Manejo expectante de gestación ectópica abdominal tras fecundación in vitro en paciente con salpinguectomía bilateral: reporte de un caso / Expectant management of abdominal ectopic pregnancy following in vitro fertilization in a patient with previous bilateral salpinguectomy: a case report

ANTECEDENTES El embarazo ectópico abdominal es el menos habitual de los embarazos ectópicos, con una prevalencia situada entre el 0.9 - 1.4%. La mortalidad materna es elevada, alcanzando un 20% y la viabilidad fetal mínima. El manejo médico en estas situaciones es complicado ya que no está bien establecido debido a su baja frecuencia. CASO CLÍNICO Mujer de 35 años, con antecedente de esterilidad por endometriosis y salpinguectomía bilateral. Tras 5 fecundaciones in vitro (FIV) consigue una primera gestación, con finalización mediante cesárea por no progresión de parto. Acude a urgencias en su segundo embarazo, logrado tras 3 (FIV), con edad gestacional de 7 semanas. Presenta sangrado vaginal escaso y la ecografía demuestra a nivel de Douglas y hacia fosa iliaca izquierda un saco gestacional de 3 cm con embrión sin latido cardiaco de 5 mm. El nivel de β-hcg es de 1477 mUI/ml. Se diagnostica de gestación ectópica abdominal y se opta por actitud expectante dada la estabilidad clínica de la paciente. En un control a las 48h la β-Hcg es de 464 mUI/ml y la paciente se mantiene estable. En controles posteriores se observan niveles descendentes de β-Hcg y tras un mes la resolución es completa. CONCLUSIÓN El embarazo ectópico abdominal es una entidad poco frecuente pero con una alta tasa de mortalidad. Aunque lo más común es optar por un abordaje quirúrgico es necesario individualizar cada caso y basarse en la clínica y las diferentes pruebas diagnósticas para seleccionar aquellos casos que se pueden beneficiar de un manejo conservador.

BACKGROUND Abdominal ectopic pregnancy accounts for only 0.9-1.4% of all ectopic pregnancies. The maternal mortality rate is high (up to 20%) and fetal viability mínimum. The managment, specially the conservatory management of these cases is difficult because of our limited experiencie due to its low frecuency. CASE PRESENTATION 35-year-old woman, with history of sterility due to endometriosis that required bilateral laparoscopic salpinguectomy. Her first pregnancy (after 5 in vitro fertilization cicles (IVF)) finalized with a caesarean section because of to the lack of labour progresion. She was admitted to our emergency department during her second pregnancy (after 3 IVF cicles), with 7 weeks of gestational age. She had a little vaginal bleeding. Ultrasound scan showed a 5mm gestational sac with a 3mm embryo without cardiac activity in the pouch of Douglas. The β-Hcg level was 1477mUI/ml. The final diagnosis was ectopic abdominal pregnancy and it was decided to undertake an expectant management because she was clinically stable. The β-Hcg level after 48 hours was 464 mUI/ml. In subsequent examinations β-Hcg showed descending levels and after one month the resolution was completed. CONCLUSION Abdominal ectopic pregnancy is very infrequent but it has a high mortality rate. The most common approach is surgical but it is necessary to study all signs and diagnostic tests to select patients that could get profit from a conservatory management.

Abdominal pregnancy in Usmanu Dan-Fodiyo university teaching hospital, Sokoto: A 10-year review

Background: Abdominal pregnancy, a rare condition with high maternal mortality (up to 50%), and even higher perinatal mortality (40 ­ 95%), is often associated with diagnostic difficulties. Objectives: To determine the mode of presentation and management of abdominal pregnancy, from cases in the Usmanu Dan-Fodiyo University Teaching Hospital (UDUTH), Sokoto. Materials and Methods: A retrospective review of the case records of all abdominal pregnancies managed in UDUTH, Sokoto, between January 2000 and December 2010. Results: During the 10-year study period, there were eight cases of abdominal pregnancies, 285 extrauterine pregnancies, and 25,506 total deliveries. All the patients were not booked for antenatal care and their ages ranged between 20 and 39 years (mean=28.1±3.4 years). The majority (88%) were grand multipara. The main presenting symptoms were persistent abdominal pain, vaginal bleeding, and prolonged pregnancy. Seven cases (87.5%) were diagnosed accurately by an ultrasound scan. There were seven perinatal deaths (87.5%) and one live birth. There was one maternal death (12.5%), which occurred in the patient whose placenta was left in-situ. Conclusion: Presence of persistent lower abdominal pain, vaginal bleeding, and prolonged pregnancy should raise the suspicion of abdominal pregnancy. Removal of the placenta, where feasible, improves the outcome of maternal health

