Successful laparoscopic treatment of a ruptured primary abdominal pregnancy

Abstract

Approximately 1% of ectopic pregnancies are abdominal and may be life threatening. Although laparoscopic management of abdominal pregnancy was recently reported, laparoscopic treatment of abdominal pregnancy in patients with intraabdominal hemorrhage is a formidable challenge and has been reported only occasionally (1Uzan M Von Theobald P Lucas V Barjot P Liegeois P Levy G Ectopic abdominal pregnancy. Two cases treated by laparoscopic surgery.J Gynecol Obstet Biol Reprod Paris. 1993; 22 (in French): 429-430PubMed Google Scholar, 2Abossolo T Sommer J.C Dancoisne P Orvain E Tuaillon J Isoard L First trimester abdominal pregnancy and laparoscopic surgical treatment. Two case reports of evolving abdominal pregnancy treated with laparoscopy at 10 and 12 weeks.J Gynecol Obstet Biol Reprod (Paris). 1994; 23 (in French): 676-680PubMed Google Scholar). We report a case of ruptured abdominal pregnancy with significant intraabdominal bleeding that was successfully managed with operative laparoscopy. A 31-year-old woman, gravida 7, para 5, affirmed abortion (AA) 1, presented 7 weeks after her last menstrual period with sudden pain in the lower abdomen. Minimal bleeding 3 weeks before admission had been interpreted as menstruation. She had no previous pelvic or abdominal surgery and no history of infertility. An intrauterine device (IUD) had been introduced 1 year before admission. Physical examination revealed tenderness in the lower abdomen; a tender, normal-sized uterus; and slightly tender bilateral adnexae. The serum β-hCG level was 830 mIU/mL. Transvaginal ultrasonography showed an empty uterus, except for the IUD and an endometrium 9 mm in thickness. Both ovaries appeared normal. A hyperechogenic mass (20 × 27 × 23 mm) was observed behind the uterus on the left side. A considerable amount of free fluid was found in the lower abdomen and pelvis. The tentative diagnosis was rupture of a tubal pregnancy with intraabdominal bleeding, and laparoscopy was performed immediately. The patient was hemodynamically stable: Blood pressure was 112/60 mm Hg, pulse rate was 83 beats/min, hemoglobin level was 12.7 g/dL, and hematocrit was 40.4%. At laparoscopy, approximately 1,700 mL of blood and blood clots were removed from the pelvis by suction-irrigation. After this procedure, the uterus and both ovaries and tubes were carefully inspected; they appeared normal. No bleeding was observed from either fimbria. A 25-mm mass containing the gestational sac and placenta was adhered to the medial side of the left uterosacral ligament (Fig. 1). Active bleeding originating from a tear in the mass was observed. The gestational tissue was removed and the bleeding at the implantation site was controlled by electrocauterization using bipolar forceps. The uterus and the adnexae were left untouched. The left ureter was carefully observed throughout the procedure, and normal ureteric peristalsis was noted through the peritoneum. The patient received two units of packed red blood cells during the operation. Twenty-four hours after surgery, the patient’s serum β-hCG level decreased to 230 mIU/mL. Her recovery was uneventful, and she was discharged 48 hours after surgery. Histologic assessment of the tissue confirmed the presence of chorionic villi without any evidence of tubal tissue, confirming the diagnosis of an abdominal pregnancy. Abdominal pregnancy occurs in 1 of every 3,372 to 7,931 births (3Martin Jr, J.N Sessums J.K Martin R.W Pryor J.A Morrison J.C Abdominal pregnancy current concepts of management.Obstet Gynecol. 1988; 71: 549-557PubMed Google Scholar). The maternal mortality rate in abdominal pregnancy is 7.7 times higher than that associated with tubal ectopic pregnancy (3Martin Jr, J.N Sessums J.K Martin R.W Pryor J.A Morrison J.C Abdominal pregnancy current concepts of management.Obstet Gynecol. 1988; 71: 549-557PubMed Google Scholar). Most abdominal pregnancies result from reimplantation of a tubal abortion (3Martin Jr, J.N Sessums J.K Martin R.W Pryor J.A Morrison J.C Abdominal pregnancy current concepts of management.Obstet Gynecol. 1988; 71: 549-557PubMed Google Scholar). Our case meets the classic Studderford criteria for abdominal pregnancy: [1] normal tubes and ovaries with no evidence of injury, [2] no evidence of uteroplacental fistula, and [3] the pregnancy adhered exclusively to the peritoneal surface early enough in gestation to eliminate the possibility of secondary implantation after primary nidation in the fallopian tube. Thus, this case represents a primary abdominal pregnancy. Known risk factors for abdominal pregnancy include history of ectopic pregnancy, pelvic infection, congenital anomalies, endometriosis, and use of ART (3Martin Jr, J.N Sessums J.K Martin R.W Pryor J.A Morrison J.C Abdominal pregnancy current concepts of management.Obstet Gynecol. 1988; 71: 549-557PubMed Google Scholar). The patient in our report had none of these risk factors. Our patient was, however, carrying an IUD. Kasby and Krins (4Kasby C Krins A Primary peritoneal pregnancy in association with intrauterine contraceptive devices two case reports.Br J Obstet Gynaecol. 1978; 85: 794-795Crossref PubMed Scopus (14) Google Scholar) reported abdominal pregnancies in two patients with IUDs and discussed a third case in the literature. They suggested a possible association between the presence of an IUD and abdominal pregnancy. Vaginal bleeding and sudden, severe, abdominal pain are characteristic symptoms in patients with all forms of ectopic pregnancy, including abdominal pregnancy. Early diagnosis of abdominal pregnancy by ultrasonography has been disappointing. Our patient presented with typical symptoms of extrauterine pregnancy, which are nonspecific and were unhelpful in distinguishing between abdominal pregnancy and other forms of ectopic pregnancy. Laparotomy has been the treatment of choice in abdominal pregnancy with concurrent intraabdominal hemorrhage. The development of efficient laparoscopic instrumentation and accumulating experience and skills of laparoscopic surgeons have led to recent reports of successful management of abdominal pregnancy by laparoscopy. However, successful laparoscopic treatment of abdominal pregnancy associated with extensive intraabdominal bleeding has rarely been reported (1Uzan M Von Theobald P Lucas V Barjot P Liegeois P Levy G Ectopic abdominal pregnancy. Two cases treated by laparoscopic surgery.J Gynecol Obstet Biol Reprod Paris. 1993; 22 (in French): 429-430PubMed Google Scholar, 2Abossolo T Sommer J.C Dancoisne P Orvain E Tuaillon J Isoard L First trimester abdominal pregnancy and laparoscopic surgical treatment. Two case reports of evolving abdominal pregnancy treated with laparoscopy at 10 and 12 weeks.J Gynecol Obstet Biol Reprod (Paris). 1994; 23 (in French): 676-680PubMed Google Scholar). Our report shows that active bleeding and hemoperitoneum in abdominal pregnancy may be treated successfully by laparoscopy and that conversion from laparoscopy to laparotomy may not be necessary. Laparoscopy remains the treatment of choice in all forms of extrauterine pregnancy, even in the presence of serious intraabdominal bleeding.