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Advanced extrauterine pregnancy: diagnostic and therapeutic challenges
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OBSTETRICS
Advanced extrauterine pregnancy: diagnostic and therapeutic challenges Kevin C. Worley, MD; Michael D. Hnat, DO; F. Gary Cunningham, MD OBJECTIVE: The objective of the study was to identify women with advanced extrauterine pregnancy, specifically assessing the problems encountered with their diagnosis and management, preoperative evaluation, and surgical removal. STUDY DESIGN: This was a case series including women diagnosed
with an extrauterine pregnancy of 18 weeks’ gestation or greater at our institution from 1980 to 2005. RESULTS: We identified 10 women with advanced extrauterine preg-
nancies during the study period. Diagnosis was not optimal, and only 6 were discovered preoperatively. Despite the fact that only 3 of 10
women met diagnostic criteria for an abdominal pregnancy, surgical dissection was universally difficult, and hemorrhage was common with 9 of 10 patients requiring blood transfusions. In 2 women, the placenta was left in situ, and both developed serious complications. All 5 viable fetuses survived, but their courses were long and complicated. CONCLUSION: Irrespective of placental implantation site, an advanced extrauterine pregnancy is a serious condition. The currently accepted definition of abdominal pregnancy is too exclusive.
Key words: abdominal pregnancy, advanced ectopic pregnancy, advanced extrauterine pregnancy
Cite this article as: Worley KC, Hnat MD, Cunningham FG. Advanced extrauterine pregnancy: diagnostic and therapeutic challenges. Am J Obstet Gynecol 2008; 198:297.e1-297.e7.
A
bdominal pregnancy has historically been defined as an implantation in the peritoneal cavity, exclusive of tubal, ovarian, or intraligamentary implantations.1 Primary peritoneal implantation is rare, and proposed criteria for its diagnosis include the following: (1) normal tubes and ovaries, (2) absence of uteroplacental fistula, and (3) sufficiently early diagnosis to exclude the possibility of secondary implantation.2 Secondary implantation after tubal rupture or fimbrial abortion accounts for the majority of peritoneal implantations. Although most of these do not have sufficient trophoblastic invasion for continued support of the pregnancy,3 a few will
From the Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX. Received March 29, 2007; revised June 1, 2007; accepted Sept. 26, 2007. Reprints: Kevin Worley, MD, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd, Dallas, TX 753909032. [email protected]. 0002-9378/$34.00 © 2008 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2007.09.044
survive and the generous capacity of the abdominal cavity may allow them to progress into or beyond the second trimester. Irrespective of the actual implantation site, these larger “advanced” pregnancies present formidable diagnostic and therapeutic challenges. Their clinical presentations, as well as complications that ensue, are largely determined by the degree of anatomic distortion and the location of placental implantation. Even with its relative rarity, because of the large obstetrical service at Parkland Hospital (Dallas, TX), we have encountered a number of women with an advanced extrauterine pregnancy, some of whom had viable fetuses. Our purpose now is to describe these women who were cared for over a 25-year period. We discuss problems encountered with their diagnosis and management, preoperative evaluation, and surgical removal.
M ATERIALS AND M ETHODS After exempt status was granted from the institutional review board, we searched medical records and research files for women diagnosed with an advanced abdominal or extrauterine pregnancy who were cared for at Parkland Hospital from 1980 through 2005. Advanced extrauter-
ine pregnancy was defined as a gestation of 18 weeks or greater in which most or all of the fetus was within the abdominal cavity. This cutoff thus included only those pregnancies that had progressed well beyond the first trimester. No cases that met these criteria were excluded. Records were extracted for variables to include demographic data, medical and obstetric historical information, clinical course, diagnostic modalities, management plans, and clinical outcomes.
R ESULTS During the 25 year period, 10 women were identified to have an advanced extrauterine pregnancy of 18 weeks’ gestation or later. Pertinent clinical information is shown in the Table. These women were older than our general population and their age ranged from 20 to 40 years (mean, 31.5 years). Their parity ranged from 0 to 3 (mean, 1.2), and none had a previous ectopic pregnancy or tubal surgery. Their demographics were otherwise representative of the medically indigent population we serve, and all conceptions were spontaneous. Gestational age at time of diagnosis ranged from 18 to 43 weeks, and half of the fetuses were considered viable. Discrepan-
MARCH 2008 American Journal of Obstetrics & Gynecology
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Summary of 10 cases of advanced extrauterine pregnancy Ultrasound
Placenta
Case
Demographics
Indications
Findings
MRI
1, 1984
32-y-old black G4P3 at 35 wks with severe preeclampsia
Possible fetal growth restriction
30 wk growthrestricted fetus, severe oligohydramnios, total previa, cervical mass
Not done
Management plan Elective cesarean delivery
Surgery
Attachment
Management
Laparotomy, lysis of adhesions
Bilateral pelvic side walls, bladder
Left in situ
Intra operative transfusions 3 U RBCs, 1 U FFP
Complications
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297.e2 TABLE
Abscess of placenta at 10 postoperative weeks treated with antibiotics; failed arterial embolization followed by 3 vascular surgeries; eventual amputation of left leg
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
2, 1986
31-y-old black G3P2 at 23 wks
No fetal movement
23 wk intrauterine demise
Not done
Induction of labor followed by D&C, both of which failed
Laparotomy, lysis of adhesions (laparotomy with placental resection)1
Right pelvic side wall, sigmoid colon
Left in situ
4 U RBCs (6 U RBCs, 1U FFP) a
Abscess of placenta at 2 postoperative weeks; failed CTguided drainage; repeat laparotomy; postoperative wound infection
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
3, 1997
35-y-old black G2P0 at 15 wks
Abdominal pain
18 wk tubal vs abdominal pregnancy
Confirms, suspect mass involving colon
Medical treatment with methotrexate
Emergent laparotomy, RSO
Right pelvic side wall and broad ligament
Removed
3 U RBCs, 3 U FFP
Antepartum intraabdominal hemorrhage after 4 of 5 doses of methotrexate
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
4, 1997
27-y-old Hispanic G2P1 at 26 wks
Suspect cervical mass
26 wk left tubal vs abdominal pregnancy
Confirms. No invasion of surrounding structures
Elective laparotomy
LSO
Left fallopian tube
Removed
n/a
Continued on page 297.e3.
