Abdominal pregnancy, a rare form of ectopic pregnancy, results from implantation in peritoneal cavity exclusive of tubal, ovarian or intraligamentary implantation. [1] It occurs due to secondary implantation from an aborted tubal pregnancy or as a result of intra-abdominal fertilization. According to Centres for Disease Control and Prevention, the estimated incidence of abdominal pregnancy is 1 in 10,000 live births accounting for 1.4% of all ectopic pregnancies. [2] [3] Advanced abdominal pregnancy refers to a situation where the pregnancy continues beyond 20 weeks with a fetus living, or showing signs of having once lived and developed, in mother's abdominal cavity. [4] Despite the availability of medical health facilities worldwide, the cases of advanced abdominal pregnancy associated with high fetomaternal morbidity and mortality are still encountered. Estimated maternal mortality rate is 5 per 1000 cases, about seven to eight times the mortality rate for ectopic in general. [2] The most important causes of maternal death are hemorrhagic shock, pulmonary embolism, coagulopathy, infection and bowel obstruction. [5] In a review, the survival of infants born after 30 weeks was found to be 63% [6] with 20–40% [6] [7] incidence of birth defects due to compression because of the absence of amniotic fluid buffer. Limb deficiencies and central nervous system anomalies are most common malformations while facial or cranial asymmetries and joint abnormalities are most common deformations. The management of advanced abdominal pregnancy remains controversial.

A 20-year-old primigravida presented to emergency department of our hospital at 38 weeks of gestation with complaints of pain in her abdomen off and on and an ultrasound report showing an abdominal pregnancy of 33 weeks. Patient got her regular antenatal check-up at a remote area. She felt quickening at 16th week of gestation. During her antenatal period she had occasional episodes indigestion and dull pain in abdomen. She was admitted at 22nd week of pregnancy for pain in abdomen associated with difficulty in micturition and was managed conservatively. She underwent an abdominal ultrasound examination at 19th week of gestation which showed live intrauterine pregnancy with placenta covering the internal os. A repeat abdominal ultrasound examination was done at 37th week of gestation. During this examination, abdominal pregnancy was suspected and she was referred to a tertiary hospital. General physical examination and systemic examination other than abdominal examination were unremarkable. On clinical examination of abdomen, fundal height was 34 weeks with longitudinal lie and breech presentation. Fetal parts were palpable superficially. Pelvic grip was empty and fetal heart rate was 140/min and regular.

A repeat abdominal ultrasound examination was done in our hospital which showed empty uterus deviated to left side with a single live fetus seen outside uterine cavity in transverse lie with adequate amniotic fluid in the amniotic sac surrounding it. Placenta was lying next to uterus with marked increase in vascularity in it and adjacent myometrium. Patient's hemoglobin was 11 g/dL with normal liver and kidney function tests. Four units of packed red blood cells were kept cross matched. Patient was taken up for emergency exploratory laparotomy under general anaesthesia on the same day. Abdomen was opened by right para median vertical incision extending above umbilicus. Per operatively omentum was seen covering an amniotic sac. The membranes were thick and were ruptured. Meconium stained liquor was drained out. A live baby girl was extracted as breech (Figures 1 and 2). The cord was doubly clamped, cut and tied close to its placental attachment. Birth weight was 1.5 kg and Apgar score was 9 and 9 at 1 and 5 minutes respectively. The exploration of abdomen for exact placental localization was avoided as this could have incited torrential hemorrhage. Placenta was left undisturbed. Thorough saline wash was done. Abdomen was closed in layers. The amount of surgical blood loss did not warrant any blood transfusion.

Patient stood the procedure well and remained hemodynamically stable. Her postoperative period was uneventful. Mother and baby were discharged in good health. Patient came for follow-up after one month with no fresh complaints. Abdominal ultrasound examination during follow-up visit showed involuting placental mass lying in the abdominal cavity surrounded by intestines. Postoperative counseling of the couple was done giving emphasis on contraception and need for early antenatal check ups in subsequent pregnancies.

Diagnosis and management of advanced abdominal pregnancy is still a challenge to today's medical world. But high index of suspicion aided with imaging studies can help in timely diagnosis of this rare obstetrical occurrence thereby preventing the associated life-threatening complications. Patient may present with complaints of vaginal bleeding, persistent abdominal pain and painful fetal movements. On examination, there may be abnormal presentation, easily palpable fetal parts, uneffaced and displaced cervix and palpation of abdominal mass seperate from uterus [8]. High index of suspicion is first step in the diagnosis. Increased maternal serum alpha feto protein levels add to the suspicion. [4] Ultrasonography and MRI are diagnostic modalities for confirmation of abdominal pregnancy. [8] Ultrasound will show empty uterus, absence of amniotic fluid between placenta and fetus, absence of myometrium between bladder and gestation and abnormal lie with fetal parts close to abdominal wall. [4] [8] [9] But sonographic diagnosis is missed in half of the cases [4]. Despite all, the diagnosis in most of the cases is made at time of surgery only.

Advanced abdominal pregnancy is difficult to manage. If the fetus is mature, immediate laparotomy is the definitive management but if fetus is immature and mother is in good health, one can opt for conservative management with strict surveillance giving mother's safety the primary importance. After delivering baby, the management of placenta is also controversial due to diffuse and unidentifiable blood supply of abnormally implanted placenta. Life-threatening hemorrhage during laparotomy is the main concern. If one cannot identify and ligate the vascular supply of placenta, it is preferable to leave it as such for natural regression [5] which can be monitored by ß-hCG levels and ultrasonography-the process taking several months. Methotrexate administration can lead to massive necrosis and subsequent infection. [5] Angiographic embolisation can be used to block placental vessels. [10]

It needs emphasis again that both obstetricians and radiologists should improve their skills further to diagnose these cases in time so that they do not reach to such an advanced stage where management itself becomes difficult.

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