Early abdominal ectopic pregnancy: challenges, update and review of current management

Abstract

Key content Early abdominal ectopic pregnancy (EAP), though rare, has a high mortality rate. There are no pathognomic symptoms of abdominal pregnancy. Symptoms are akin as for other types of ectopic pregnancy, thus a high index of suspicion is necessary for diagnosis. The tool of choice for diagnosis is ultrasound but it only gives 50% accuracy when used along with clinical evaluation. On occasion, magnetic resonance imaging may help to diagnose EAP. Medical management is commonly used where potential life‐threatening bleeding is anticipated. A number of women who are treated medically may need subsequent treatment with multiple therapies. Surgical management requires a great deal of surgical expertise and in most cases a multidisciplinary approach in anticipation of possible life‐threatening bleeding during the operation. Learning objectives To outline the classification of EAP. To understand the common risk factors associated with EAP. To understand how to diagnose EAP. To be aware of the different medical and surgical management of EAP and the ethical issues associated with diagnosis and treatment. Ethical issues Distinguishing an abdominal pregnancy from the more common variants of ectopic pregnancy remains difficult and a definitive diagnosis is usually made at surgery. There is no established guidance available for the diagnosis and management of EAP. Many EAP are never diagnosed because of a successful response to medical management for a pregnancy of unknown location. As it is not uncommon to diagnose EAP for the first time during surgery, the difficulties in diagnosis prior to surgery means that patients require life‐saving surgery beyond the scope of the preoperative signed consent form.

A painless pelvic wall ectopic pregnancy

“…Risk factors for abdominal pregnancy are similar to those of any ectopic pregnancy and include low-socioeconomic status, PID, endometriosis, previous pelvic surgery, intrauterine contraceptive devices and history of ectopic pregnancy 7 8 15 21. The patient described here was not from a low socioeconomic group, although she did have a history of PID, which may have contributed to her risk of developing this rare form of ectopic pregnancy.…”

“…A recent review of 225 abdominal pregnancies reported the most common sites as (from most frequent to least): the pouches around the uterus (most commonly the Pouch of Douglas), the adnexae, omentum, bowel/appendix, liver, spleen, retroperitoneum and the abdominal wall 9. In addition, implantation sites at the diaphragm and renal fascia have been described 15 18 19…”

“…There have also been cases of successful management with intralesional methotrexate, with some authors advocating intralesional administration after failed systemic therapy prior to resorting to surgical management 14. Interventional radiology may also have a role through embolisation of feeding vessels, either as a primary treatment modality, in preoperative optimisation for surgical removal, or postoperatively, as haemorrhage control 14 15. In addition, intracardiac potassium chloride administered to the embryo as an agent for feticide has also been used to augment methotrexate therapy 13…”

Advanced abdominal pregnancy with dead foetus: a case report

“…11 Depending on the gestational period at which they detected, the abdominal pregnancy can also be classified into early abdominal pregnancy, i.e., detected at or before 20 weeks of gestation, and advanced abdominal pregnancy, i.e., detected after 20 weeks of gestation. 12 In this case, it was the advanced abdominal pregnancy identified after 38 weeks of pregnancy, which is a rarer condition compared to the early abdominal pregnancy.…”

Insights into abdominal pregnancy

“…[21] A report from Nigeria places the frequency in that country at 34 per 100,000 deliveries and a report from Zimbabwe, 11 per 100,000 deliveries. [5][22] [23] The maternal mortality rate is estimated to be about 5 per 1,000 cases, about seven times the rate for ectopics in general, and about 90 times the rate for a delivery (1987 US data). [21] History Albucasis (936-1013), an Arab Muslim physician is credited with first recognizing abdominal pregnancy which was apparently unknown to Greek and Roman physicians and was not mentioned in the writings of Hippocrates; Jacopo Berengario da Carpi (1460-1530) the Italian physician is credited with the first detailed anatomical description of abdominal pregnancy.…”