Abdominal pregnancy represents a grave risk to the health of the pregnant woman. This is a case report of a 24-year-old primipara with repeated secondary abdominal pregnancy following ruptured tubal ectopic pregnancy. She had past history of heterotropic pregnancy following ovulation induction therapy. She delivered preterm quadruplets at home and visited the maternity hospital 1month 15 days later with acute abdomen. It was a secondary abdominal pregnancy from a ruptured rudimentary horn of a unicornuate uterus and live term female baby was deliverd from the peritoneal cavity. It is a very rare condition. Mother and baby survived after such a catastrophe.
Keywords: Abdominal pregnancy, Tubal abortion, Heterotropic pregnancy, Quadruplet intrauterine pregnancy, Rudimentary horn pregnancy, Secondary abdominal pregnancy.
Abdominal pregnancy is a rare event. An abdominal pregnancy is defined as an ectopic pregnancy that implants in the peritoneal cavity,(1) classified as primary and secondary. Secondary abdominal pregnancy is most common. It results from tubal abortion, tubal rupture or implantation within abdomen following uterine rupture. In first and early second trimesters abdominal pregnancy is self-limited and mimics tubal ectopic gestation. Clinical presentation is more variable pregnancy in advanced abdominal pregnancy. The patient reports with complaints of painful fetal movement, sudden cessation of movements or fetal movements high in abdomen. The risk factors for ectopic pregnancy are PID, assisted reproductive technique, smoking, use of IUCD, endometriosis, tubal surgery. Prior ectopic pregnancy has ten fold increased risk.(2)
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Majority of the reported heterotopic pregnancies are of singleton intrauterine pregnancies. Triplet and quadruplet heterotopic pregnancies have also been reported, though extremely rare.(3,4) It can be multiple as well.(5) They can be seen frequently with assisted conceptions. Heterotopic pregnancy is defined as the coexistence of intrauterine and extrauterine gestation. The incidence of heterotopic pregnancy is very low.
A 24 year old primipara presented to obstetrics department with amenorrhea of 11 weeks. She had complaints of spotting pervaginum and pain in lower abdomen since 12 days. On examination she was anaemic but haemodynamically stable. On perabdominal examination previous laprotomy scar seen, tenderness was present in the right iliac fossa and right lumbar region but no marked guarding or rebound tenderness. A 14 week sized suprapubic lump was found. On vaginal examination cervical os was closed and slight bleeding per os was present.
Internal examination suggested the same lump. She had UPT positive and Her USG showed an extrauterine sac with one live embryo in right adnexa corresponding to 10 weeks 4 days gestational age which was suggestive of secondary abdominal pregnancy with mild to moderate intraperitoneal haemorrhage .
Laprotomy was planned. Peroperatively right sided ruptured ectopic with secondary abdominal pregnancy with intact sac with fetus inside the sac was found. Left sided tubes and ovaries not found. Uterus was unicornuate. Right sided salpingectomy was done. Procedure was carried out uneventfully. Patient was transfused 2 units of packed cell transfused after cross matching. Postoperative period was uneventful and patient was discharged postoperative day 11. A follow up USG showed empty uterine cavity with normal endometrial thickness.
Patient had history of preterm vaginal quadruplets delivery at 28 weeks of gestation 4 years back. Perinatal outcome was poor two were stillborn and two were neodeath. 1 month 10 days postnatally patient reported to institute with acute lower abdominal pain for which USG was done which revealed live fetus in abdominal cavity with empty endometrial cavity. On laprotomy secondary abdominal viable pregnancy following rupture of non-communicating horn of uterus was found, which is a very rare condition. Mother and baby were in good condition after this catastroph. This baby is still alive with congenital heart disease. Patient had history of taking ovulation induction drug prior to this pregnancy.
Figure1 : Unicornuate Uterus with Right Tube
Note: Left tubes and ovary not present as patient had laprotomy and exision of ruptured rudimentary horn on left side during her previous heterotropic pregnancy.
Shoen and Novak (1975) concluded that 30% of patients who have an ectopic first pregnancy will have repeat ectopic pregnancy.(6)Abdominal pregnancy is a rare obstetric complication characterized by implantation in the peritoneal cavity exclusive of tubal, ovarian or intraligamentary implantaion It has high maternal and perinatal morbidity and mortality. Centre for Disease Control and Prevention estimated its incidence to be 1 in 10,000 live births.(7) As early rupture of tubal ectopic pregnancy is the usual antecedent of a secondary abdominal pregnancy, a suggestive history can usually be obtained. If there is failure of spontaneous onset of labor or failed induction for termination of pregnancy or persistent fetal malpresentation, one should review the diagnosis. About 50% of diagnosis are missed on ultrasound(8) but MRI and CT are both excellent diagnostic tools to diagnose secondary abdominal pregnancy.(9,10) In our case patient had USG showing secondary abdominal pregnancy with intraperitoneal haemorrhage which is likely following tubal rupture. Serious hemorrhage can occur because of inadvertent disruption of blood supply in the process of fetal removal as well as the difficult surgical challenges presented by extensive adhesion
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The illustrated case had a history of the heterotopic gestation (quadruplet intrauterine pregnancy and ectopic pregnancy in rudimentary horn) conceived after ovulation induction drug.
Heterotopic pregnancy can have various presentations. It should be considered more likely (a) after assisted reproduction techniques, (b) with persistent or rising chorionic gonadotropin levels after dilatation and curettage for an induced/spontaneous abortion, (c) when the uterine fundus is larger than for menstrual dates, (d) when more than one corpus luteum is present in a natural conception, and (e) when vaginal bleeding is absent in the presence of sings and symptoms of ectopic gestation.(11) There may be an increased risk in patients with previous tubal surgeries.(12)
The incidence was originally estimated on theoretical basis to be 1 in 30,000 pregnancies. However, more recent data indicate that the rate is higher due to assisted reproduction and is approximately 1 in 7000 overall and as high as 1 in 900 with ovulation induction.(13,14)
The increased incidence of multiple pregnancy with ovulation induction and IVF increases the risk of both ectopic and heterotopic gestation. The hydrostatic forces generated during embryo transfer may also contribute to the increased risk.(13)
Most commonly, the location of ectopic gestation in a heterotopic pregnancy is the fallopian tube. However, cervical, rudimentary horn and ovarian heterotopic pregnancies have also been reported.(15,16) Other surgical conditions of acute abdomen can also simulate heterotopic gestation clinically and hence the difficulty in clinical diagnosis.(17)
This case presents a rare obstetric condition which can result in catastrophic haemorrhage. Early diagnosis of abdominal pregnancy is difficult but critical because of its high maternal and perinatal mortality and morbidity. High index of suspicion should be kept in mind in patients who have previous history of ectopic pregnancy and inferility. This type of rare pregnancies presents with variety of manifestations and hence delays the diagnosis.