CASE PRESENTATION

ABDOMINAL PREGNANCY
Presented by :
dr. Inne
(4th Semester)

Resident of Obstetric and Gynecology

Medical Faculty of Sebelas Maret University
Doctor Moewardi General Hospital Surakarta
2018
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Chronology
A G5P2A2, 38 years old, gestational age 24 weeks come
alone with chief complain abdominal pain, tenderness
and dyspnoe. She felt 6 month of pregnancy. No
amniotic leackage, no blood slime, and no vaginal
bleeding. This patient has been consult by emergency
room practician to Surgeon by complain of abdominal
pain. Then she has got abdominal sonography with
notice : FREE FLUID EXTRALUMINAL. In urinary
examination, found ẞ-hCG (+) for pregnancy, then the
patient has been consult to obstetrician for the next
advice.
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Obstetric history

• I. Male,spontaneous labor, 3000gr, 19 years old

• II. Female, spontaneous labor, 3000gr, 17 years old
• III. 2013, Ab, curetage at 14 wga, Purbalingga
• IV. 2017, Ab, curetage at uk 8 wga, Purbalingga
• V. This pregnancy

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Antenatal Care history

• At midwife.

Prior Illnes

• High Blood pressure /Astma /Alergic / Heart disease/ DM denied

• History of febrile and other illness during pregnancy denied

History drugs abused during pregnancy

• No history about using any medication or drugs

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PHYSICAL EXAMINATION
• CM , Mild , Height : 160 , Weight : 58 , IMT : 22,7
GC/VS • BP : 100/60 , HR : 110, RR :24 x, T : 36,5

• Eyes : anemic (+/+)

Head • Sklera Icterik (-/-)

Thorax • Cor and pulmo in normal rang

• Distended , tenderness (+) all abdominal field,

Abdomen Fundal height and fetus could not be evaluate

• V/U normal, vagina wall normal, portio felt soft in

consistency, uterine corpus felt bigger appropriate to
Genital 8 weeks of pregnancy, slinger pain (+) blood (-),
discharge (-)

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SUPPORTIVE EXAMINATION
Laboratory Ultrasonography

• Seen bladder fullfil enough

• Hb 9,1 • Hb 6,8 • Seen uterine bigger, no fetus
• Ht 29 • Ht 21 intrauterine, EL (+), seen
• Al 15,4 placental insertion at serosal
• AL 30,4 tunica of uterine fundus
• AT 362
• AT 231 • Seen fetus extrauterine,
• Ae 3,0
• Goldar O • AE 2,3 impressed from abdominal
• GDS 216 cavity, amniotic fluid (+), no
• Ur/Cr10/0,5 fetal heart rate
• OT/PT 18/6 • Seen free fluid at abdominal
• HbSAg NR cavity
• B hCG test (+) • Summary : Appropriate to
Abdominal pregnancy

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USGUUSUSG USG
Fetus with
amniotic
Free fluid membrane
at outside, FHR (-),
abdominal impressed from
extrauterine
cavity

Uterine seen bigger, no fetus

intrauterine, EL (+), seen
placental insertioin at serosa
tunica of uterine fundus

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DIAGNOSIS

• Ectopic pregnancy, Susp. Abdominal

pregnancy with fetal death

PLAN

• Pro Emergency Laparotomi

Exploration

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DURING OPERATION
The placental
insertion at
uterine fundus,
half part to
Uterine fundus omentum

Peritoneum parietale was opened,

seen fresh blood and hematocele
evacuation, seen fetus at
abdominal cavity
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DURING OPERATION

With consideration, there was masive

bleeding pre operation and half part of
placentae was separate from tunica
serosa of uterine, beside the risk on
going bleeding if placentae leave in
situ, operator decide to release all part
of placentae from uterine fundus and
omentum (was perform partial
omentectomy)

When placentae released, seen trophoblast invade to myometrium,

operator try to control bleeding from placental bed  no succeed. There
was uterine atonia after placental bed bleeding could not controle  decide
to performed supracervical hysterectomy.
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Type of Abdominal
pregnancy in this case

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PROBLEM

Pregnancy
Prenatal diagnosis
management

Surgical Placental
management management
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Abdominal Pregnancy
1 PRIMARY
Insidence 1 in 10.000 births Direct implantation to peritoneal cavity
1,4 % from all ectopic pregnancy (on operating filed, seen intact
Fallopians’s tubes )
Implantation site: 2 SECONDARY
1. Uterine Tunica serosa
2. Omentum Re-Implantation of Abortion/ Rupture
3. Pelvic wall Fallopian’s tube pregnancy
4. Douglass pouch
5. Liver, Spleen
6. Bowel
7. Great vesell on pelvic area
8. Diafragma

Yasumoto K, Sato Y, Ueda Y, Ito T, Kawaguchi H, Nakajima M, Muneshige N. 2017. Expectant

management for abdominal pregnancy. Gynecology and Minimally Invasive Therapy
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Abdominal Pregnancy
Mortality

