Diagnostic Utility of Endometrial Aspiration Cytology in Women with Abnormal Uterine Bleeding.

CONTEXT: Abnormal uterine bleeding (AUB) is a common problem for which women seek gynecological consultation. Endometrial aspiration cytology (EAC) has emerged as a minimally invasive and cost-effective diagnostic procedure for screening the endometrial status of these patients that can aid in diagnosis in high-burden and resource-limited settings. AIMS: The study was conducted to evaluate the utility of EAC in women with AUB, and the cytological diagnosis was compared with the histopathology. MATERIALS AND METHODS: A total of 100 patients presenting with AUB were subjected to EAC using a 4-mm Karman's cannula. Later, they also underwent endometrial dilation and curettage. The cytology smears were evaluated for architectural and cytomorphological features. The cytological diagnoses henceforth made were compared with the histopathological diagnosis to calculate sensitivity, specificity, and diagnostic accuracy of EAC. RESULTS: EAC showed a sample adequacy of 89% viz a viz 90% for histopathology. EAC showed a sensitivity of 87.5% and 100% for diagnosing benign and malignant conditions, respectively. There was a good overall agreement between cytological and histopathological diagnosis (κ = 0.585). CONCLUSIONS: EAC is an effective and minimally invasive procedure for the primary investigation of women with AUB.

Vitamin D Status in Mothers and Their Newborns and Its Association with Pregnancy Outcomes: Experience from a Tertiary Care Center in Northern India.

OBJECTIVE: Study was planned to know vitamin D status in mothers and their newborns and effect of vitamin D deficiency on pregnancy outcome. Study design: Two hundred consecutive pregnant women with singleton pregnancy admitted to the labor ward of a tertiary care center were recruited for the study. Maternal and cord blood samples were taken and analyzed for 25(OH) D level. Maternal and fetal outcomes were studied. RESULTS: High prevalence of hypovitaminosis D was found among pregnant women. Eighty-six percentage had vitamin D deficiency, 9.5% had insufficiency, and only 4.5% had sufficient vitamin D level. Women with preeclampsia had statistically significant vitamin D deficiency and insufficiency as compared to patients who had normal blood pressure levels (p = 0.04). Cesarean section rate was significantly higher in patients with vitamin D deficiency and insufficiency compared to sufficient group (p = 0.004). Cord blood 25(OH) D levels strongly correlated with maternal serum 25 (OH) D levels (p = 0.001, correlation coefficient r = 0.84). CONCLUSIONS: This study showed a very high prevalence of hypovitaminosis D among pregnant women and excellent correlation between maternal and fetal 25(OH) D levels. Hypovitaminosis D was associated with preeclampsia, increased Cesarean rate, and low birth weight babies.

Risk Factors and Incidence of Puerperal Genital Haematomas.

INTRODUCTION: Puerperal genital haematomas although an uncommon entity but is elusive. This painful condition is not only distressing and dangerous to patient but is embarrassing to the obstetrician who has conducted the delivery. AIM: This study has been planned to evaluate the incidence and risk factors for puerperal genital haematomas. MATERIALS AND METHODS: A case control study was done from August 2005 to August 2015, of all puerperal genital haematomas. All patients, who had undergone drainage for the puerperal genital haematoma, were enrolled as cases. Two controls were chosen for each case, who had delivered immediately after the case. All the patients were evaluated for the characteristics of haematoma and the management of the same. Cases and controls were compared for the evaluation of risk factors for puerperal genital haematoma. RESULTS: During the study period 27,826 vaginal deliveries were performed in our institute. Thirty nine haematomas were drained during this period. Incidence of haematomas was one in 1,113 deliveries, in our institute. Among the puerperal haematomas, vulvovaginal was the most common type. Perineal pain was the most common complaint. To evaluate the risk factors, 77 controls were enrolled. Primigravida, hypertensive disease of pregnancy and coagulopathy were the significant risk factors with p-value of <0.01, 0.01 and 0.03 respectively. Episiotomy too was a risk factor with a p-value of 0.002. CONCLUSION: Primigravida, hypertensive disease of pregnancy, coagulopathy and episiotomy are still the most common risk factors.

