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J Emerg Trauma Shock. 2009 Sep–Dec; 2(3): 196–198.

PMCID: PMC2776369
doi: 10.4103/0974-2700.55342.
Copyright © Journal of Emergencies, Trauma, and Shock

Abdominal pregnancy as a cause of hemoperitoneum


Sheikh Muzamil Shafi, Misbha Afsheen Malla, Parvaiz Ahmed Salaam, and Omer Shareef
Kirmani
Postgraduate Department of Surgery, SMHS Hospital, Srinagar, India
Address for correspondence: Dr. Sheikh Muzamil Shafi, E-mail: drsmshafi@gmail.com
Received November 7, 2008; Accepted February 18, 2009.

This is an open-access article distributed under the terms of the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.

Abstract
The coexistence of intrauterine and extrauterine pregnancy, the heterotopic pregnancy, is a
rare obstetric phenomenon. The preoperative diagnosis of this condition is very difficult;
leading to a higher maternal morbidity and fetal loss. We experienced a case of intrauterine
pregnancy and ruptured abdominal pregnancy implanted on the illeocaecal region in a 26-
year-old primiparous woman. She was clinically misdiagnosed as a case of ruptured ectopic
pregnancy, but ultrasonography showed it to be a case of heterotopic pregnancy.
Subsequently, the patient was subjected to laparotomy and the ruptured abdominal
pregnancy was evacuated. She continued with the intrauterine pregnancy till term and
delivered a healthy female baby. Although this condition is unusual, any general surgeon in
the emergency department must be aware of this complication and its management, which
is often initially misdiagnosed.
Keywords: Abdominal pregnancy, ectopic pregnancy, heterotopic pregnancy

Other Sections▼
o AbstractINTRODUCTIONCASE
REPORTDISCUSSIONCONCLUSIONREFERENCESINTRODUCTION
Abdominal pregnancy is a rare event but is associated with significant morbidity and
mortality. The incidence varies widely with geographical location, degree of antenatal
attendance, level of medical care and socioeconomic status.[1] It is believed that abdominal
pregnancy is more common in developing countries probably because of the high frequency
of pelvic inflammatory disease in these areas.[2] Heterotopic pregnancy is the coexistence
of intrauterine and extra-uterine pregnancies. Abdominal pregnancies make up a small
percentage of ectopic pregnancies which are a common occurrence.[3] Moreover, 98% of
all extra-uterine pregnancies are intra-tubal, one percent is ovarian and the rest are primary
or secondary peritoneal implantations. Atrash and colleagues estimated the incidence of
abdominal pregnancy at 10.9 per 100,000 live births and 9.2 per 1,000 ectopic pregnancies
in the United States.[1]
Abdominal pregnancies can be classified as ‘primary’ when fertilization takes place outside
the uterine adnexae, or as ‘secondary’ (thought to be more common) believed to result from
undetected rupture of a tubal pregnancy. Implantation can occur anywhere in the abdomen
including ligaments, liver, and spleen. Recent estimated rate of occurrence of heterotopic
pregnancy is 1 in 15,000 live births and the ectopic component is commonly tubal. Its
incidence is increased in women undergoing assisted conception with superovulation, IVF-
ET and GIFT.[4]

Other Sections▼
o AbstractINTRODUCTIONCASE
REPORTDISCUSSIONCONCLUSIONREFERENCESCASE REPORT
A 26-year-old primigravida presented to our emergency surgical department as a case of
pain in right lower abdomen of two days duration with history of three months amenorrhea.
The patient had 2-3 episodes of vomiting and was febrile from last one day. She gave a
history of giddiness on standing. On examination, she was conscious and oriented with
pulse of 98 beats per minute and BP of 90/65 mmHg. Her abdomen was mildly distended
and tender in the right iliac fossa (RIF). A tender lump about 10 × 12 cms was found in her
RIF. Based on the history and clinical examination, the patient was clinically diagnosed as
a case of ruptured ectopic pregnancy.
The patient was immediately resuscitated with I.V. fluids and a urinary catheter was put in
to monitor the output. Subsequently, an ultrasonographic (USG) examination was
conducted which diagnosed her as a case of heterotopic pregnancy; with intrauterine
pregnancy [Figure 1] and the other one in the abdomen, implanted on the iliocolic region
[Figure 2] of 13 weeks duration. USG also showed the presence of significant free fluid in
the peritoneal cavity (hemoperitoneum). She was immediately prepared for emergency
laparotomy under general anesthesia. Abdomen was opened by lower midline incision. On
opening the abdomen, about 1.5 liters of free blood was found in the peritoneal cavity. The
intra abdominal pregnancy was confirmed; and the partially detached placenta was seen
implanted over the illiocolic region, leading to the hemoperitoneum. The fetus was
delivered and the placenta was meticulously separated [Figure 3]. Intrauterine pregnancy
was not disturbed. Complete hemostasis was achieved and abdomen was closed. Her
postoperative course was unremarkable. She was discharged on 5th postoperative day with
no surgical or any other postoperative complication.
The patient was followed till term and delivered a normal female baby by caesarean section
due to the persistent oblique position of the fetus confirmed by USG examination. There
were no postoperative complications and the patient was discharged without any untoward
event.

