. The goal is to remove the foetus within half an hour of
cardiac arrest.
b. In most instances a peri-mortem caesarean section is
performed within the recommended time frames.
180 A.E. Laher et al.
c. The main objective is to relieve the pressure of the
gravid uterus on the IVC, thus improving maternal
venous return.
d. The goal is to remove the foetus within 5 min of cardiac
arrest.
e. The goal is to remove the foetus within 15 min of car-
diac arrest.
2. Indications for ED thoracotomy include:
a. Cardiac in a patient with blunt chest trauma.
b. Pericardiotomy in a trauma patient with a pericardial
tamponade and ineffective pericardiocentesis.
c. Clamping of the descending aorta in trauma patients
with uncontrolled intra-abdominal haemorrhage.
d. Large pericardial effusion with a normal blood
pressure.
e. Bilateral large pleural effusions in a severely distressed
patient with lymphoma.
3. Management recommendations for intra-abdominal, non-
traumatic haemorrhage in the peri-arrest patient in the
ED include:
a. Contact gynaecologist/surgeon promptly.
b. Only contact the gynaecologist/surgeon if the patient is
not responding to resuscitative measures.
c. Consider early blood/blood product administration
with packed red blood cells: fresh frozen plasma: plate-
lets in a ratio of 3:2:1.
d. Consider early blood/blood product administration
with packed red blood cells: fresh frozen plasma: plate-
lets in a ratio of 4:2:1.
e. Maintain a high index of suspicion of pregnancy and its
complications in any female between the age of 19 and
36.
Conict of interest
The authors declare no conict of interest.
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Peri-mortem laparotomy in a patient with a ruptured intra-abdominal pregnancy 181