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TABLE
Summary of 10 cases of advanced extrauterine pregnancy Continued from page 297.e2. Surgery
Attachment
Management
Intra operative transfusions
Supracervical hysterectomy
Anterior lower uterine segment, perforating into myometrium
Removed
2 U RBCs
Left broad ligament
Removed
Ultrasound
Placenta
Case
Demographics
Indications
Findings
MRI
5, 1999
30-y-old Hispanic G2P1 at 30 wks with chronic HTN and superimposed preeclampsia
Elevated MSAFP
22.4 wk fetus with normal anatomy, possible succenturiate placenta
Not done
35-y-old Hispanic G2P1 at 43⫹ wks with severe preeclampsia
Uncertain EGA
Management plan Elective repeat cesarean delivery
Complications 5 cm cystotomy at surgery
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
6, 2000
35.7 wks, anterior placenta, megacephaly, small abdominal circumference
Not done
Induction of labor, which failed
Possible fetal growth restriction, suspect oligohydramnios
30 wk posterior CDS abdominal pregnancy, severe growth restriction, oligohydramnios
Not done
Abdominal pain, syncope
21.9 wk live fetus, uterine anomaly, fluid between bladder and placenta, hemoperitoneum
Not done
18 wk abdominal pregnancy
Confirms. No invasion of surrounding structures
Elective laparotomy
Not done
Emergent laparotomy
TAH, LSO
21 U RBCs, 12 U FFP, 6-pack platelets
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
7, 2001
28-y-old Hispanic G2P1 at 40 wks
Elective laparotomy
LSO
Left fallopian tube
Removed
2u RBCs
8, 2004
40-y-old middle eastern G3P2 at 21 wks with bicornuate uterus
Emergent laparotomy
TAH, LSO
Ruptured left uterine horn
Removed
6u RBCs
Pulmonary edema
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
9, 2005
37-y-old black G2P0 at 17 wks
Elevated MSAFP
RSO
Right fallopian tube
Removed
4u RBCs
Postoperative wound infection
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
10, 2006
20-y-old Hispanic G2P1 at 20 wks
Abdominal pain
20 wk extrauterine pregnancy, hemoperitoneum
LSO, resection of noncommunicating rudimentary horn
Ruptured left uterine horn
Removed
3u RBCs
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
a
Indicates procedure and blood product information for repeat operation.
Worley. Advanced extrauterine pregnancy. Am J Obstet Gynecol 2008.
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CDS, cul de sac; CT, computed tomography; D&C, dilation and curettage; EGA, estimated gestational age; FFP, fresh frozen plasma; G, gravida; HTN, hypertension; LSO, left salpingo-oophorectomy; MSAFP, maternal serum alpha-feto protein; n/a, data not available; P, para; RBCs, red blood cells; RSO, right salpingo-oophorectomy; TAH, total abdominal hysterectomy.
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cies in estimates of gestational age based on clinical vs ultrasound dating resulted from fetal growth restriction (patients 1 and 7) or uncertain last menstrual period dating (patient 6). No cases were managed expectantly; thus, once a diagnosis of extrauterine pregnancy was made, a surgical management plan was promptly devised. Although all of the women had at least 1 ultrasound examination, we were successful in identifying or strongly suspecting the correct diagnosis in only 6 of 10 cases (Table). In 3 of these 6 cases, magnetic resonance imaging (MRI) was used to further evaluate anatomic derangements from placental implantation. In the 4 women in whom the extrauterine pregnancy was not identified at ultrasonography, the diagnosis became apparent at time of laparotomy, either after failed induction of labor or at time of intended cesarean delivery. All 4 of these women had abnormal ultrasound findings: Patient 1 was reported to have a complete previa with a cervical mass and severe oligohydramnios; patient 2 had a fetal demise; patient 5 was reported to have a possible succenturiate placenta; and patient 6 had a fetus with megacephaly and a small abdominal circumference. MRI was sometimes a valuable adjunct to ultrasound. For patients 4 and 9, MRI findings established that there was no placental implantation into abdominal viscera or parasitization of adjacent major vessels. These findings were confirmed at laparotomy, and the placenta was removed without difficulty in each case. In patient 3, however, MRI was misleading. Because it suggested placental invasion into the colon or its mesentery, the woman was treated with preoperative methotrexate. Intraabdominal bleeding 4 days later prompted emergency laparotomy with findings of no invasion into the colon or its blood supply, and the placenta was easily removed. Although placental implantation sites were variable, they were generally confined to pelvic structures. Strictly defined, only 3 patients would have met diagnostic criteria for an abdominal pregnancy (patients 1, 2, and 5). Of these, the placental implantation site of patient 5 was directly over and perforat297.e4
www.AJOG.org ing into the previous cesarean scar, suggesting that an abdominal pregnancy resulted from an early cesarean scar separation with extrusion of the embryo. The remaining cases included 2 intraligamentous pregnancies (patients 3 and 6), 3 tubal pregnancies (patients 4, 7, and 9), and 2 ruptured uterine horn pregnancies (patients 8 and 10). In the latter 2 cases, extrusion of the amniotic sac into the abdominal cavity occurred prior to the onset of hemorrhage, and both fetuses were alive at time of diagnosis. Patient 8 had undergone genetic amniocentesis at 15 weeks and then presented with sudden-onset abdominal pain at 19 weeks. By ultrasound there was an appropriate-sized live fetus, a large fluid collection between the bladder and the placenta, and free fluid surrounding the maternal liver. The patient was stable and was discharged with suspected persistent amniotic fluid leak, but she presented to our institution 3 weeks later with abdominal pain and syncopal episodes. With ultrasound a live extrauterine fetus and hemoperitoneum were identified, and laparotomy confirmed a complete bicornuate uterus with a ruptured left uterine horn. Patient 10 was clinically stable with a presumptive diagnosis of a 20 week abdominal pregnancy. While undergoing a detailed preoperative ultrasound the following day, she became syncopal and was taken emergently to surgery. At laparotomy, a ruptured noncommunicating left uterine horn was identified and resected. Irrespective of the location of placental implantation, surgical dissection was difficult and hemorrhage common with 9 of 10 patients requiring intraoperative blood transfusions. In each case, there was an experienced obstetric faculty member present for the operation, and when needed, gynecology/oncology was consulted to assist with the procedure. In the most recent 8 women, the placenta and fetus were removed at initial operation. This practice was based on experiences from the 2 earliest patients, in which the placenta was covering the pelvic side walls, and it was left in situ to avoid injury to major underlying vessels. Both of these women developed numer-
American Journal of Obstetrics & Gynecology MARCH 2008
ous complications which are now presented:
Patient 1 Ultrasound at 30 weeks described marked oligohydramnios, total placenta previa, and a cervical mass suggestive of a leiomyoma. There were poor fetal growth and persistent oligohydramnios, and at 35 weeks, she developed severe preeclampsia. At the time of intended cesarean delivery, the abdominal pregnancy was discovered, and a healthy but growth-restricted infant was delivered. Because the placenta was adherent to the bladder, bilateral pelvic side walls, and pelvic viscera, it was left in situ. She was discharged 11 days postoperatively and 2 months later developed abdominal pain, nausea, vomiting, and chills. Intravenous antimicrobial therapy was given for a suspected intraabdominal infection, and plans were made for arterial embolization of the feeding vessels followed by surgical removal of the placenta. Attempts at embolization failed and were complicated by a left common femoral artery laceration that required arteriotomy, embolectomy, or arterial bypass on 3 occasions over the next 48 hours. Meanwhile her sepsis syndrome and clinical findings improved with antimicrobial treatment, and plans for laparotomy were canceled. Despite physical rehabilitation for chronic vascular insufficiency of the left lower extremity, chronic ischemia persisted and the limb ultimately required amputation. She was asymptomatic when last seen a year after this surgery, and the placenta was still within the abdominal cavity. Afterward she was lost to follow-up.