Embarazo ectópico: variante abdominal: presentación de caso / Ectopic pregnacy: abdominal variant: case report

El embarazo abdominal es una forma rara de gestación ectópica. El riesgo de muerte materna del embarazo abdominal es ocho veces mayor que el de los embarazos ectópicos tubáricos. Presenta sintomatología inespecífica con marcado dolor abdominal de origen inexplicable. Diagnóstico dificultoso, en el cual la ecografía sólo diagnostica el 60% de los casos. El siguiente es el caso clínico de una paciente de 44 años, con dolor, distensión abdominal y metrorragia de varios días. Se realizó ecografía en la cual se observó feto extrauterino único, transverso, sin actividad cardíaca, biometría fetal para 20 semanas. Se realizó laparotomía con excéresis del saco, extracción fetal y placentaria e histeroctomía total. Un adecuado control prenatal y tratamiento oportuno permitiría la reducción de las complicaciones de este tipo de gestaciones.

Secondary abdominal pregnancy

Secondary abdominal pregnancy is a rare form of ectopic pregnancy. A 21 weeks viable secondary abdominal pregnancy after tubal rupture has been found at laparotomy. The case is reported because of its rarity

Unusual cases of cervical pregnancy and secondary abdominal pregnancy.

A 22-year-old lady, 3rd gravida presented with discomfort in the lower abdomen and bleeding per vagina following 6 months amenorrhoea. USG of abdomen showed single dead foetus of 21 weeks gestation occupying in the cervical region, endometrial cavity was empty. On laparotomy, cervical region was seen enlarged and distended and over which body of uterus lied. After bilateral internal iliac artery ligation, vertical incision was made over the body of the uterus and cervical region. During the removal of foetal parts and placenta from the cervical region, there was severe haemorrhage for which immediate total hysterectomy was necessitated. In another case, a 28-year-old primigravida was admitted to the hospital with the complaints of abdominal pain at 34 weeks of gestation and she gave history of recurrent pain abdomen throughout pregnancy. USG of abdomen showed a suspected case of secondary abdominal pregnancy. Immediate laparotomy was done and after making a transverse incision over the gestation sac, a live foetus was delivered. A bulky uterus was visible behind the gestation sac and placenta was seen situated,over a part of sigmoid colon and the greatvessels. To see the location of placenta, a part of it got separated spontaneously and severe bleeding started which could not be properly controlled. She received 9 units of blood transfusion but ultimately died. The weight of the baby was 1.9 kg and it had talipes equinovarus. Baby was discharged after 5 days in good condition.

Embarazo ectópico ovárico / Ovarian ectopic pregnacy

Presentación del caso de una paciente de 36 años, multípara, que cursaba amenorrea de 7 semanas y dolor en el hipogastrio. Mediante una ecografía transvaginal se visualizó un saco gestacional con embrión sin cinética cardíaca, y se procedió a una cirugía laparoscópica.

Embarazo abdominal a término: presentación de un caso / Term abdominal pregnancy: presentation of a case

El embarazo ectópico es una entidad extremadamente peligrosa que, de no realizar un diagnóstico adecuado y un tratamiento precoz, conlleva una alta mortalidad. En las últimas décadas ha aumentado la frecuencia, oscilando entre 4,5 y 12,5 por mil embarazos. Hemos realizado un estudio retrospectivo tomando como base un caso que tuvimos la oportunidad de tratar mientras nos encontrábamos cumpliendo misión internacionalista en Guatemala. Se presenta el testimonio gráfico del mismo.

Ectopic pregnancy is an extremely dangerous entity, leading to a high mortality if an adequate diagnosis and an early treatment are not made. During the last decades its frequency has increased, oscillating form 4, 5 to 12, 5/1 000 pregnancies. We carried out a retrospective study, beginning from a case we attended when were in an international mission in Guatemala. We present a graphic testimony of the case.