Postoperative pain relief following hysterectomy: A randomized controlled trial.

BACKGROUND: Women experience moderate to severe postoperative pain following total abdominal hysterectomy (TAH). The transversus abdominis plane (TAP) block is a new modality for providing postoperative pain relief in these patients. MATERIALS AND METHODS: The present study was a single center, prospective randomized trial. After the Institutional Ethics Committee approval and informed consent, patients were randomized to either epidural group: Epidural block placement + general anesthesia (GA) or TAP group: Single shot TAP block + GA. Patients in both the groups received standard general anesthetic technique and intravenous tramadol patient-controlled analgesia in the postoperative period. Patients were monitored for tramadol consumption, visual analog scale (VAS) both at rest and on coughing, hemodynamics, and side effects at 0, 2, 4, 6, 8, 12, and 24 h postoperatively. RESULTS: The total consumption of tramadol in 24 h was greater in TAP group as compared to epidural group (68.8 [25.5] vs. 5.3 [11.6] mg, P < 0.001). The VAS scores at rest and on coughing were higher in TAP group as compared to the epidural group at 6, 8, 12, and 24 h postoperatively (P < 0.05). None of the patients in either group had any adverse effects. CONCLUSION: Epidural analgesia provided greater tramadol-sparing effect with superior analgesia postoperatively as compared to TAP block in patients up to 24 h following TAH.

Management of ovarian cysts with percutaneous aspiration and methotrexate injection.

BACKGROUND: To evaluate ultrasonographic-guided cyst aspiration and methotrexate injection in the management of simple and endometriotic ovarian cysts in selected patients. SUBJECTS AND METHODS: This prospective study was conducted in the Department of Obstetrics and Gynaecology in Government Medical College and Hospital, Chandigarh, from November 2007 to October 2009. It included 132 female patients (age range, 15-72 years; mean, 38.7 years) with simple or endometriotic ovarian cysts (3.0-10.6 cm) at ultrasonic examinations. We performed puncture and aspiration followed by methotrexate injection into the cyst. All patients were followed for 12 months. None was lost to follow-up. RESULTS: At follow-up ultrasonography, cysts had disappeared in 120 patients (90.90%) and persisted in 12 patients (9%). No major complications were observed in our study population during or after the procedure. Only 10 patients reported mild pelvic pain, and four others reported dizziness or nausea during or after the procedure. Malignant cells were not found in any of the cases at cytologic examination. We did not observe any cases of infection after the procedure. CONCLUSION: Ultrasonography-guided transabdominal aspiration of cyst fluid and subsequent methotrexate injection appears to be an alternative treatment for both simple and endometriotic ovarian cysts in selected cases.

Prediction of perinatal outcome in preeclampsia using middle cerebral artery and umbilical artery pulsatility and resistance indices.

OBJECTIVE: In preeclampsia, changes in fetal hemodynamics can be detected 2-3 weeks earlier than any changes in cardiotocogram. Thus, these Doppler changes can be used to predict perinatal outcome. The present study is planned to assess the accuracy of the middle cerebral artery to umbilical artery (UA) pulsatility index (PI) and resistance index (RI) in predicting adverse perinatal outcome in pregnancies complicated by preeclampsia. METHODS: Total of 115 and 108 pregnant women were included in preeclampsia and control group, respectively. Weekly Doppler study was done in both groups starting from 30 weeks till 36 weeks or delivery, whichever is later. RESULTS: Mean gestational age at delivery was 250 ± 13 and 273 ± 8 days, respectively, in preeclampsia and control group (p < 0.01). Thirty-four babies in preeclampsia group had been admitted to nursery; out of which three died (p < 0.01). On receiver operating characteristic analysis, MCA /UmA PI ratio and MCA /UmA RI ratio had sensitivity of 9% and 9.7% and specificity of 98% and 96.6%, respectively, for predicting adverse perinatal outcome. CONCLUSION: Doppler indices of MCA and Um A are significantly abnormal in preeclampsia. But on diagnostic statistical analysis they have good specificity but low sensitivity for detecting adverse perinatal outcome.