Patient 2 After removal of the 23 week macerated fetus at laparotomy, the placenta was left in situ because it was implanted on the right pelvic sidewall as well as on the sigmoid colon. She developed an intraabdominal abscess 2 weeks postoperatively, and after an unsuccessful attempt at computed tomography– guided drainage, a laparotomy was performed for abscess drainage and placental removal. Hemorrhage was significant and
Obstetrics
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FIGURE 1
Sagittal view of ultrasound image of an 18 week ectopic pregnancy
Ultrasound image of an 18 week ectopic pregnancy (patient 9) in the sagittal view. The fetus is noted to be outside an empty uterus (ut). Worley. Advanced extrauterine pregnancy. Am J Obstet Gynecol 2008.
required multiple blood transfusions. Subsequent readmission was required for treatment of a surgical wound infection. Neonatal outcomes were evaluated for the 5 fetuses that were born at viable gestational ages. All 5 of these survived, but their hospital courses were long and complicated. Their average hospital stay was 46 days (range 26-53 days). Although expected morbidity was common in the 3 preterm infants, the 2 term infants also had complicated hospital courses. One had meconium aspiration requiring extracorporeal membrane oxygenation and the other had severe growth restriction complicated by sepsis. Only the infant of patient 7 had deformation anomalies. She had bilateral foot valgus, upper extremity deformities, and abnormal facies with a flattened nasal bridge and nose. Chromosomal karyotyping was normal. Although improved, the infant did not have full range of motion by time of discharge. No information was available on the long-term follow-up of these infants.
C OMMENT Over a 25 year period at Parkland Hospital, 10 women were identified to have
an advanced extrauterine pregnancy of 18 weeks’ gestation or greater, and the courses of those women now described permit us to make a number of observations. First, they present significant diagnostic challenges, even with current technology. Second, their management is much more complex than that for early ectopic pregnancies. Third, in addition to the other complications observed in these women, preeclampsia occurred in nearly a third of them. Finally, significant morbidity exists for these women irrespective of the site of placental implantation, and the currently accepted definition of abdominal pregnancy is likely too exclusive. A high index of suspicion is warranted with advanced extrauterine gestations because they cause symptoms that are often vague and nonspecific. Presenting complaints may include abdominal pain, nausea and vomiting, bleeding, or decreasing to absent fetal movements,1,2 but some women will be asymptomatic. Findings that might suggest the diagnosis include elevated levels of MSAFP, abnormal fetal lie, displaced cervix, oligohydramnios, maternal intraperitoneal fluid, and lack of uterine stimulation with oxytocin induction.4 Confirmation of the diagnosis requires imaging studies, but even with current diagnostic technology, we made the correct diagnosis in only 6 of 10 women despite the fact that all had abnormal sonographic findings. Only 6 women had ultrasound findings that Stanley et al5 reported to be the most frequent and reliable from their review. These include an empty uterus separate from the fetus, as shown in Figures 1 and 2, and an ectopic intraabdominal placenta. Although there have been marked improvements in the quality of ultrasound equipment over the course of the study period, the fact that identification of extrauterine pregnancy was not ideal in our series emphasizes the importance of confirming that a pregnancy lies within the confines of the uterus with each obstetric ultrasound examination. In addition to confirming the diagnosis, imaging studies may help to identify placental implantation over major vessels, bowel, or other vital structures. In
Research
FIGURE 2
Extended field of view ultrasound image of a 20 week rudimentary horn pregnancy
Extended field of view ultrasound image of a 20 week rudimentary horn pregnancy (patient 10). The live fetus (thin arrow) is outside the uterine cavity (thick arrow). The bladder (bl) is noted anterior to the uterus. Worley. Advanced extrauterine pregnancy. Am J Obstet Gynecol 2008.
the clinically stable patient, MRI may be a useful adjunct to ultrasound (Figure 3). Unfortunately, MRI has shortcomings as described with this series of women. Specifically, although we found MRI helpful in the preoperative planning for patients 4 and 9, MR images in patient 3 were suggestive of placental implantation into the cecum; however, this finding was not confirmed at surgery. Similarly, Cotter et al6 described 2 cases of abdominal pregnancy in which they were unsuccessful in localizing the placental implantation site using MRI. They reported better results with extended field-of-view sonography (Figure 2). Despite these limitations, it seems wise to perform both studies to have maximal information for surgical planning. Assessment of the gestational age and potential fetal viability is essential with advanced extrauterine pregnancies. Perinatal salvage is the exception rather than the rule with a reported mortality rate of 80-90%.7 In our current series, the gestational age was 26 weeks or more in 5 of 10 pregnancies, and these 5 survived despite protracted hospital courses. Whereas some have suggested expectant hospital management of select patients to await fetal maturity,8 we consider the risk for life-threatening hemor-
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FIGURE 3
Coronal view of T2-weighted single shot fast spin echo MRI of an 18 week extrauterine pregnancy
T2-weighted single shot fast spin echo (SSFSE) MRI of an 18 week extrauterine pregnancy (patient 9) in the coronal view. The fetal head (thin arrow) is not contained within the uterine cavity (thick arrow). The maternal bladder (bl) is inferior to these structures. The high signal intensity area superior to the uterus is an ovarian cyst. Worley. Advanced extrauterine pregnancy. Am J Obstet Gynecol 2008.