Other Sections▼
o AbstractINTRODUCTIONCASE
REPORTDISCUSSIONCONCLUSIONREFERENCESDISCUSSION
Heterotopic pregnancy is a potentially fatal disease. Incidence of heterotopic pregnancy has
been reported as 1/8000-1/30,000 in natural conception.[5] It may increase as high as 1%
with assisted reproductive techniques. Diagnosis of heterotopic pregnancy is a challenge
not only for the obstetricians but also for other physicians who are following or treating the
patient.
Spontaneous progression of undetected intrauterine pregnancy from the time of surgical
management of acute or subacute ruptured ectopic pregnancy on postoperative follow up is
rare. On the contrary, spontaneous abortion of an intrauterine pregnancy has followed
ectopic rupture.[6]
Risk factors include a history of tubal pregnancies, pelvic inflammatory disease, tubal
sterilization, and tubal infertility or tubal reconstructive surgery. Other women at risk
include those who conceive despite the use of an intra- uterine contraceptive device (IUCD)
or progestogen only contraceptive pills.[7] Since none of the above risk factors were
present, the undetected rupture of a tubal pregnancy was considered as case of heterotopic
pregnancy in our case.
Early diagnosis depends on the clinician having a high index of suspicion. Reece et al.[8]
defined four common symptoms and findings. These are; abdominal pain, adnexal mass,
peritoneal irritation, and increase in the size of the uterus. While Tal et al., reported
abdominal pain in 83% and abdominal tenderness with hypovolemic shock in 13% of the
heterotopic pregnancy cases and vaginal bleeding in half of the patients. Finding of vaginal
bleeding that can be concurrent in ectopic pregnancies is rarely seen in heterotopic
pregnancies on account of intact endometrium of intrauterine pregnancy.[9] Quantitative
measurements of serum beta human chorionic gonadotropin (β-HCG) levels are of no use,
because the intra-uterine pregnancy will be producing normal and increasing levels of
serum β-HCG.[10]
Abdominal pregnancy poses a serious threat to the survival of equally the mother and the
fetus. Hence it is vital that the diagnosis is made early in the pregnancy. Maternal mortality
ranges between 0 and 30 percent.[11] This is principally because of the risk of massive
hemorrhage from incomplete or entire placental separation. The placenta can be attached to
the uterine wall, bowel, mesentery, liver, spleen, bladder, and ligaments, which can
separate at anytime during pregnancy leading to heavy blood loss. The fetal outcome tends
to be poorer than the mother's with perinatal mortality ranging between 40 and 95
percent.[12] Fetal abnormalities are also high with a number of congenital malformations
being common. However, with advanced pregnancy and if the fetus is surrounded by a
normal volume of amniotic fluid, fetal outcome tends to be better.[11]
The diagnosis of abdominal pregnancy is complex. Ultrasound, when coupled with clinical
evaluation, has approximately a 50 percent success rate in the diagnosis.[3] Allibone et
al.[13] have provided guidelines for the use of USG to diagnose abdominal pregnancy; the
reported diagnostic errors in different series have ranged from 50 to 90%. In our case, USG
was able to accurately diagnose this condition. An MRI scan can also be used to confirm
the diagnosis of abdominal pregnancy. Laboratory tests such as abnormally increasing
human chorionic gonadotrophin, are not sufficiently reliable on their own to make a
diagnosis, as are signs and symptoms such as the abdominal pain and tenderness, persistent
transverse or oblique lie and palpable fetal parts.[3]
For the management of abdominal pregnancy, factors such as maternal hemodynamic
status, fetal congenital abnormality, fetal viability, gestational age at presentation, and the
availability of neonatal facilities should be considered. If the fetus is dead, surgical
intervention is generally indicated owing to the risk of infection and disseminated
intravascular coagulation. Various clinicians, however, recommend a period of observation
of 3 to 8 weeks to allow atrophy of placental vessels to occur.[14] If the fetus is alive,
laparotomy should be performed, regardless of gestational age or foetal condition.[2] The
reason is mainly based on the unpredictability of placental separation and consequential
massive haemorrhage.

