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European Journal of Obstetrics & Gynecology and

Reproductive Biology 109 (2003) 106107

Case report
Surgical packing as a means of controlling massive haemorrhage in
association with advanced abdominal pregnancy
Galal E.E. Farag*, Susmita Ray, Angela Ferguson
Department of Obstetrics and Gynaecology, North Manchester General Hospital, Delaunays Road, Crumpsall, Manchester M8, UK
Received 31 July 2002; received in revised form 10 October 2002; accepted 14 November 2002


A case of advanced abdominal pregnancy was diagnosed at laparotomy. During surgery, there was massive haemorrhage from the placenta
which was controlled using surgical gauze packing.
# 2002 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Abdominal pregnancy; Ectopic pregnancy; Surgical packing; Obstetric haemorrhage

1. Case report and the open wound was covered with dressings. The packs
were removed 48 h later and there was no active bleeding.
A 30-year-old primigravida was referred to antenatal The placenta was left in situ and the abdomen was closed
booking clinic at 15 weeks. She had multiple admissions without drainage. The patient was hospitalised in the inten-
and ultrasound scans for abdominal pain and vaginal spot- sive care unit for 6 days. She received in total 36 units of
ting at 15, 20, 32 and 36 weeks. At 38 weeks she was blood, 4 bags of platelets and 24 units of fresh frozen plasma.
admitted with constant backache and shingles at the level of She left hospital with her healthy baby 3 weeks post-
T10. The foetal lie was oblique. She was treated with delivery. During that time, she had an incision and drainage
acyclovir and a decision was made to deliver by elective of an infected rectus sheath haematoma followed a week
Caesarean section 5 days later. At laparotomy, an intra- later by a successful repair of partial wound dehiscence.
abdominal pregnancy was discovered. The baby was lying Both mother and baby remained well at follow up.
transversely in the peritoneal cavity. The sac was incised and
the liquor was clear. A live male baby was delivered and
showed no gross malformations. The APGAR scores were 2 2. Discussion
at 1 min and 7 at 5 min and the birth weight was 3130 g.
Almost immediately moderate to severe bleeding started Abdominal pregnancy is a rare though serious obstetric
within the peritoneal cavity. The placental site was explored, condition with an incidence of 1:10 000 pregnancies. It
but no attempt was made to remove the placenta. The constitutes 1% of ectopic pregnancies [1]. The risk of dying
placenta was adherent to the sigmoid mesentery and des- from abdominal pregnancy is 7.7 times greater than from a
cending colon. The placenta appeared to be separating with tubal pregnancy and 90% higher than from intrauterine
massive haemorrhage; however, some of the bleeding came pregnancy [2]. Perinatal mortality is approximately 70
from bursting vessels on the foetal surface of the placenta. 80% at gestations of 30 weeks with a 3090% chance
An attempt at surgical dissection and removal of the placenta of congenital malformation in the surviving infant [3]. Most
was unsuccessful. Haemostatic sutures were inserted into authors have reported a diagnostic error in 5090% of the
the substance of the placenta but the bleeding continued. cases.
Finally, the abdominal cavity was packed with 14 large A high index of suspicion is the cornerstone to diagnosis.
sterile swabs. The haemorrhage was substantially controlled Cocaine abuse has been identified as a risk factor specific
for abdominal pregnancy and increases the risk up to
Corresponding author. Tel.: 44-161-720-2025;
20-fold [4]. Clinical clues are abnormal vaginal bleeding
fax: 44-161-720-2141. in early pregnancy, unusual abdominal pain, painful
E-mail address: (G.E.E. Farag). foetal movements, easily palpable superficial foetal parts,

0301-2115/02/$ see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved.
G.E.E. Farag et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 109 (2003) 106107 107

malpresentation, excessive nausea and vomiting, evidence compression using surgical packing, which was life saving
of intrauterine growth retardation, oligohydramnios, unef- in our case. The procedure of surgical packing has been
faced closed cervix, and failure to respond to prostaglandin mentioned before by Myerscough [8]. However, he is of the
or syntocinon. opinion that the procedure is most unsatisfactory in con-
Ultrasonography has been a useful diagnostic tool parti- trolling placental haemorrhage associated with advanced
cularly in early pregnancy, although absolute diagnosis by abdominal pregnancy. To our knowledge, this is the first
ultrasound is an uncommon event. Magnetic resonance reported case where surgical packing proved to be successful
imaging (MRI) is the investigation of choice in suspected in controlling such a catastrophic haemorrhage.
cases due to better clarity of images in multiple planes and
absence of irradiation to the live foetus. The placenta and
its vasculature can be well defined and where the placenta
is left in situ, MRI is useful in the follow up of placental
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involution [5]. pregnancy: description of 38 cases with literature survey. Obstet
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that placental attachment to the uterus appears to be a factor [2] Martin JN, Sessums JK, Martin RW, Pyror JA, Morrison JC.
for better foetal survival, although in our case the foetus Abdominal pregnancy: current concepts of management. Obstet
Gynecol 1988;71:54957.
survived despite mesenteric and colonic attachment of the
[3] Stevens C. Malformations and deformations in abdominal pregnancy.
placenta. Am J Med Genet 1993;47:118995.
Intraoperative decision regarding removal or non-manip- [4] Audain L, Brown WE, Smith DM, Clark JF. Cocaine use as a risk
ulation of the placenta is an important management issue. If factor for abdominal pregnancy. J Nat Med Assoc 1988;90:27783.
the blood supply to the placenta can be ligated safely, [5] Harris MB, Angtuaco T, Frazier CN, Mattison DR. Diagnosis of viable
abdominal pregnancy by magnetic resonance imaging. Am J Obstet
removal in toto results in a smooth postoperative recovery
Gynecol 1988;159:1501.
[7], but leaving the placenta behind increases the morbidity [6] Dubinsky TJ, Guerra F, Gormaz G, Maklad N. Fetal survival in
and mortality of the patient. The risks include peritonitis, abdominal pregnancy: a review of 11 cases. J Clin Ultrasound
abscess formation, wound breakdown, sepsis, dessiminated 1996;24:5137.
intravascular coagulation and persistent trophoblastic dis- [7] Hreshchyshyn MM, Bogen B, Loughran CH. What is the actual
present day management of the placenta in the late abdominal
ease. If the placenta is left in situ, every effort should be
pregnancy? Analysis of 101 cases. Am J Obstet Gynecol 1961;81:
made to avoid leaving a drainage tube in place to prevent risk 30317.
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