rhage too great. For example, 3 of these 10 women required emergency laparotomy for intraabdominal bleeding. Once placental implantation has been assessed, there are a number of options available. Preoperative angiographic embolization has been used successfully in women with advanced abdominal pregnancies.9-12 Similar successes have been described for the management of placenta percreta.13-17 Other preoperative considerations include the insertion of ureteral catheters, bowel preparation, assurance of sufficient blood products, and availability of a multidisciplined surgical team. Should such resources not be available, elective transfer of a woman with a known advanced extrauterine pregnancy to a tertiary care facility is appropriate. If discovery is not made until attempted cesarean delivery, then an alternative would be to defer delivery if possible, close the abdominal incision, and transfer the woman to a level III hospital. This could be done even after delivery of the fetus-neonate with the placenta left in situ if there was no bleeding. 297.e6
www.AJOG.org The principal surgical objectives include delivery of the viable fetus and careful assessment of placental implantation without provoking hemorrhage. Anatomic derangements often complicate fetal delivery and increase the risk for intraoperative injury. After delivery, placental implantation can be assessed carefully because the surrounding areas will be quite vascular, even if there is no invasion into major vessels. The 2 women in our series who were managed by leaving the placenta in situ both developed serious complications, and we prefer placental removal if at all possible, mindful that this will always incite hemorrhage of some degree. Preoperative methotrexate treatment has been described for abdominal pregnancy. Our experiences are limited to patient 3, who was given daily methotrexate therapy, but sudden placental separation with acute hemorrhage developed after 4 days. Postoperative methotrexate administration has been recommended by some if the placenta is left in situ. Others have condemned such a practice, suggesting that rapid placental destruction leads to an accumulation of necrotic debris, inviting bacterial growth.18,19 Rahman et al18 described 5 patients treated postoperatively with methotrexate. Although they had rapidly declining urinary gonadotropin levels, all 5 developed intraabdominal infections and 2 died. Because its mechanism of action is to inhibit rapidly dividing cells, methotrexate likely has limited effects on the mature placenta with its limited proliferative activity. With or without its utilization, the retained placenta will frequently undergo suppuration and require surgical removal. It is intriguing that preeclampsia developed in 3 women who had progressed into the third trimester. This phenomenon has been reported by others,20-22 and it is accepted that intrauterine implantation is not necessary for development of the preeclampsia syndrome. Certainly, abnormal implantation with ectopic placentation must be associated with defective endovascular trophoblastic invasion and vessel remodeling.23 Piering et al22 described a fascinating
American Journal of Obstetrics & Gynecology MARCH 2008
case of a woman with an abdominal pregnancy who clinically had preeclampsia for 99 days, during which time a renal biopsy demonstrated characteristic endotheliosis. Her preeclampsia resolved with placental removal, and a follow-up renal biopsy was normal. We did not use the commonly cited definition for abdominal pregnancy that would exclude tubal, broad ligament, or ovarian pregnancies, and we believe that such a distinction is not clinically relevant. In our small series of advanced extrauterine pregnancies, serious hemorrhage was nearly universal, but blood loss did not differ on the basis of placental implantation site. Thus, the surgical resection of these advanced extrauterine pregnancies, including those associated with uterine anomalies, are as challenging as the resection of most “true” abdominal pregnancies. Perhaps a more clinically useful definition of abdominal pregnancy is an extrauterine pregnancy in which all or most of the fetus develops within the abdominal cavity. Certainly our experiences suggest that all advanced extrauterine pregnancies are perilous conditions for both mother and fetus, and the risks associated with them should be appreciated by practitioners f who may encounter such patients. REFERENCES 1. Atrash AK, Friede A, Hogue CJR. Abdominal pregnancy in the United States: frequency and maternal mortality. Obstet Gynecol 1987;69: 333-7. 2. Delke I, Veridiano NP, Tancer ML. Abdominal pregnancy: review of current management and addition of 10 cases. Obstet Gynecol 1982;60:200-4. 3. Hallat JG, Grove JA. Abdominal pregnancy: a study of twenty-one consecutive cases. Am J Obstet Gynecol 1985;152:444-9. 4. Cotter A, Izquierdo L, Heredia F. Abdominal pregnancy. Available at: http://www.TheFetus. net 2002-10-22-11. 5. Stanley JH, Horger III EO, Fagan CJ, Andriole JG, Fleischer AC. Sonographic findings in abdominal pregnancy. AJR 1986;147:1043-6. 6. Cotter A, Jacques EG, Izquierdo LA. Extended field of view sonography: a useful tool in the diagnosis and management of abdominal pregnancy. J Clin Ultrasound 2004;32:207-10. 7. Cotlar AM. Extrauterine pregnancy: a historical review. Curr Surg 2000;57:484-92. 8. Tasnim N, Mahmud G. Advanced abdominal pregnancy—a diagnostic and management di-
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www.AJOG.org lemma. J Coll Physicians Surg Pak 2005; 15:493-6. 9. Cardosi RJ, Nackley AC, Londono J, Hoffman MS. Embolization for advanced abdominal pregnancy with a retained placenta. A case report. J Reprod Med 2002;47:861-3. 10. Kivikoski AI, Martin C, Weyman P, Picus D, Giudice L. Angiographic arterial embolization to control hemorrhage in abdominal pregnancy: a case report. Obstet Gynecol 1988;71:456-9. 11. Martin JN Jr, Ridgway LE 3rd, Connors JJ, Sessums JK, Martin RW, Morrison JC. Angiographic arterial embolization and computed tomography-directed drainage for the management of hemorrhage and infection with abdominal pregnancy. Obstet Gynecol 1990; 76:941-5. 12. Rahaman J, Berkowitz R, Mitty H, Gaddipati S, Brown B, Nezhat F. Minimally invasive management of an advanced abdominal pregnancy. Obstet Gynecol 2004;103:1064-8. 13. Oyelese Y, Smulian JC. Placenta previa, placenta accreta, and vasa previa. Obstet Gynecol 2006;107:927-41.
14. Hansch E, Chitkara U, McAlpine J, ElSayed Y, Dake MD, Razavi MK. Pelvic arterial embolization for control of obstetric hemorrhage: a five-year experience. Am J Obstet Gynecol 1999;180:1454-60. 15. Dubois J, Garel L, Grignon A, Lemay M, Leduc L. Placenta percreta: balloon occlusion and embolization of the internal iliac arteries to reduce intraoperative blood losses. Am J Obstet Gynecol 1997;176:723-6. 16. Kidney DD, Nguyen AM, Ahdoot D, Bickmore D, Deutsch LS, Majors C. Prophylactic perioperative hypogastric artery balloon occlusion in abnormal placentation. AJR 2001; 176:1521-4. 17. Chou MM, Hwang JI, Tseng JJ, Ho ESC. Internal iliac artery embolization before hysterectomy for placenta accreta. J Vasc Interv Radiol 2003;14:1195-9. 18. Rahman MS, Al-Suleiman SA, Rahman J, AlSibai M. Advanced abdominal pregnancy— observations in 10 cases. Obstet Gynecol 1982;59:366-72.
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19. Roberts RV, Dickinson JE, Leung Y, Charles AK. Advanced abdominal pregnancy: still an occurrence in modern medicine. Aust N Z J Obstet Gynaecol 2005;45:518-21. 20. Baehler RW, Copeland WE, Stein JH, Ferris TF. Plasma renin and aldosterone in an abdominal pregnancy with toxemia. Am J Obstet Gynecol 1975;122:545-8. 21. Moodley J, Subrayen KT, Sankar D, Pitsoe SB. Advanced extra-uterine pregnancy associated with eclampsia. a report of 2 cases. S Afr Med J 1987;71:460-1. 22. Piering WF, Garancis JG, Becker CG, Beres JA, Lemann J Jr. Preeclampsia related to a functioning extrauterine placenta: report of a case and 25-year follow-up. Am J Kidney Dis 1993;21:310-3. 23. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap LC, Wenstrom KD. Hypertensive disorders in pregnancy. In: Williams obstetrics. 22nd ed. New York: McGraw-Hill; 2005. p. 761-808.
