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Missed abdominal ectopic pregnancy
The Journal of Emergency Medicine, Vol. 30, No. 2, pp. 171–174, 2006 Copyright © 2006 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/06 $–see front matter
doi:10.1016/j.jemermed.2005.04.018
Clinical Communications: OB/GYN
MISSED ABDOMINAL ECTOPIC PREGNANCY Antonio L. Brandt,
MD, MC*
and Dedra Tolson,
MD†
*Madigan Army Medical Center/University of Washington Combined Emergency Medicine Program, Tacoma, Washington and †Division of Emergency Medicine, University of Washington Medical Center, Tacoma, Washington Reprint Address: Antonio L. Brandt, MD, MC, Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, WA 98431
e Abstract—A case of a ruptured 10-week abdominal ectopic pregnancy, originally diagnosed and treated as pelvic inflammatory disease, is reported. The patient was treated surgically and recovered uneventfully. The case is discussed and a review of the literature is presented. © 2006 Elsevier Inc.
primary care physician after 1 week of pain. A bimanual examination and urinalysis were performed. No pregnancy test was performed. She was diagnosed with PID and prescribed twice-daily dosing of ciprofloxacin and metronidazole. The patient stated she had been taking her antibiotics only once daily, however. She presented to our Emergency Department (ED) with complaints of worsening pain, inability to tolerate food or liquid, nausea, and one episode of non-bilious, non-bloody emesis over the past 24 h. On review of systems, she reported subjective fevers and chills. She denied night sweats, syncope, dysuria, vaginal discharge, chest or shoulder pain, and dyspnea. She was taking only ciprofloxacin and metronidazole, had no prior surgical or medical problems, no history of intrauterine device use, no prior PID or sexually transmitted diseases, no family history of ectopic pregnancy, and a single uncomplicated vaginal delivery 20 years previously. The last menstrual period was estimated at 6 weeks before presentation and was normal except that it was shorter than usual. She denied ever using any assisted reproductive techniques or medications. The patient was hemodynamically stable with a pulse of 88 beats/min, blood pressure of 108/70 torr, temperature of 36.5°C, respiratory rate of 16 breaths/min, and oxygen saturation of 100% on room air. The abdomen was diffusely tender without rebound, guarding, or rigidity, although she did have pain with shaking of the bed. There was a thick, cloudy discharge at the cervical os with no bleeding. There was marked cervical motion
e Keywords—abdominal; ectopic; pregnancy; laparotomy; ultrasound; missed
INTRODUCTION Abdominal pregnancies are rare, with the first documented report in the book Al Tasif by Albucasis (Abu El Kassim El-Zaharawi, 1013–1106), an Andalusian (Spanish) Arab surgeon (1). Diagnosis is problematic, in part because it can frequently mimic other abdominal and pelvic pathology, including pelvic inflammatory disease (PID). Due to delays in diagnosis and difficulties in the management of abdominal pregnancy, the risk of mortality is significantly higher than for uncomplicated ectopic pregnancies.
CASE REPORT A 37-year-old woman, G1P1, presented with a history of 2 weeks of abdominal pain. The patient described it as sharp, crampy, persistent, and localized to bilateral lower quadrants and the epigastrium. She had presented to her
RECEIVED: 18 February 2004; FINAL ACCEPTED: 1 April 2005
SUBMISSION RECEIVED:
7 March 2005; 171
172
A. L. Brandt and D. Tolson
Figure 1. A close-up view of fetus estimated at 10 weeks and 5 days by size.
tenderness, uterine tenderness, and bilateral adnexal tenderness. There were no palpable masses. Intravenous access was obtained, and laboratory tests were performed. The electrolytes, glucose, renal function, and liver function tests were all within normal limits. The white blood cell (WBC) count was 11,000/cc3 without a left shift, and the hematocrit (Hct) was 32%. A quantitative human chorionic gonadotropin (hCG) test was 104,056 mIU/mL, and rhesus factor (Rh) positive. Transvaginal and transabdominal pelvic ultrasounds were performed, which revealed a live fetus of 11 weeks estimate gestational age (crown-rump length of 38 mm) in the cul-de-sac (rectouterine pouch) (Figures 1 and 2).
The obstetric service was consulted, and the patient was immediately taken to the operating room for laparotomy, where a ruptured ampullary pregnancy and 400 cc of blood was found with secondary reimplantation in the cul-de-sac.