Litopedión: reporte de un caso / Litopedhyon: report of one case

El Litopedion es una rara consecuencia del embarazo abdominal, donde, por pasar asintomático y escaparse al diagnóstico médico, el feto y/o sus membranas entran en un proceso de petrificación, ocurren en 0.0045% de todas las gestaciones. Se informa un caso de una paciente de 31 años a quien se le descubrió un Litopedion de término, con medidas óseas en percentiles altos, retenido en el abdomen durante 13 años. La frecuencia de embarazos extrauterinos ha aumentado, sin embargo el diagnóstico de Litopedion es menos frecuente debido a la detección temprana de los embarazos abdominales.

Grossesse abdominale au CHU de Yopougon : a propos de 10 cas colliges en trois ans

Notre etude prospective; est realisee dans le service de gynecologie obstetrique du CHU de YOPOUGON sur une periode de trois ans du ler Janvier 2000 au 31 Decembre 2002 L'objectif est de:-Etablir le profil epidemiologique des patientes.-Evaluer la frequence des grossesses abdominales.-Apporter notre experience dans la prise en charge des grossesses abdominales.Dix grossesses abdominales ont ete recensees sur la periode et elles representent 1/723 accouchements. Malgre le petit echantillonnage nous pouvons ressortir un profil des patientes les plus exposees notamment: le bas niveau socio-economique (100pour cent des cas); l'age moyen de 28 ans; la nulliparite (60pour cent des cas); les antecedents d'interruption volontaire de grossesse (70pour cent des cas) qui peut laisser entrevoir un profil infectieux.Le diagnostic est tardif 80pour cent des cas au cours du deuxieme trimestre. Il est domine par l'hemoperitoine 70pour cent des cas et par la douleur abdomino-pelvienne 90pour cent des cas.La prise en charge necessite une intervention chirurgicale. Dans notre contexte; elle a ete realisee en urgence dans 90pour cent des cas. La difficulte chirurgicale reside dans l'extirpation du placenta en fonction de son siege. Dans 100pour cent des cas elle a ete totale; associe a des gestes : hysterectomie 1pour cent; salpingectomie 2pour cent; omentectomie 1pour cent.Le pronostic maternel est bon. Par contre le pronostic foetal est catastrophique avec 100pour cent de deces.La reduction de la frequence de la grossesse abdominale passe par:-la prevention et le traitement precoce et efficace des infections genitales.-La reglementation de la pratique de l'interruption volontaire de grossesse.-le diagnostic precoce de la grossesse abdominale par la systematisation de l'echographie des le premier trimestre.Une sensibilisation du personnel medical dans ce sens parait utile

Abdominal Pregnancy [about 4 cases]

The epidemiology, diagnosis and prognosis of abdominal pregnancy are discussed based on four cases seen from 1992 to 2000. Surgery is obligatory and its difficulty is dominated by hemostasis during the extraction of the placenta which also limits the laparoscopic surgery treatment of early abdominal pregnancies. The abdominal pregnancy is of very bad fetal prognosis and at high risk for the pregnant woman

Calcified abdominal pregnancy with eighteen years of evolution: case report

CONTEXT: The lithopedion (calcified abdominal pregnancy) is a rare phenomenon and there are less than 300 cases reported in the medical literature. CASE REPORT: In this case, a 40 year-old patient had had her only pregnancy 18 years earlier, without medical assistance since then. She came to our hospital with pain and tumoral mass of approximately 20 centimeters in diameter. Complementary examinations (abdominal X-ray, ultrasonography and computerized tomography) demonstrated an extra-uterine abdominal 31-week pregnancy with calcification areas. Exploratory laparotomy was performed, with extirpation of a well-conserved fetus with partially calcified ovular membranes

Primary peritoneal pregnancy implanted on the uterosacral ligament: a case report

Peritoneal pregnancies are classified as primary and secondary. Primary implantation on the peritoneum is extremely rare in extrauterine pregnancy and is a potentially life-threatening variation of ectopic pregnancy within the peritoneal cavity, representing a grave risk to maternal health. Secondary abdominal pregnancies are by far the most common and result from tubal abortion or rupture, or less often, after uterine rupture with subsequent implantation within abdomen. Early diagnosis and appropriate surgical management, regardless of stage of gestation, appear to be important in achieving good results. We report a case of primary peritoneal pregnancy in a 28-year-old woman, who had severe lower abdominal pain one day before laparotomy for a preoperative diagnosis of ectopic pregnancy. The conceptus was implanted on the left uterosacral ligament. A fresh embryo of approximately 8 weeks' gestation was found in the conceptus.

