Asymptomatic 39 Weeks Abdominal Pregnancy – Video Report of a Case Occurred in Ivory Coast Resulting in a Live Birth

Despite advances in diagnostic imaging and focused antenatal care, cases of undiagnosed abdominal pregnancies at term are still reported in obstetric practice, mostly in low- and middle-income countries [1, 2]. They are frequently missed in routine antenatal care in resource-limited settings or for few/no obstetric check-ups of the pregnant women and delayed diagnosis is usually associated with poor foetal and maternal outcomes, including death [3]. An abdominal pregnancy is a rare and highly morbid typology of extrauterine pregnancy that requires skilled management. It accounts for approximately 1% of ectopic pregnancies and ectopic pregnancies account for 1–2% of all pregnancies [4]. Asymptomatic presentation late in pregnancy is unusual and rarely results in a live birth at term with no evidence of growth restriction or preeclampsia in the mother, despite the unfavorable implantation site. In addition, abdominal pregnancies are associated with a high risk of surgical complications and postoperative morbidity [5].

Abdominal pregnancy with a normal live foetus at such an advanced gestational age is rare. Our survey of the literature revealed fewer than 10 postdated reported cases of abdominal pregnancy [1, 6], mostly in the context of under-equipped health centres. In no case is there an available video of the surgical procedure performed. The higher incidence of abdominal pregnancy in developing countries is associated with low socioeconomic status, pelvic infections and substandard or poor obstetrical care—all are more prevalent in these countries.

In this specific case, the patient did not perform any ultrasound during the poor prenatal check-ups she did, which meant that the diagnosis of abdominal pregnancy was made late in the 39th week of gestation.

Both maternal and foetal mortality rates in such cases are high, as well as the malformation rate among the affected foetus [3]. In a more fortunate health centre, particularly one with good prenatal diagnostic facilities, the planning of management, delivery and clinical outcome may well have been different despite the late presentation at 39 weeks with the benefit of a multi-disciplinary team including geneticists, neonatal intensivists, and vascular and GI surgeons complementing the obstetric teams.

Treatment is surgery. Immediate termination of pregnancy can be offered if the diagnosis is made before 20 weeks of gestation [7]. Patients diagnosed with advanced abdominal pregnancies with stable conditions can be monitored under close surveillance and surgical delivery can be scheduled at 34 weeks of gestation after lung maturity is achieved [7, 8]. Although removal of the placenta carries a higher risk of haemorrhage, a partially detached placenta can be delivered with minimal morbidity and a good maternal outcome.

Given the documented low survival rates of neonates in such cases, neonatal units must be adequately equipped and staffed to support them. The issue of removing the placenta during the operation is controversial. Treatment of the remaining placenta with methotrexate has recently been abandoned in favor of the clinical and instrumental monitoring of the patient in the short and long term. Where available, interventional radiology procedures allowing for preoperative embolization of placental vessels are helpful in preventing severe intraoperative blood loss [9] and imaging such as MRI may help clearly demonstrate placental attachments to the bowel, omentum and other intra-abdominal organs prior to surgery.

These pre-operative procedures would make the surgeon aware of what to expect at surgery and reduce the associated maternal morbidity and mortality.