EPIDEMIOLOGY AND PATHOPHYSIOLOGY Abdominal pregnancy accounts for 0.6 to 4% of all ectopic pregnancies, and 1 in 3372 to 1 in 21,439 live births (2–10). Of these, most are secondary; that is, they result from the reimplantation of a ruptured tubal or
Figure 2. A view clearly displaying the fetus outside the uterus and in the abdominal cavity.
Abdominal Pregnancy
ampullary pregnancy, as in this case (11). A small proportion are primary, with normal Fallopian tubes and adnexa and no evidence of recent or remote injury (12). Most of these are in the cul-de-sac, with placental attachment to the rectal or uterine serosa, although the conceptus will very rarely travel to distant parts of the abdomen and attach to the omentum, aorta, peritoneum, or any other vascular portion of the intrabdominal anatomy (13). Maternal mortality rates range from 0 to over 50%, with the largest series reporting an 8- to 17-fold increase over mortality rates reported for tubal pregnancies (6,14 –17). Some fetuses live to term, with overall fetal mortality rates reported to range from 40% to 95% (6,14,15). Risk factors for abdominal ectopic pregnancy are similar to those for tubal ectopic pregnancies (18,19). Abdominal pregnancy has even been reported after hysterectomy, and should be considered in any woman with an acute abdomen and any remaining ovarian tissue (5,6,14,20 –22).
CLINICAL PRESENTATION The presenting symptoms of abdominal ectopic pregnancy are similar to tubal ectopic pregnancy, with lower abdominal pain, amenorrhea, and vaginal bleeding the most common presenting symptoms in most series (23– 25). In addition, early satiety, nausea, vomiting, diarrhea, rectal bleeding, or constipation are also common with abdominal pregnancy, due to gastrointestinal irritation or obstruction (9,17,26 –28). Physical signs are similar to tubal ectopic pregnancy, with the addition of palpable masses or perhaps even fetal parts in the abdomen or cul-de-sac, a uterus separately palpable from the fetus, or rectal or cul-de-sac tenderness (23–25).
DIAGNOSIS AND MANAGEMENT Due to its rarity and frequently bizarre presentations, abdominal pregnancy is typically not suspected at its first presentation. Of all the tests available, the cornerstone to diagnosis is the pregnancy test: all female patients of childbearing age with symptoms potentially referable to an ectopic pregnancy (e.g., syncope or light-headedness, chest or shoulder pain, vomiting or diarrhea, bowel obstruction, or abdominal or groin pain) should have a pregnancy test performed. With concerning symptoms and a positive pregnancy test, further testing is usually warranted. In the ED, the test of choice is usually ultrasonography. Unfortunately,
173
even in the hands of experts, its sensitivity for abdominal pregnancy is variable, ranging from 50% to 90% (14,29 – 31). Critical sonographic features of abdominal pregnancy (in decreasing order of occurrence) are fetal parts lying outside the uterus, an extrauterine placenta, oligohydramnios, close approximation of fetal parts to maternal abdominal wall, fetal malpresentation (transverse lie), lack of uterine wall between products of conception and maternal bladder, maternal peritoneal fluid, and fetal death (29). The unreliability of ultrasound diagnosis of abdominal pregnancy has led to the occasional use of magnetic resonance imaging (MRI). Its advantages over laparascopy are readily apparent: avoidance of radiation and the operative risks of laparascopy. However, laparascopy remains the standard for diagnosis, particularly for the hemodynamically unstable patient, and can be easily converted to laparotomy if needed.
SUMMARY Pregnancy tests are critical in the evaluation of women with abdominal complaints, and it should not be assumed that the first (or second or third) physician who has seen a patient has performed a pregnancy test. Abdominal pregnancies in particular may present very late in pregnancy, and it should not be assumed that a viable infant cannot be delivered once the diagnosis of abdominal ectopic pregnancy is made. Unfortunately, there are many pitfalls in diagnosing abdominal pregnancy by ultrasound, and MRI, laparascopy or laparotomy is required to make a definitive diagnosis of abdominal pregnancy.