Prenhez abdominal: relato caso / Abdominal pregnancy: report of case

A prenhez abdominal é rara, e representa aproximadamente 1 por cento de todas as gestaçöes ectópicas. Os autores apresentam um relato de caso prenhez abdominal em uma paciente de 27 anos, com 12 semanas de gestaçäo. A mesma havia sido submetida a uma interrupçäo voluntária da gestaçäo (IVG) após a OVG, a paciente deu entrada ultra-sonográfico, foi feito diagnóstico de prenhez abdominal evolutiva e sangue livre na cavidade. Os autores propöem uma discussäo sobre o tema e desenvolvem uma revisäo de literatura

Gravidez abdominal avançada / Advanced abdominal pregnancy

É relatado um caso de gravidez abdominal a termo (40 semanas), cujo diagnóstico foi realizado no ato cirúrgico (parto cesareana), que resultou em um concepto único, vivo, sexo feminino, com 3.340 gramas, APGAR 9 e 10. A recém nascida apresentava torcicolo. A placenta foi deixada na cavidade abdominal, após clampeamento e secção do cordão junto a sua inserção. A paciente e sua filha receberam alta hospitalar no trigésimo pós operatório, porém, decorridos 5 meses, a primeira retornou ao Serviço, com dor abdominal intensa e tumoração abdominal de 20cm, em região pélvica, sendo submetida a laparotomia exploradora que revelou tumor de origem placentária. Nesta entidade rara, ressaltamos aspectos de etiologia, frequência, quadro clínico, complicações, diagnóstico e conduta

Embarazo abdominal, a propósito de un caso / Abdominal pregnancy. A case report

We present a case of primary abdominal pregnancy that represented a diagnostic and therapeutic challenge because its inespecific clinical presentation. Knowledge of the differential diagnosis and the complications of abdominal pregnancy is required to avoid the mistakes that could be life threatening for the mother.

Embarazo abdominal: caso clínico y revisión / Abdominal pregnancy: Case report and review

El embarazo abdominal es una forma rara de embarazo ectópico con alta morbi-mortalidad materno fetal. Un manejo quirúrgico apropiado e individualizado de pacientes embarazadas con este problema, puede ayudar a prevenir complicaciones y mortalidad. Reportamos un caso con revisión de la literatura

Embarazo heterotópico: presentación de un caso / Heterotopic pregnancy: report of two cases

La coexistencia de un embarazo intrauterino y extrauterino se estima a nivel mundial de una en 30000 embarazos. Nosotros presentamos 2 casos. 1.- Paciente con dolor abdominal en estudio, se concluye por ultrasonido que tiene embarazo intrauterino de 6 semanas y múltiples cálculos la vesícula biliar. Dos días depués se exacerba el cuadro dolorosa, hay choque, anemia y abdomen quirúrgico. La laparotomía reveló embarazo ectópico anembrionado izquierdo abortado a cavidad abdominal. No se practicó legrado y su evolución post-operatoria fue satisfactoria. Treinta días después se practicó colecistectomía sin complicaciones. Se consideró falla diagnóstica ecográfica y no se repitieron ecografías post-operatorimente. Fue hasta las 22 semanas de gestación que se diagnosticó embarazo intrauterino y en adecuada relación con la ecografía de las 6 semanas. La condición prenatal, natal y post natal fue normal. 2.- Paciente con dolor abdominal, manchado sanguineo transvaginal, a la cual se le práctica ultrasonido encontrándose saco gestacional intra y extrauterino (tubárico derecho); ambos con embriones para 7 semanas sin actividad cardíaca. Se practica salpinguectomía derecha y legrado uterino