Comparison of analgesic efficacy of flupirtine maleate and ibuprofen in gynaecological ambulatory surgeries: A randomized controlled trial.

BACKGROUND AND AIMS: Flupirtine maleate is a centrally acting, non-opioid analgesic with unique muscle relaxant properties as compared to common analgesics. The aim of this study was to compare post-operative analgesic efficacy of flupirtine maleate and ibuprofen in patients undergoing gynaecological ambulatory surgeries. METHODS: This prospective, randomised controlled study was conducted in 60 women of American Society of Anesthesiologists physical status I/II, 18-70 years of age and scheduled to undergo gynaecological ambulatory surgeries. The participants were randomised to receive either 100 mg oral flupirtine maleate (group flupirtine, n = 30) or 800 mg oral ibuprofen (group ibuprofen, n = 30), 1 h prior to surgery and then every 8 h for 48 h. Verbal Numerical Rating Scale (VNRS) on movement was assessed at 0, 2, 4, 6 and 8 h following surgery. Following discharge from hospital, the patients were interviewed telephonically at 12, 24 and 48 h post-operatively. VNRS was statistically analysed using Mann-Whitney test. RESULTS: VNRS on movement was statistically reduced at 2 h after surgery (P = 0.04) in group flupirtine as compared to group ibuprofen. The analgesic efficacy was similar in both the groups at 4, 6, 8, 12, 24 and 48 h after surgery. The satisfaction scores at 24 and 48 h post-operatively were superior in group flupirtine as compared to group ibuprofen (P < 0.001). CONCLUSION: Analgesic efficacy of flupirtine maleate was comparable with ibuprofen in patients in ambulatory gynaecological patients up to 48 h postoperatively with superior satisfaction scores.

Dengue in pregnancy: an under-reported illness, with special reference to other existing co-infections.

OBJECTIVE: To keep the level of awareness high as far as incidence of dengue among pregnant women is concerned. METHODS: A total of 300 blood samples of patients with fever in pregnancy were received in the Department of Microbiology to rule out dengue infection (January 2011 to December 2012). The samples were put up for presence of dengue IgM antibodies and NS1Ag by ELISA. The patients who turned out to be positive for dengue serology were retrospectively analysed with respect to patient's age, gestational age, clinical presentation, complications, platelet counts and maternal as well as foetal outcomes. RESULTS: Out of 300 females tested, 22 (7.3%) were found positive for dengue infection during the said time period. Out of them 9 were positive for IgM antibodies against dengue and 10 were found to be positive for NS1Ag, while 3 were positive for both IgM antibody and NS1Ag. Five patients presented with dengue in first trimester, 9 in second trimester and 8 in third trimester. Two patients had coinfections. Patient with coinfection of dengue with malaria had intrauterine death of fetus at 37 weeks while the second one having dengue with typhoid had a preterm vaginal delivery at 35 weeks. CONCLUSIONS: Establishing diagnosis of dengue infection in pregnancy is important for effective management by the obstetricians particularly the mode of delivery due to the potential risk of hemorrhage for both the mother and the newborn. Co-infections seen in endemic areas may be more common than usually reported.

Clinical outcome of abdominal sacrocolpopexy.