REFERENCES 1. Attapattu JAF, Menon S. Abdominal pregnancy. Int J Gynaecol Obstet 1993;43:51–5. 2. Alto WA. Abdominal pregnancy. Am Fam Physician 1990;41: 209 –14. 3. Strafford JG, Ragan WD. Abdominal pregnancy: review of current management. Obstet Gynecol 1977;50:548. 4. Tsai HD, Chen HY, Yeh LS. A 12-year survey of 681 ectopic pregnancies. Zhonghua Yi Xue Za Zhi (Taipei) 1995;55:457– 62. 5. Costa SD, Presley J, Bastert G. Advanced abdominal pregnancy. Obstet Gynecol Surv 1991;46:515–25. 6. Atrash HK, Friede A, Hogue CJR. Abdominal pregnancy in the United States: frequency and maternal mortality. Obstet Gynecol 1987;69:333. 7. Dover RW, Powell MD. Management of primary abdominal pregnancy. Am J Obstet Gynecol 1995;172:1603– 4. 8. Ombelet W, Vandermerwe JV, Van Assche FA. Advanced extrauterine pregnancy: description of 38 cases with literature survery. Obstet Gynecol Surv 1988;43:386 –97. 9. Sfar E, Kaabar H, Marrakechi O, et al. Abdominal pregnancy, a rare anatomoclinical entity, 4 case reports 1981–1990. Rev Fr Gynaecol Obstet 1993;88:261–5.
174 10. Cetin MT, Aridogan N, Coskun A. Abdominal pregnancy, six personal cases. Rev Fr Gynecol Obstet 1992; 87:76 – 8. 11. Hallatt JG, Grove JA. Abdominal pregnancy: a study of twentyone consecutive cases. Am J Obstet Gynecol 1985;152:444 –9. 12. Studdiford WE. Primary peritoneal pregnancy. Am J Obstet Gynecol 1942;44:487–91. 13. Cavanagh D. Primary peritoneal pregnancy. Am J Obstet Gynecol 1958;76:523– 4. 14. Martin JN Jr, Sessums JK, Martin RW, Pryor JA, Morrison JC. Abdominal pregnancy: current concepts of management. Obstet Gynecol 1988;71:549 –57. 15. Hibbard LT. The management of secondary abdominal pregnancy. Am J Obstet Gynecol 1957;74:543. 16. Speroff L, Glass RH, Kase NG. Ectopic pregnancy. In: Speroff L, ed. Clinical gynecologic endocrinology and infertility. Baltimore: Williams & Williams; 1994:947. 17. Bornman PC, Collins JS, Abrahamson MJ, Gilinsky NH. Live abdominal pregnancy presenting as massive rectal bleeding. Postgrad Med J 1985;61:759 – 60. 18. Pisarska MD, Carson SA, Buster JE. Ectopic pregnancy. Lancet 1998;351:1115–20. 19. Marchbanks PA, Annegers JF, Coulam CB, Strathy JH, Kurland LT. Risk factors for ectopic pregnancy. A population-based study. JAMA 1988;259:1823–7. 20. Hsieh CH, Hsu TY, Changchien CC. Abdominal pregnancy— report of two cases and review of the literature. Changgeng Yi Xue Za Zhi 1994;17:268 –75. 21. Rahman MS, Al-Suleiman SA, Rahman J, Al-Sibai MH. Advanced
A. L. Brandt and D. Tolson
22.
23. 24. 25.
26.
27.
28. 29.
30. 31.
abdominal pregnancy— observations in 10 cases. Obstet Gynecol 1982;59:366 –72. Jackson P, Barrowclough IW, France JT, Phillips LI. A successful pregnancy following total hysterectomy. Br J Obstet Gynecol 1980;87:353–5. Cornell EL, Lash AF. Abdominal pregnancy. Surg Gynecol Obstet, Int Abstr Surg 1983;57:98. Radman HM. Abdominal pregnancy: pathogenesis, diagnosis and treatment. South Med J 1978;71:670. Delke I, Veridiano NP, Tancer ML. Abdominal pregnancy: review of current management and addition of ten cases. Obstet Gynecol 1982;60:200. Saravanane C, Robinson Smile S, Chandra SS, Habeebullah S. Rectal bleeding: a rare complication of abdominal pregnancy. Aust N Z J Obstet Gynaecol 1997;37:124 –5. Edgar J. Ectopic gestation with formation of large hematocele and secondary rupture into upper third of sigmoid flexure. Glasgow Med J 1901;56:143– 4. Seow C, Goh HS, Sim CS. Massive bleeding from rectum from a caecal pregnancy. Ann Acad Med Singapore 1992;21:818 –20. Stanley JH, Horger EO 3rd, Fagan CJ, Andriole JG, Fleischer AC. Sonographic findings in abdominal pregnancy. Am J Radiol 1986; 147:1043– 6. Ali V, Saldana L. Pitfalls in sonographic diagnosis of abdominal pregnancy. South Med J 1981;74:4771. Mbura JS, Mgaya HN. Advanced abdominal pregnancy in Muhimbili Medical Centre, Tanzania. Int J Gynecol Obstet 1986;24:169.