CONCLUSION
To conclude, our case exemplifies the inclusion of heterotopic pregnancy in the causes of
hemoperitoneum in young females since this condition is often forgotten due to its rarity
and atypical presentations. As such high index of suspicion is required for the salvage of
the intrauterine pregnancy as well as for the accurate diagnosis at an early stage before fatal
complications occur.

Source of Support: Nil.


Conflict of Interest: None declared.

Other Sections▼
o AbstractINTRODUCTIONCASE
REPORTDISCUSSIONCONCLUSIONREFERENCESREFERENCES
1. Atrash HK, Friede A, Hogue CJ. Abdominal pregnancy in the United States: Frequency and maternal mortality.
Obstet Gynecol. 1987;69:333–7. [PubMed: 3822281]
2. Maas DA, Slabber CF. Diagnosis and treatment of advanced extra-uterine pregnancy. S Afr Med J.
1975;49:2007–10. [PubMed: 1198234]
3. Costa SD, Presley J, Bastert G. Advanced abdominal pregnancy. Obstet Gynecol Surv. 1991;46:515–25.
[PubMed: 1886705]
4. Ojeme Selo DO, GoodFellow CF. Simultaneous intrauterine and ovarian pregnancy following treatment with
clomiphene citrate. Arch Gynecol Obstet. 2002;266:232–4. [PubMed: 12192486]
5. Ceci O, Caradonna F, Loizzi P, Lobascio A, Bratta FG, Ferreri R, et al. Ultrasound diagnosis of heterotopic
pregnancy with viable fetuses. Eur J Obstet Gynecol Reprod Biol. 1993;52:229–31. [PubMed: 8163042]
6. Storeide O, Veholmen M, Eide M, Bergsjo P, Sandvei R. The incidence of ectopic pregnancy in Hordaland
County, Norway 1976-1993. Acta Obstet Gynecol Scand. 1997;76:345–9. [PubMed: 9174429]
7. Levent Tutuncu, Ercument Mungen, Murat Muhcu, Murat Sancaktar, Yusuf Ziya Yergok. Does Previous
Cesarean Delivery Increase the Risk of Ectopic Pregnancy? Perinatal Journal. 2005;13(2):105–9.
8. Reece EA, Petrie RH, Sirmans MF, Finster M, Todd WD. Combined intrauterine and extrauterine gestations: A
rewiev. Am J Obstet Gynecol. 1983;146:323–30. [PubMed: 6344638]
9. Jacobson A, Galen D. Heterotopic pregnancies and IVF. Fertil Steril. 1990;54:179–80. [PubMed: 2358088]
10. Ozgur Dundar, Levent Tutuncu, Ercument Mungen, Murat Muhcu, Yusuf Ziya Yergok. Heterotopic pregnancy:
Tubal ectopic pregnancy and monochorionic monoamniotic twin pregnancy: A case report. Perinatal Journal.
2006;14:96–100.
11. Martin JN, McCaul JF. Emergent management of abdominal pregnancy. Clin Obstet Gynecol. 1990;33:438–47.
[PubMed: 2225575]
12. Ang LP, Tan AC, Yeo SH. Abdominal pregnancy: A case report and literature review. Singapore Med J.
2000;41:454–7. [PubMed: 11193119]
13. Allibone GW, Fagan CJ, Porter SC. The sonographic features of intra-abdominal pregnancy. J Clin Ultrasound.
1981;9:383–7. [PubMed: 6792237]
14. Meinert J. Advanced ectopic pregnancy including combined ectopic and intrauterine pregnancy [in German]
Geburtshilfe Frauenheikd. 1981;41:490–5.

Figures and Tables

Figure 1
Ultrasonography showing intra-uterine pregnancy
Figure 2
Ultrasonography showing intra-abdominal pregnancy
Figure 3
Intra-abdominal fetus being delivered

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