INTRODUCTION: Vaginal vault prolapse is one of the distressing conditions which occur after hysterectomy. This is due to the weakness or detachment of sacrouterine cardinal ligament complex from the vaginal cuff. Till now, the most accepted procedure for this condition is sacrocolpopexy. MATERIALS AND METHODS: We present a cohort of patients who underwent abdominal sacrocolpopexy (ASC) from April 2009 to August 2013. These patients were followed till April 2014 and were evaluated for subjective and objective outcomes following ASC. RESULTS: One patient had intraoperative hemorrhage and postoperative hematoma formation. One patient had vault abscess which was managed conservatively. Hundred percent success rate was noted at 1 year. Long-term patient satisfaction score was 85 (70-90).

Perforated duodenal ulcer -a rare cause of acute abdomen in pregnancy.

Acute abdomen during pregnancy is a medico-surgical emergency demanding concerted, synchronized specialties approach of obstetrician, surgeon and gastroenterologist. Duodenal perforation is one of the rarer causes of acute abdomen in pregnancy. Here, we report a case of duodenal perforation with peritonitis in third trimester of pregnancy requiring surgical management. Our aim of reporting this case is to stress the physicians to keep the differential of duodenal perforation also in mind while dealing with cases of acute abdomen in pregnancy and to proceed with multidisciplinary approach for better feto-maternal outcome.

Second stage caesarean section: evaluation of patwardhan technique.

OBJECTIVE: To compare the maternal and neonatal morbidities between the Patwardhan technique and the routine "Push" and "Pull" method for extraction of the foetus in second stage caesarean sections. METHOD: Retrospective analysis was done of all caesarean sections performed in full dilatation of cervix in 3 years between 2004 to 2006. All the cases were divided into two groups. Group 1 being the Patwardhan technique group and Group 2 where baby was delivered as cephalic or as breech. Maternal morbidity in terms of uterine extensions, need for blood transfusions, as well as, neonatal morbidity, was compared between the two techniques. RESULTS: Review of 79 patients revealed significantly less number of uterine extensions, as well as, need for blood transfusions with Patwardhan technique, which thus amounted to a decreased maternal morbidity. However, there were no differences in neonatal outcomes in both the groups. CONCLUSION: Patwardhan technique is a superior and a safe technique for delivery of foetus in second stage caesarean sections as compared to "Push" and "Pull" methods. While foetal complications are comparable in both methods, maternal morbidities are lesser in Patwardhan technique.

Maternal serum median levels of alpha-foetoprotein, human chorionic gonadotropin & unconjugated estriol in second trimester in pregnant women from north-west India.

BACKGROUND & OBJECTIVES: Triple test as prenatal screening procedure does not form a part of routine health care of pregnant women in India. Hence, median values of triple test biomarkers are lacking for Indian population. This study was undertaken to establish population-specific medians for biomarkers viz. alpha-foetoprotien (AFP), human chorionic gonadotropin (hCGß), and unconjugated estriol (uE3) for detection of Down's syndrome, Edward's syndrome and neural tube defects (NTDs) in pregnant women in north-west India. METHODS: Serum biomarker values were derived from 5420 pregnant women between 15-20 wk of gestation who were enrolled for triple test investigations at Department of Gynecology and Obstetrics, Government Medical College and Hospital, Chandigarh, India, between January, 2007 to December, 2009. Median values were calculated for rounded weeks using database comprising pregnancies with normal outcomes only. Simple statistical analysis and log-linear regression were used for median estimation of the biomarker values. RESULTS: The levels of the three biomarkers were found to be ranging from 1.38 to 187.00 IU/ml for AFP, 1.06 to 315 ng/ml for hCGß, and 0.25 to 28.5 nmol/l for uE3. The age of women ranged from 18 to 47 yr and mean weight was 57.9 ± 9.8 kg. Data revealed that AFP, hCGß and uE3 medians in our study population were not significantly different from those reported from other countries or when compared ethnically. INTERPRETATION & CONCLUSION: The population-specific median values for the three biomarkers (AFP, hCGß, uE3) may be used as reference values during prenatal screening in Indian pregnant women.