doi:10.1016/j.jemermed.2005.04.018
Clinical Communications: OB/GYN
MISSED ABDOMINAL ECTOPIC PREGNANCY Antonio L. Brandt,
MD, MC*
and Dedra Tolson,
MD†
*Madigan Army Medical Center/University of Washington Combined Emergency Medicine Program, Tacoma, Washington and †Division of Emergency Medicine, University of Washington Medical Center, Tacoma, Washington Reprint Address: Antonio L. Brandt, MD, MC, Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, WA 98431
e Abstract—A case of a ruptured 10-week abdominal ectopic pregnancy, originally diagnosed and treated as pelvic inflammatory disease, is reported. The patient was treated surgically and recovered uneventfully. The case is discussed and a review of the literature is presented. © 2006 Elsevier Inc.
primary care physician after 1 week of pain. A bimanual examination and urinalysis were performed. No pregnancy test was performed. She was diagnosed with PID and prescribed twice-daily dosing of ciprofloxacin and metronidazole. The patient stated she had been taking her antibiotics only once daily, however. She presented to our Emergency Department (ED) with complaints of worsening pain, inability to tolerate food or liquid, nausea, and one episode of non-bilious, non-bloody emesis over the past 24 h. On review of systems, she reported subjective fevers and chills. She denied night sweats, syncope, dysuria, vaginal discharge, chest or shoulder pain, and dyspnea. She was taking only ciprofloxacin and metronidazole, had no prior surgical or medical problems, no history of intrauterine device use, no prior PID or sexually transmitted diseases, no family history of ectopic pregnancy, and a single uncomplicated vaginal delivery 20 years previously. The last menstrual period was estimated at 6 weeks before presentation and was normal except that it was shorter than usual. She denied ever using any assisted reproductive techniques or medications. The patient was hemodynamically stable with a pulse of 88 beats/min, blood pressure of 108/70 torr, temperature of 36.5°C, respiratory rate of 16 breaths/min, and oxygen saturation of 100% on room air. The abdomen was diffusely tender without rebound, guarding, or rigidity, although she did have pain with shaking of the bed. There was a thick, cloudy discharge at the cervical os with no bleeding. There was marked cervical motion
e Keywords—abdominal; ectopic; pregnancy; laparotomy; ultrasound; missed
INTRODUCTION Abdominal pregnancies are rare, with the first documented report in the book Al Tasif by Albucasis (Abu El Kassim El-Zaharawi, 1013–1106), an Andalusian (Spanish) Arab surgeon (1). Diagnosis is problematic, in part because it can frequently mimic other abdominal and pelvic pathology, including pelvic inflammatory disease (PID). Due to delays in diagnosis and difficulties in the management of abdominal pregnancy, the risk of mortality is significantly higher than for uncomplicated ectopic pregnancies.
CASE REPORT A 37-year-old woman, G1P1, presented with a history of 2 weeks of abdominal pain. The patient described it as sharp, crampy, persistent, and localized to bilateral lower quadrants and the epigastrium. She had presented to her
RECEIVED: 18 February 2004; FINAL ACCEPTED: 1 April 2005
SUBMISSION RECEIVED:
7 March 2005; 171
172
A. L. Brandt and D. Tolson
Figure 1. A close-up view of fetus estimated at 10 weeks and 5 days by size.
tenderness, uterine tenderness, and bilateral adnexal tenderness. There were no palpable masses. Intravenous access was obtained, and laboratory tests were performed. The electrolytes, glucose, renal function, and liver function tests were all within normal limits. The white blood cell (WBC) count was 11,000/cc3 without a left shift, and the hematocrit (Hct) was 32%. A quantitative human chorionic gonadotropin (hCG) test was 104,056 mIU/mL, and rhesus factor (Rh) positive. Transvaginal and transabdominal pelvic ultrasounds were performed, which revealed a live fetus of 11 weeks estimate gestational age (crown-rump length of 38 mm) in the cul-de-sac (rectouterine pouch) (Figures 1 and 2).
The obstetric service was consulted, and the patient was immediately taken to the operating room for laparotomy, where a ruptured ampullary pregnancy and 400 cc of blood was found with secondary reimplantation in the cul-de-sac.
EPIDEMIOLOGY AND PATHOPHYSIOLOGY Abdominal pregnancy accounts for 0.6 to 4% of all ectopic pregnancies, and 1 in 3372 to 1 in 21,439 live births (2–10). Of these, most are secondary; that is, they result from the reimplantation of a ruptured tubal or
Figure 2. A view clearly displaying the fetus outside the uterus and in the abdominal cavity.