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OBSTETRICS
Advanced extrauterine pregnancy: diagnostic and therapeutic challenges Kevin C. Worley, MD; Michael D. Hnat, DO; F. Gary Cunningham, MD OBJECTIVE: The objective of the study was to identify women with advanced extrauterine pregnancy, specifically assessing the problems encountered with their diagnosis and management, preoperative evaluation, and surgical removal. STUDY DESIGN: This was a case series including women diagnosed
with an extrauterine pregnancy of 18 weeks’ gestation or greater at our institution from 1980 to 2005. RESULTS: We identified 10 women with advanced extrauterine preg-
nancies during the study period. Diagnosis was not optimal, and only 6 were discovered preoperatively. Despite the fact that only 3 of 10
women met diagnostic criteria for an abdominal pregnancy, surgical dissection was universally difficult, and hemorrhage was common with 9 of 10 patients requiring blood transfusions. In 2 women, the placenta was left in situ, and both developed serious complications. All 5 viable fetuses survived, but their courses were long and complicated. CONCLUSION: Irrespective of placental implantation site, an advanced extrauterine pregnancy is a serious condition. The currently accepted definition of abdominal pregnancy is too exclusive.
Key words: abdominal pregnancy, advanced ectopic pregnancy, advanced extrauterine pregnancy
Cite this article as: Worley KC, Hnat MD, Cunningham FG. Advanced extrauterine pregnancy: diagnostic and therapeutic challenges. Am J Obstet Gynecol 2008; 198:297.e1-297.e7.
A
bdominal pregnancy has historically been defined as an implantation in the peritoneal cavity, exclusive of tubal, ovarian, or intraligamentary implantations.1 Primary peritoneal implantation is rare, and proposed criteria for its diagnosis include the following: (1) normal tubes and ovaries, (2) absence of uteroplacental fistula, and (3) sufficiently early diagnosis to exclude the possibility of secondary implantation.2 Secondary implantation after tubal rupture or fimbrial abortion accounts for the majority of peritoneal implantations. Although most of these do not have sufficient trophoblastic invasion for continued support of the pregnancy,3 a few will
From the Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX. Received March 29, 2007; revised June 1, 2007; accepted Sept. 26, 2007. Reprints: Kevin Worley, MD, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd, Dallas, TX 753909032. [email protected]. 0002-9378/$34.00 © 2008 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2007.09.044
survive and the generous capacity of the abdominal cavity may allow them to progress into or beyond the second trimester. Irrespective of the actual implantation site, these larger “advanced” pregnancies present formidable diagnostic and therapeutic challenges. Their clinical presentations, as well as complications that ensue, are largely determined by the degree of anatomic distortion and the location of placental implantation. Even with its relative rarity, because of the large obstetrical service at Parkland Hospital (Dallas, TX), we have encountered a number of women with an advanced extrauterine pregnancy, some of whom had viable fetuses. Our purpose now is to describe these women who were cared for over a 25-year period. We discuss problems encountered with their diagnosis and management, preoperative evaluation, and surgical removal.
M ATERIALS AND M ETHODS After exempt status was granted from the institutional review board, we searched medical records and research files for women diagnosed with an advanced abdominal or extrauterine pregnancy who were cared for at Parkland Hospital from 1980 through 2005. Advanced extrauter-
ine pregnancy was defined as a gestation of 18 weeks or greater in which most or all of the fetus was within the abdominal cavity. This cutoff thus included only those pregnancies that had progressed well beyond the first trimester. No cases that met these criteria were excluded. Records were extracted for variables to include demographic data, medical and obstetric historical information, clinical course, diagnostic modalities, management plans, and clinical outcomes.
R ESULTS During the 25 year period, 10 women were identified to have an advanced extrauterine pregnancy of 18 weeks’ gestation or later. Pertinent clinical information is shown in the Table. These women were older than our general population and their age ranged from 20 to 40 years (mean, 31.5 years). Their parity ranged from 0 to 3 (mean, 1.2), and none had a previous ectopic pregnancy or tubal surgery. Their demographics were otherwise representative of the medically indigent population we serve, and all conceptions were spontaneous. Gestational age at time of diagnosis ranged from 18 to 43 weeks, and half of the fetuses were considered viable. Discrepan-
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Summary of 10 cases of advanced extrauterine pregnancy Ultrasound
Placenta
Case
Demographics
Indications
Findings
MRI
1, 1984
32-y-old black G4P3 at 35 wks with severe preeclampsia
Possible fetal growth restriction
30 wk growthrestricted fetus, severe oligohydramnios, total previa, cervical mass
Not done
Management plan Elective cesarean delivery
Surgery
Attachment
Management
Laparotomy, lysis of adhesions
Bilateral pelvic side walls, bladder
Left in situ
Intra operative transfusions 3 U RBCs, 1 U FFP
Complications
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297.e2 TABLE
Abscess of placenta at 10 postoperative weeks treated with antibiotics; failed arterial embolization followed by 3 vascular surgeries; eventual amputation of left leg
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2, 1986
31-y-old black G3P2 at 23 wks
No fetal movement
23 wk intrauterine demise
Not done
Induction of labor followed by D&C, both of which failed
Laparotomy, lysis of adhesions (laparotomy with placental resection)1
Right pelvic side wall, sigmoid colon
Left in situ
4 U RBCs (6 U RBCs, 1U FFP) a
Abscess of placenta at 2 postoperative weeks; failed CTguided drainage; repeat laparotomy; postoperative wound infection
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
3, 1997
35-y-old black G2P0 at 15 wks
Abdominal pain
18 wk tubal vs abdominal pregnancy
Confirms, suspect mass involving colon
Medical treatment with methotrexate
Emergent laparotomy, RSO
Right pelvic side wall and broad ligament
Removed
3 U RBCs, 3 U FFP
Antepartum intraabdominal hemorrhage after 4 of 5 doses of methotrexate
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4, 1997
27-y-old Hispanic G2P1 at 26 wks
Suspect cervical mass
26 wk left tubal vs abdominal pregnancy
Confirms. No invasion of surrounding structures
Elective laparotomy
LSO
Left fallopian tube
Removed
n/a
Continued on page 297.e3.