Congenital anomalies in North Western Indian population - a fetal autopsy study

Better knowledge of unexpected fetal loss is the promise for better parental counseling and for prevention of recurrences. Fetal autopsy can provide a clue to ascertain cause of death in these cases. Variations in the incidence can be attributed to multiple factors. The present study was carried out to help us to develop a database concerning number of autopsies, incidence and types of congenital malformations (CMF) in the North-Western Indian population. The period of study was from January 2010 to November 2011. Autopsy was carried out on 150 fetuses following guidelines provided by a fetal autopsy protocol. Prior to autopsy, prenatal investigations such as ultrasound and radiographs were procured; a brief maternal and family history was noted. Out of a total of 150 autopsies, 87(58%) were induced abortions and 63(42%) spontaneous abortions. In total, the incidence of CMF was 104(69%) of fetal autopsies. The types of CMF were classified as central nervous system defects (CNS) in 49 (33%), gastrointestinal tract (GIT) disorders in 48 (32%), musuculoskeletal (MS) disorders in 31 (21%), genito-urinary (GU) in 25 (17%), and genetic disorders in 12 (8%). Multiple anomalies were present in 40 (27%) fetuses. Anencephaly (meroencephaly) turned out to be the most prevalent anomaly (29%). A few cases showed the occurrence of some uncommon syndromes. Major CMFs manifested very early in intra-uterine life, and could lead to termination of pregnancy (spontaneous or induced) in the 2nd trimester of gestation. Hence the presence of any CMF at the time of birth cannot provide the total percentage of CMF occurring in a given population. The above findings are discussed in the light of the available literature (AU)

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Vascular endothelial growth factor (VEGF) induced proliferation of human fetal derived ciliary epithelium stem cells is mediated by jagged-N cadherin pathway.

The pigmented ciliary epithelium (PCE) of mammalian eye harbors resident population of stem cells that lie in apposition with endothelial cells which release vascular endothelial growth factor (VEGF) that may influence the fate and function of these stem cells in ways that remain unclear. We examined the role of VEGF in proliferation of PCE stem cells and expression of Notch, Jagged, N-Cadherin and ß-Catenin which are known to maintain proliferation state of neural stem cells. We cultured human PCE cells obtained from 12-20 weeks old fetal eyes. The neurospheres were analyzed for the proliferation capacity of PCE stem cells in presence of VEGF on 3,6 and 9 day. Real time PCR was used to quantitate the mRNA expression of above mentioned genes on PCE derived neurospheres on 3,6 and 9 day. We found increased number of neurospheres when PCE stem cells were stimulated with VEGF along with epidermal growth factor (EGF) and basic fibroblast growth factor (bFGF) than EGF and bFGF. BrdU immunostaining was done to analyze the proliferation of CE cells and presence of neural and retinal progenitor markers such as Nestin and Pax6 were also investigated. An increased Notch and Jagged mRNA was observed on 6(th) day in VEGF, EGF and bFGF treated PCE cells as compared to 0,3 and 9 day. A similar pattern was noticed with N-cadherin and ß-catenin mRNA levels. These findings may clarify the role of VEGF on PCE stem cell proliferation with possible involvement of Notch, Jagged, N-cadherin and ß-Catenin. The data may suggest importance of harvesting 6(th) day neurospheres for transplantation purposes in preclinical investigations pertaining to retinal degenerative diseases, however, additional studies are needed to substantiate the findings.

Rudimentary horn pregnancy: a 10-year experience and review of literature.