Abdominal Pregnancy
ampullary pregnancy, as in this case (11). A small proportion are primary, with normal Fallopian tubes and adnexa and no evidence of recent or remote injury (12). Most of these are in the cul-de-sac, with placental attachment to the rectal or uterine serosa, although the conceptus will very rarely travel to distant parts of the abdomen and attach to the omentum, aorta, peritoneum, or any other vascular portion of the intrabdominal anatomy (13). Maternal mortality rates range from 0 to over 50%, with the largest series reporting an 8- to 17-fold increase over mortality rates reported for tubal pregnancies (6,14 –17). Some fetuses live to term, with overall fetal mortality rates reported to range from 40% to 95% (6,14,15). Risk factors for abdominal ectopic pregnancy are similar to those for tubal ectopic pregnancies (18,19). Abdominal pregnancy has even been reported after hysterectomy, and should be considered in any woman with an acute abdomen and any remaining ovarian tissue (5,6,14,20 –22).
CLINICAL PRESENTATION The presenting symptoms of abdominal ectopic pregnancy are similar to tubal ectopic pregnancy, with lower abdominal pain, amenorrhea, and vaginal bleeding the most common presenting symptoms in most series (23– 25). In addition, early satiety, nausea, vomiting, diarrhea, rectal bleeding, or constipation are also common with abdominal pregnancy, due to gastrointestinal irritation or obstruction (9,17,26 –28). Physical signs are similar to tubal ectopic pregnancy, with the addition of palpable masses or perhaps even fetal parts in the abdomen or cul-de-sac, a uterus separately palpable from the fetus, or rectal or cul-de-sac tenderness (23–25).
DIAGNOSIS AND MANAGEMENT Due to its rarity and frequently bizarre presentations, abdominal pregnancy is typically not suspected at its first presentation. Of all the tests available, the cornerstone to diagnosis is the pregnancy test: all female patients of childbearing age with symptoms potentially referable to an ectopic pregnancy (e.g., syncope or light-headedness, chest or shoulder pain, vomiting or diarrhea, bowel obstruction, or abdominal or groin pain) should have a pregnancy test performed. With concerning symptoms and a positive pregnancy test, further testing is usually warranted. In the ED, the test of choice is usually ultrasonography. Unfortunately,
173
even in the hands of experts, its sensitivity for abdominal pregnancy is variable, ranging from 50% to 90% (14,29 – 31). Critical sonographic features of abdominal pregnancy (in decreasing order of occurrence) are fetal parts lying outside the uterus, an extrauterine placenta, oligohydramnios, close approximation of fetal parts to maternal abdominal wall, fetal malpresentation (transverse lie), lack of uterine wall between products of conception and maternal bladder, maternal peritoneal fluid, and fetal death (29). The unreliability of ultrasound diagnosis of abdominal pregnancy has led to the occasional use of magnetic resonance imaging (MRI). Its advantages over laparascopy are readily apparent: avoidance of radiation and the operative risks of laparascopy. However, laparascopy remains the standard for diagnosis, particularly for the hemodynamically unstable patient, and can be easily converted to laparotomy if needed.
SUMMARY Pregnancy tests are critical in the evaluation of women with abdominal complaints, and it should not be assumed that the first (or second or third) physician who has seen a patient has performed a pregnancy test. Abdominal pregnancies in particular may present very late in pregnancy, and it should not be assumed that a viable infant cannot be delivered once the diagnosis of abdominal ectopic pregnancy is made. Unfortunately, there are many pitfalls in diagnosing abdominal pregnancy by ultrasound, and MRI, laparascopy or laparotomy is required to make a definitive diagnosis of abdominal pregnancy.