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TABLE
Summary of 10 cases of advanced extrauterine pregnancy Continued from page 297.e2. Surgery
Attachment
Management
Intra operative transfusions
Supracervical hysterectomy
Anterior lower uterine segment, perforating into myometrium
Removed
2 U RBCs
Left broad ligament
Removed
Ultrasound
Placenta
Case
Demographics
Indications
Findings
MRI
5, 1999
30-y-old Hispanic G2P1 at 30 wks with chronic HTN and superimposed preeclampsia
Elevated MSAFP
22.4 wk fetus with normal anatomy, possible succenturiate placenta
Not done
35-y-old Hispanic G2P1 at 43⫹ wks with severe preeclampsia
Uncertain EGA
Management plan Elective repeat cesarean delivery
Complications 5 cm cystotomy at surgery
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6, 2000
35.7 wks, anterior placenta, megacephaly, small abdominal circumference
Not done
Induction of labor, which failed
Possible fetal growth restriction, suspect oligohydramnios
30 wk posterior CDS abdominal pregnancy, severe growth restriction, oligohydramnios
Not done
Abdominal pain, syncope
21.9 wk live fetus, uterine anomaly, fluid between bladder and placenta, hemoperitoneum
Not done
18 wk abdominal pregnancy
Confirms. No invasion of surrounding structures
Elective laparotomy
Not done
Emergent laparotomy
TAH, LSO
21 U RBCs, 12 U FFP, 6-pack platelets
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
7, 2001
28-y-old Hispanic G2P1 at 40 wks
Elective laparotomy
LSO
Left fallopian tube
Removed
2u RBCs
8, 2004
40-y-old middle eastern G3P2 at 21 wks with bicornuate uterus
Emergent laparotomy
TAH, LSO
Ruptured left uterine horn
Removed
6u RBCs
Pulmonary edema
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
9, 2005
37-y-old black G2P0 at 17 wks
Elevated MSAFP
RSO
Right fallopian tube
Removed
4u RBCs
Postoperative wound infection
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10, 2006
20-y-old Hispanic G2P1 at 20 wks
Abdominal pain
20 wk extrauterine pregnancy, hemoperitoneum
LSO, resection of noncommunicating rudimentary horn
Ruptured left uterine horn
Removed
3u RBCs
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
a
Indicates procedure and blood product information for repeat operation.
Worley. Advanced extrauterine pregnancy. Am J Obstet Gynecol 2008.
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CDS, cul de sac; CT, computed tomography; D&C, dilation and curettage; EGA, estimated gestational age; FFP, fresh frozen plasma; G, gravida; HTN, hypertension; LSO, left salpingo-oophorectomy; MSAFP, maternal serum alpha-feto protein; n/a, data not available; P, para; RBCs, red blood cells; RSO, right salpingo-oophorectomy; TAH, total abdominal hysterectomy.
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cies in estimates of gestational age based on clinical vs ultrasound dating resulted from fetal growth restriction (patients 1 and 7) or uncertain last menstrual period dating (patient 6). No cases were managed expectantly; thus, once a diagnosis of extrauterine pregnancy was made, a surgical management plan was promptly devised. Although all of the women had at least 1 ultrasound examination, we were successful in identifying or strongly suspecting the correct diagnosis in only 6 of 10 cases (Table). In 3 of these 6 cases, magnetic resonance imaging (MRI) was used to further evaluate anatomic derangements from placental implantation. In the 4 women in whom the extrauterine pregnancy was not identified at ultrasonography, the diagnosis became apparent at time of laparotomy, either after failed induction of labor or at time of intended cesarean delivery. All 4 of these women had abnormal ultrasound findings: Patient 1 was reported to have a complete previa with a cervical mass and severe oligohydramnios; patient 2 had a fetal demise; patient 5 was reported to have a possible succenturiate placenta; and patient 6 had a fetus with megacephaly and a small abdominal circumference. MRI was sometimes a valuable adjunct to ultrasound. For patients 4 and 9, MRI findings established that there was no placental implantation into abdominal viscera or parasitization of adjacent major vessels. These findings were confirmed at laparotomy, and the placenta was removed without difficulty in each case. In patient 3, however, MRI was misleading. Because it suggested placental invasion into the colon or its mesentery, the woman was treated with preoperative methotrexate. Intraabdominal bleeding 4 days later prompted emergency laparotomy with findings of no invasion into the colon or its blood supply, and the placenta was easily removed. Although placental implantation sites were variable, they were generally confined to pelvic structures. Strictly defined, only 3 patients would have met diagnostic criteria for an abdominal pregnancy (patients 1, 2, and 5). Of these, the placental implantation site of patient 5 was directly over and perforat297.e4
www.AJOG.org ing into the previous cesarean scar, suggesting that an abdominal pregnancy resulted from an early cesarean scar separation with extrusion of the embryo. The remaining cases included 2 intraligamentous pregnancies (patients 3 and 6), 3 tubal pregnancies (patients 4, 7, and 9), and 2 ruptured uterine horn pregnancies (patients 8 and 10). In the latter 2 cases, extrusion of the amniotic sac into the abdominal cavity occurred prior to the onset of hemorrhage, and both fetuses were alive at time of diagnosis. Patient 8 had undergone genetic amniocentesis at 15 weeks and then presented with sudden-onset abdominal pain at 19 weeks. By ultrasound there was an appropriate-sized live fetus, a large fluid collection between the bladder and the placenta, and free fluid surrounding the maternal liver. The patient was stable and was discharged with suspected persistent amniotic fluid leak, but she presented to our institution 3 weeks later with abdominal pain and syncopal episodes. With ultrasound a live extrauterine fetus and hemoperitoneum were identified, and laparotomy confirmed a complete bicornuate uterus with a ruptured left uterine horn. Patient 10 was clinically stable with a presumptive diagnosis of a 20 week abdominal pregnancy. While undergoing a detailed preoperative ultrasound the following day, she became syncopal and was taken emergently to surgery. At laparotomy, a ruptured noncommunicating left uterine horn was identified and resected. Irrespective of the location of placental implantation, surgical dissection was difficult and hemorrhage common with 9 of 10 patients requiring intraoperative blood transfusions. In each case, there was an experienced obstetric faculty member present for the operation, and when needed, gynecology/oncology was consulted to assist with the procedure. In the most recent 8 women, the placenta and fetus were removed at initial operation. This practice was based on experiences from the 2 earliest patients, in which the placenta was covering the pelvic side walls, and it was left in situ to avoid injury to major underlying vessels. Both of these women developed numer-
American Journal of Obstetrics & Gynecology MARCH 2008
ous complications which are now presented:
Patient 1 Ultrasound at 30 weeks described marked oligohydramnios, total placenta previa, and a cervical mass suggestive of a leiomyoma. There were poor fetal growth and persistent oligohydramnios, and at 35 weeks, she developed severe preeclampsia. At the time of intended cesarean delivery, the abdominal pregnancy was discovered, and a healthy but growth-restricted infant was delivered. Because the placenta was adherent to the bladder, bilateral pelvic side walls, and pelvic viscera, it was left in situ. She was discharged 11 days postoperatively and 2 months later developed abdominal pain, nausea, vomiting, and chills. Intravenous antimicrobial therapy was given for a suspected intraabdominal infection, and plans were made for arterial embolization of the feeding vessels followed by surgical removal of the placenta. Attempts at embolization failed and were complicated by a left common femoral artery laceration that required arteriotomy, embolectomy, or arterial bypass on 3 occasions over the next 48 hours. Meanwhile her sepsis syndrome and clinical findings improved with antimicrobial treatment, and plans for laparotomy were canceled. Despite physical rehabilitation for chronic vascular insufficiency of the left lower extremity, chronic ischemia persisted and the limb ultimately required amputation. She was asymptomatic when last seen a year after this surgery, and the placenta was still within the abdominal cavity. Afterward she was lost to follow-up.
