Ultrasound Case of Interest – August 2020

David Pigott MD., RDMS, FACEP
Co-Director UAB Emergency Ultrasound

23F transferred from outside hospital for evaluation of possible abdominal pregnancy at ~37 weeks. Clearly, this diagnosis is very rare (1-2% of ectopic pregnancies, or around 1:10,000 to 1:30,000 pregnancies) and warrants special attention. The patient reportedly knew she was pregnant but did not seek routine prenatal care. On arrival, the patient complained of severe abdominal pain. VS were notable for HR 110 but otherwise normal.

Bedside ultrasound was performed:

Clinical course

The patient was taken emergently to the OR by OB/GYN where a laparotomy was performed. Upon entering the abdomen, a live infant was found without amniotic sac or membranes. The infant was delivered in good condition and handed off to the pediatricians, and a three-vessel umbilical cord was tied and cut. The placenta was found to be densely adherent within the pelvis and plans were made to leave the placenta in situ and obtain imaging studies for possible future embolization.

Note the tortuous placental vessels seen overlying and invading the uterus in this intra-operative photo:

Following the operation but prior to transfer out of the OR, the patient became acutely unstable and re-operation was performed. Upon re-entry into the abdomen, 3L hemoperitoneum was found and supracervical hysterectomy was performed with good hemostasis. The patient required 6U PRBC, 6 plts, 1 FFP.

The patient stabilized, requiring 1U PRBC for fall in Hct. She was discharged in good condition with a normal newborn 3 days later. Pathology findings noted a ruptured cornual ectopic pregnancy that resulted in an abdominal pregnancy.

As noted above, abdominal ectopic pregnancy is exceptionally rare and is associated with marked increases in maternal mortality (90x higher than intrauterine pregnancy) and fetal mortality ranging from 40-95%. The most common clinical findings include persistent and abdominal or suprapubic pain, gastrointestinal symptoms and painful fetal movement.

A good case report and discussion of abdominal ectopic pregnancy can be found here:

Hailu FG, Yihunie GT, Essa AA, Tsega WK. Advanced abdominal pregnancy, with live fetus and severe preeclampsia, case report. BMC Pregnancy Childbirth. 2017;17(1):243.

Copyright permission has been obtained from the UAB Department of Emergency Medicine Division of Ultrasound, Dr. David C. Pigott MD Co-Director of UAB EM Emergency Ultrasound