REFERENCES 1. Attapattu JAF, Menon S. Abdominal pregnancy. Int J Gynaecol Obstet 1993;43:51–5. 2. Alto WA. Abdominal pregnancy. Am Fam Physician 1990;41: 209 –14. 3. Strafford JG, Ragan WD. Abdominal pregnancy: review of current management. Obstet Gynecol 1977;50:548. 4. Tsai HD, Chen HY, Yeh LS. A 12-year survey of 681 ectopic pregnancies. Zhonghua Yi Xue Za Zhi (Taipei) 1995;55:457– 62. 5. Costa SD, Presley J, Bastert G. Advanced abdominal pregnancy. Obstet Gynecol Surv 1991;46:515–25. 6. Atrash HK, Friede A, Hogue CJR. Abdominal pregnancy in the United States: frequency and maternal mortality. Obstet Gynecol 1987;69:333. 7. Dover RW, Powell MD. Management of primary abdominal pregnancy. Am J Obstet Gynecol 1995;172:1603– 4. 8. Ombelet W, Vandermerwe JV, Van Assche FA. Advanced extrauterine pregnancy: description of 38 cases with literature survery. Obstet Gynecol Surv 1988;43:386 –97. 9. Sfar E, Kaabar H, Marrakechi O, et al. Abdominal pregnancy, a rare anatomoclinical entity, 4 case reports 1981–1990. Rev Fr Gynaecol Obstet 1993;88:261–5.
174 10. Cetin MT, Aridogan N, Coskun A. Abdominal pregnancy, six personal cases. Rev Fr Gynecol Obstet 1992; 87:76 – 8. 11. Hallatt JG, Grove JA. Abdominal pregnancy: a study of twentyone consecutive cases. Am J Obstet Gynecol 1985;152:444 –9. 12. Studdiford WE. Primary peritoneal pregnancy. Am J Obstet Gynecol 1942;44:487–91. 13. Cavanagh D. Primary peritoneal pregnancy. Am J Obstet Gynecol 1958;76:523– 4. 14. Martin JN Jr, Sessums JK, Martin RW, Pryor JA, Morrison JC. Abdominal pregnancy: current concepts of management. Obstet Gynecol 1988;71:549 –57. 15. Hibbard LT. The management of secondary abdominal pregnancy. Am J Obstet Gynecol 1957;74:543. 16. Speroff L, Glass RH, Kase NG. Ectopic pregnancy. In: Speroff L, ed. Clinical gynecologic endocrinology and infertility. Baltimore: Williams & Williams; 1994:947. 17. Bornman PC, Collins JS, Abrahamson MJ, Gilinsky NH. Live abdominal pregnancy presenting as massive rectal bleeding. Postgrad Med J 1985;61:759 – 60. 18. Pisarska MD, Carson SA, Buster JE. Ectopic pregnancy. Lancet 1998;351:1115–20. 19. Marchbanks PA, Annegers JF, Coulam CB, Strathy JH, Kurland LT. Risk factors for ectopic pregnancy. A population-based study. JAMA 1988;259:1823–7. 20. Hsieh CH, Hsu TY, Changchien CC. Abdominal pregnancy— report of two cases and review of the literature. Changgeng Yi Xue Za Zhi 1994;17:268 –75. 21. Rahman MS, Al-Suleiman SA, Rahman J, Al-Sibai MH. Advanced
A. L. Brandt and D. Tolson
22.
23. 24. 25.
26.
27.
28. 29.
30. 31.
abdominal pregnancy— observations in 10 cases. Obstet Gynecol 1982;59:366 –72. Jackson P, Barrowclough IW, France JT, Phillips LI. A successful pregnancy following total hysterectomy. Br J Obstet Gynecol 1980;87:353–5. Cornell EL, Lash AF. Abdominal pregnancy. Surg Gynecol Obstet, Int Abstr Surg 1983;57:98. Radman HM. Abdominal pregnancy: pathogenesis, diagnosis and treatment. South Med J 1978;71:670. Delke I, Veridiano NP, Tancer ML. Abdominal pregnancy: review of current management and addition of ten cases. Obstet Gynecol 1982;60:200. Saravanane C, Robinson Smile S, Chandra SS, Habeebullah S. Rectal bleeding: a rare complication of abdominal pregnancy. Aust N Z J Obstet Gynaecol 1997;37:124 –5. Edgar J. Ectopic gestation with formation of large hematocele and secondary rupture into upper third of sigmoid flexure. Glasgow Med J 1901;56:143– 4. Seow C, Goh HS, Sim CS. Massive bleeding from rectum from a caecal pregnancy. Ann Acad Med Singapore 1992;21:818 –20. Stanley JH, Horger EO 3rd, Fagan CJ, Andriole JG, Fleischer AC. Sonographic findings in abdominal pregnancy. Am J Radiol 1986; 147:1043– 6. Ali V, Saldana L. Pitfalls in sonographic diagnosis of abdominal pregnancy. South Med J 1981;74:4771. Mbura JS, Mgaya HN. Advanced abdominal pregnancy in Muhimbili Medical Centre, Tanzania. Int J Gynecol Obstet 1986;24:169.