Maternal Perinatal
0,5 to 18% 40 to 95%
Maternal morbidity cause by Perinatal morbidity
1. Massive bleeding and anemia
2. Infection 20% to 40% from fetus has
3. DIC malformation, altered by
4. Pulmonary embolism oligohydramnios in abdominal
5. Gastro intestin fistule, cause by fetal bone pregnancy
in abdominal cavity

Bertrand G, Le Ray C, Émond LS, Dubois J, Leduc L. 2008. Imaging in the Management of
Abdominal Pregnancy: A Case Report and Review of the Literature

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Abdominal Pregnancy
Clasification
Early Abdominal Late Abdominal
pregnancy (<20 wga) pregnancy (> 20 wga)
Studdiford (1942) report that early abdominal pregnancy should be following
criteria :

1. Normal tubes and ovaries with no evidence of recent or remote injury

2. Absence of any evidence of a uteroperitoneal fistula
3. Presence of a pregnancy related exclusively to the peritoneal surface
4. Early enough to eliminate the possibility of secondary mplantation following a
primary nidation in the tube.

2014
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Poole A, Haas D, Magann EF. Early abdominal ectopic pregnancies: a

systematic review of the literature. Gynecol Obstet Invest 2012;74:249–60.
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Prenatal Diagnosis
1 2 3
Identification risk factor Clinical Sign and Symptom Supportive examination
modality
1. Prior ectopic 1. Abdominal pain or persistent
pregnancy suprapubic pain 1. ẞ-hCG titer (+)
2. Vaginal bleeding 2. Transabdominal dan
2. Prior tubal surgery
3. GIT disorder : nausea, vomit transvaginal sonography
3. Prior curetage 4. No fetal movement, or uterine bigger, seen no
4. Endometriosis decreasing fetal movement, or conception intrauterine
5. Prior PID patien feel pain when the fetus 3. MRI with contras
6. Used of IUD move Gadolinium  when the
7. Patient in IVF therapy 5. Uterine size was not fetus was death, the benefit is
appropriate to getational age to know implantation to
(in late abdominal pregnancy) adjasent organs
6. Malaise 4. Diagnostic laparoscopy

Occurly asymptomatic

Hailu FG et al 2017. Advanced abdominal pregnancy, with live fetus and severe preeclampsia, case
report. BMC pregnancy and childbirth. 17:243DOI 10.1186/s12884-017-1437-y

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Abdominal Pregnancy Management

When abdominal pregnancy established?

EARLY LATE

Medical treatment Expectant management in life

1. Using methotrexate (local and sistemic) fetus
2. Local injection intracapsular KCl, 1. Informed choice, between benefical and
hyperosmolar glucose risk to maternal and fetus if placentae
3. Use prostaglandin, mifepristone, leave in situ
etoposide, danazol 2. Placental colony majority in uterine wall,
4. Angiographic arterial embolization, because the blood suply enough for the
especially vessels that suply blood to baby and risk of bleeding minimal in this
placentae site of implantation. (Huang et al 2014)
3. Consideration to terminate in 34 weeks of
getational age  high survival rate
Surgical treatment
Laparoscopy untilLaparotomy
Surgical treatment  LAPAROTOMY

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SURGICAL MANAGEMENT
RELEASE OR LEAVE PLACENTAE?

1. Release placentae could be perform in 1. Placentae leave in situ , must be routine

death fetus, because the blood flow to follow up to evaluate resorption process,
placentae was decrease by β-hCG titer, USG and MRI
2. Leave placentae in situ incresing risk of
2. Consideration to relesae the placentae
infection, necrosis and the next
only perform if operator sure that the
procedure if there is a complication.
blood vessel to the placentae could be
ligate if there was massive bleeding on
placental bed after release. Avoid to
release partially the placentae

Tucker K, et al. 2017. Delayed diagnosis and management Brewster EM, Braithwaite EA, Brewster Jr EM. 2011. Advanced
of second trimester abdominal pregnancy. BMJ Case Rep. Abdominal Pregnancy A Case Report of Good Maternal and
doi:10.1136/bcr-2017-221433 Perinatal Outcome. West Indian Med ; 60 (5): 587

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SURGICAL MANAGEMENT

Spontaneous Emergency Laparotomy Exploration

separation of
placentae 
massive bleeding
Consideration perform hysterektomi,
salpingoophorektomy, bowel or bladder
resection if the placentae has deep
invasion (adherent placentae)
1. Direct compression to
bleeding site
2. Ligation to blood vessels that
give suply to the placentae
3. Use local coagulation
agent(gelatin sponge) and
sistemic (tranexamic acid,
plasminogen derivate)

Hailu FG et al 2017. Advanced abdominal pregnancy, with live fetus and severe preeclampsia, case
report. BMC pregnancy and childbirth. 17:243DOI 10.1186/s12884-017-1437-y

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