Patient 2 After removal of the 23 week macerated fetus at laparotomy, the placenta was left in situ because it was implanted on the right pelvic sidewall as well as on the sigmoid colon. She developed an intraabdominal abscess 2 weeks postoperatively, and after an unsuccessful attempt at computed tomography– guided drainage, a laparotomy was performed for abscess drainage and placental removal. Hemorrhage was significant and
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FIGURE 1
Sagittal view of ultrasound image of an 18 week ectopic pregnancy
Ultrasound image of an 18 week ectopic pregnancy (patient 9) in the sagittal view. The fetus is noted to be outside an empty uterus (ut). Worley. Advanced extrauterine pregnancy. Am J Obstet Gynecol 2008.
required multiple blood transfusions. Subsequent readmission was required for treatment of a surgical wound infection. Neonatal outcomes were evaluated for the 5 fetuses that were born at viable gestational ages. All 5 of these survived, but their hospital courses were long and complicated. Their average hospital stay was 46 days (range 26-53 days). Although expected morbidity was common in the 3 preterm infants, the 2 term infants also had complicated hospital courses. One had meconium aspiration requiring extracorporeal membrane oxygenation and the other had severe growth restriction complicated by sepsis. Only the infant of patient 7 had deformation anomalies. She had bilateral foot valgus, upper extremity deformities, and abnormal facies with a flattened nasal bridge and nose. Chromosomal karyotyping was normal. Although improved, the infant did not have full range of motion by time of discharge. No information was available on the long-term follow-up of these infants.
C OMMENT Over a 25 year period at Parkland Hospital, 10 women were identified to have
an advanced extrauterine pregnancy of 18 weeks’ gestation or greater, and the courses of those women now described permit us to make a number of observations. First, they present significant diagnostic challenges, even with current technology. Second, their management is much more complex than that for early ectopic pregnancies. Third, in addition to the other complications observed in these women, preeclampsia occurred in nearly a third of them. Finally, significant morbidity exists for these women irrespective of the site of placental implantation, and the currently accepted definition of abdominal pregnancy is likely too exclusive. A high index of suspicion is warranted with advanced extrauterine gestations because they cause symptoms that are often vague and nonspecific. Presenting complaints may include abdominal pain, nausea and vomiting, bleeding, or decreasing to absent fetal movements,1,2 but some women will be asymptomatic. Findings that might suggest the diagnosis include elevated levels of MSAFP, abnormal fetal lie, displaced cervix, oligohydramnios, maternal intraperitoneal fluid, and lack of uterine stimulation with oxytocin induction.4 Confirmation of the diagnosis requires imaging studies, but even with current diagnostic technology, we made the correct diagnosis in only 6 of 10 women despite the fact that all had abnormal sonographic findings. Only 6 women had ultrasound findings that Stanley et al5 reported to be the most frequent and reliable from their review. These include an empty uterus separate from the fetus, as shown in Figures 1 and 2, and an ectopic intraabdominal placenta. Although there have been marked improvements in the quality of ultrasound equipment over the course of the study period, the fact that identification of extrauterine pregnancy was not ideal in our series emphasizes the importance of confirming that a pregnancy lies within the confines of the uterus with each obstetric ultrasound examination. In addition to confirming the diagnosis, imaging studies may help to identify placental implantation over major vessels, bowel, or other vital structures. In
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FIGURE 2
Extended field of view ultrasound image of a 20 week rudimentary horn pregnancy
Extended field of view ultrasound image of a 20 week rudimentary horn pregnancy (patient 10). The live fetus (thin arrow) is outside the uterine cavity (thick arrow). The bladder (bl) is noted anterior to the uterus. Worley. Advanced extrauterine pregnancy. Am J Obstet Gynecol 2008.
the clinically stable patient, MRI may be a useful adjunct to ultrasound (Figure 3). Unfortunately, MRI has shortcomings as described with this series of women. Specifically, although we found MRI helpful in the preoperative planning for patients 4 and 9, MR images in patient 3 were suggestive of placental implantation into the cecum; however, this finding was not confirmed at surgery. Similarly, Cotter et al6 described 2 cases of abdominal pregnancy in which they were unsuccessful in localizing the placental implantation site using MRI. They reported better results with extended field-of-view sonography (Figure 2). Despite these limitations, it seems wise to perform both studies to have maximal information for surgical planning. Assessment of the gestational age and potential fetal viability is essential with advanced extrauterine pregnancies. Perinatal salvage is the exception rather than the rule with a reported mortality rate of 80-90%.7 In our current series, the gestational age was 26 weeks or more in 5 of 10 pregnancies, and these 5 survived despite protracted hospital courses. Whereas some have suggested expectant hospital management of select patients to await fetal maturity,8 we consider the risk for life-threatening hemor-
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297.e5
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FIGURE 3
Coronal view of T2-weighted single shot fast spin echo MRI of an 18 week extrauterine pregnancy
T2-weighted single shot fast spin echo (SSFSE) MRI of an 18 week extrauterine pregnancy (patient 9) in the coronal view. The fetal head (thin arrow) is not contained within the uterine cavity (thick arrow). The maternal bladder (bl) is inferior to these structures. The high signal intensity area superior to the uterus is an ovarian cyst. Worley. Advanced extrauterine pregnancy. Am J Obstet Gynecol 2008.
rhage too great. For example, 3 of these 10 women required emergency laparotomy for intraabdominal bleeding. Once placental implantation has been assessed, there are a number of options available. Preoperative angiographic embolization has been used successfully in women with advanced abdominal pregnancies.9-12 Similar successes have been described for the management of placenta percreta.13-17 Other preoperative considerations include the insertion of ureteral catheters, bowel preparation, assurance of sufficient blood products, and availability of a multidisciplined surgical team. Should such resources not be available, elective transfer of a woman with a known advanced extrauterine pregnancy to a tertiary care facility is appropriate. If discovery is not made until attempted cesarean delivery, then an alternative would be to defer delivery if possible, close the abdominal incision, and transfer the woman to a level III hospital. This could be done even after delivery of the fetus-neonate with the placenta left in situ if there was no bleeding. 297.e6
www.AJOG.org The principal surgical objectives include delivery of the viable fetus and careful assessment of placental implantation without provoking hemorrhage. Anatomic derangements often complicate fetal delivery and increase the risk for intraoperative injury. After delivery, placental implantation can be assessed carefully because the surrounding areas will be quite vascular, even if there is no invasion into major vessels. The 2 women in our series who were managed by leaving the placenta in situ both developed serious complications, and we prefer placental removal if at all possible, mindful that this will always incite hemorrhage of some degree. Preoperative methotrexate treatment has been described for abdominal pregnancy. Our experiences are limited to patient 3, who was given daily methotrexate therapy, but sudden placental separation with acute hemorrhage developed after 4 days. Postoperative methotrexate administration has been recommended by some if the placenta is left in situ. Others have condemned such a practice, suggesting that rapid placental destruction leads to an accumulation of necrotic debris, inviting bacterial growth.18,19 Rahman et al18 described 5 patients treated postoperatively with methotrexate. Although they had rapidly declining urinary gonadotropin levels, all 5 developed intraabdominal infections and 2 died. Because its mechanism of action is to inhibit rapidly dividing cells, methotrexate likely has limited effects on the mature placenta with its limited proliferative activity. With or without its utilization, the retained placenta will frequently undergo suppuration and require surgical removal. It is intriguing that preeclampsia developed in 3 women who had progressed into the third trimester. This phenomenon has been reported by others,20-22 and it is accepted that intrauterine implantation is not necessary for development of the preeclampsia syndrome. Certainly, abnormal implantation with ectopic placentation must be associated with defective endovascular trophoblastic invasion and vessel remodeling.23 Piering et al22 described a fascinating
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case of a woman with an abdominal pregnancy who clinically had preeclampsia for 99 days, during which time a renal biopsy demonstrated characteristic endotheliosis. Her preeclampsia resolved with placental removal, and a follow-up renal biopsy was normal. We did not use the commonly cited definition for abdominal pregnancy that would exclude tubal, broad ligament, or ovarian pregnancies, and we believe that such a distinction is not clinically relevant. In our small series of advanced extrauterine pregnancies, serious hemorrhage was nearly universal, but blood loss did not differ on the basis of placental implantation site. Thus, the surgical resection of these advanced extrauterine pregnancies, including those associated with uterine anomalies, are as challenging as the resection of most “true” abdominal pregnancies. Perhaps a more clinically useful definition of abdominal pregnancy is an extrauterine pregnancy in which all or most of the fetus develops within the abdominal cavity. Certainly our experiences suggest that all advanced extrauterine pregnancies are perilous conditions for both mother and fetus, and the risks associated with them should be appreciated by practitioners f who may encounter such patients. REFERENCES 1. Atrash AK, Friede A, Hogue CJR. Abdominal pregnancy in the United States: frequency and maternal mortality. Obstet Gynecol 1987;69: 333-7. 2. Delke I, Veridiano NP, Tancer ML. Abdominal pregnancy: review of current management and addition of 10 cases. Obstet Gynecol 1982;60:200-4. 3. Hallat JG, Grove JA. Abdominal pregnancy: a study of twenty-one consecutive cases. Am J Obstet Gynecol 1985;152:444-9. 4. Cotter A, Izquierdo L, Heredia F. Abdominal pregnancy. Available at: http://www.TheFetus. net 2002-10-22-11. 5. Stanley JH, Horger III EO, Fagan CJ, Andriole JG, Fleischer AC. Sonographic findings in abdominal pregnancy. AJR 1986;147:1043-6. 6. Cotter A, Jacques EG, Izquierdo LA. Extended field of view sonography: a useful tool in the diagnosis and management of abdominal pregnancy. J Clin Ultrasound 2004;32:207-10. 7. Cotlar AM. Extrauterine pregnancy: a historical review. Curr Surg 2000;57:484-92. 8. Tasnim N, Mahmud G. Advanced abdominal pregnancy—a diagnostic and management di-
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www.AJOG.org lemma. J Coll Physicians Surg Pak 2005; 15:493-6. 9. Cardosi RJ, Nackley AC, Londono J, Hoffman MS. Embolization for advanced abdominal pregnancy with a retained placenta. A case report. J Reprod Med 2002;47:861-3. 10. Kivikoski AI, Martin C, Weyman P, Picus D, Giudice L. Angiographic arterial embolization to control hemorrhage in abdominal pregnancy: a case report. Obstet Gynecol 1988;71:456-9. 11. Martin JN Jr, Ridgway LE 3rd, Connors JJ, Sessums JK, Martin RW, Morrison JC. Angiographic arterial embolization and computed tomography-directed drainage for the management of hemorrhage and infection with abdominal pregnancy. Obstet Gynecol 1990; 76:941-5. 12. Rahaman J, Berkowitz R, Mitty H, Gaddipati S, Brown B, Nezhat F. Minimally invasive management of an advanced abdominal pregnancy. Obstet Gynecol 2004;103:1064-8. 13. Oyelese Y, Smulian JC. Placenta previa, placenta accreta, and vasa previa. Obstet Gynecol 2006;107:927-41.
14. Hansch E, Chitkara U, McAlpine J, ElSayed Y, Dake MD, Razavi MK. Pelvic arterial embolization for control of obstetric hemorrhage: a five-year experience. Am J Obstet Gynecol 1999;180:1454-60. 15. Dubois J, Garel L, Grignon A, Lemay M, Leduc L. Placenta percreta: balloon occlusion and embolization of the internal iliac arteries to reduce intraoperative blood losses. Am J Obstet Gynecol 1997;176:723-6. 16. Kidney DD, Nguyen AM, Ahdoot D, Bickmore D, Deutsch LS, Majors C. Prophylactic perioperative hypogastric artery balloon occlusion in abnormal placentation. AJR 2001; 176:1521-4. 17. Chou MM, Hwang JI, Tseng JJ, Ho ESC. Internal iliac artery embolization before hysterectomy for placenta accreta. J Vasc Interv Radiol 2003;14:1195-9. 18. Rahman MS, Al-Suleiman SA, Rahman J, AlSibai M. Advanced abdominal pregnancy— observations in 10 cases. Obstet Gynecol 1982;59:366-72.
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19. Roberts RV, Dickinson JE, Leung Y, Charles AK. Advanced abdominal pregnancy: still an occurrence in modern medicine. Aust N Z J Obstet Gynaecol 2005;45:518-21. 20. Baehler RW, Copeland WE, Stein JH, Ferris TF. Plasma renin and aldosterone in an abdominal pregnancy with toxemia. Am J Obstet Gynecol 1975;122:545-8. 21. Moodley J, Subrayen KT, Sankar D, Pitsoe SB. Advanced extra-uterine pregnancy associated with eclampsia. a report of 2 cases. S Afr Med J 1987;71:460-1. 22. Piering WF, Garancis JG, Becker CG, Beres JA, Lemann J Jr. Preeclampsia related to a functioning extrauterine placenta: report of a case and 25-year follow-up. Am J Kidney Dis 1993;21:310-3. 23. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap LC, Wenstrom KD. Hypertensive disorders in pregnancy. In: Williams obstetrics. 22nd ed. New York: McGraw-Hill; 2005. p. 761-808.
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