UNLABELLED: Rudimentary horn pregnancy is rare, but can cause considerable morbidity and mortality. We discuss five cases presented to our hospital in the last 10 years and systematically review the 10-year literature of rudimentary horn pregnancies diagnosed antenatally pre-rupture. OBJECTIVES OF THE REVIEW: The aim of the review was to find radiologic investigations/criteria to diagnose rudimentary horn pregnancy antenatally pre-rupture. SEARCH METHODS: A systematic literature review was carried out in Pubmed search for rudimentary horn pregnancies. The radiologic findings of the cases diagnosed before rupture were analyzed. RESULTS: Ultrasound is the most commonly used technique, though MRI seems to delineate details better. Non-continuity of the lumen of the cervix with the pregnant uterine horn is an important imaging finding. High clinical suspicion and radiologic skill for diagnosis are emphasized. CONCLUSIONS: The review presents the existing imaging criteria to diagnose rudimentary horn pregnancy and suggests future research to enhance the limited evidence.

Maternal serum second trimester screening for chromosomal disorders and neural tube defects in a government hospital of North India.

OBJECTIVE: Down syndrome (DS) has major resource implications especially in developing countries being third most important cause of mental handicap. Maternal serum screening for chromosomal aneuploidies and neural tube defects (NTDs) is practiced worldwide in many countries and has been integrated into mainstream health care, while it is gradually gaining momentum in Asian countries. METHODS: This prospective cohort study was carried out in pregnant women undergoing triple screening test between January 2007 and December 2010 after informed consent. Biomarkers alpha-fetoprotein, human-chorionic-gonadotropin and unconjugated-estriol were tested, and risk of pregnancy being affected with DS, Edward's syndrome or NTDs were calculated. Screen-positive patients were referred for detailed ultrasonography and confirmatory amniocentesis. Follow-up record was maintained until delivery. RESULTS: Of 7400 pregnant women enrolled, 419(5.7%) were screen-positive, including 339 positive for DS, two for trisomy 18, and 62 for NTDs. Total eight cases of DS were eventually diagnosed in the population (prevalence of DS = 1 : 925), seven of which were detected in utero following diagnostic evaluation for positive serum screen (DR of DS screen = 87.5%). Total five cases of NTD were observed, yielding NTD prevalence of 0.67/1000. CONCLUSIONS: Triple screening in the second trimester is reasonably effective for the detection of major chromosomal defects and NTDs, and can be implemented successfully also in India.

Pelvic tuberculosis mimicking advanced ovarian malignancy.

We sought to identify the characteristic features of pelvic tuberculosis (TB) in women with symptoms and sonogaphic findings which were otherwise consistent with an ovarian malignancy. This study is a retrospective analysis of 138 women who underwent an operation and had a preoperative diagnosis of ovarian malignancy at the Government Medical College Hospital, Chandigarh, from January 2004 to January 2008. Among these 138 women, seven cases (5.7%) of pelvic TB were identified. Abdominal pain and distension were the most common presenting symptoms. All patients had a pelvic mass, six had ascites (85%) and five had a fever (71%). The mean cancer antigen (CA) 125 level was 295 IU (13-529). Pelvic TB can present with symptoms and signs which mimic ovarian malignancy. Therefore, a high-index of clinical suspicion should be maintained when treating patients in countries with a high prevalence of TB.

Risk factors for perinatal mortality due to asphyxia among emergency obstetric referrals in a tertiary hospital.

OBJECTIVES: To evaluate the clinical, behavioral and health-care associated risk factors of intrapartum perinatal mortality (IPPM). DESIGN: Prospective cohort study. SETTING: Labor room and postnatal wards of a teaching hospital in North India. PARTICIPANTS: Pregnant women were eligible for enrollment in the study if period of gestation at delivery was 35 weeks or more or baby weighed at least 2000 g at birth, index pregnancy was not booked in antenatal clinic of the study hospital and fetus was delivered within 24 h of admission in the hospital. METHODS: Information about antenatal care and events surrounding labor and delivery were retrieved from antenatal care records, referral notes, hospital clinical records and interview of mothers. Multivariate analysis was conducted using forward stepwise logistic regression analysis. MAIN OUTCOME MEASURE: IPPM was defined as asphyxia-specific stillbirth or asphyxia-specific early neonatal death. RESULTS: Among 248 emergency obstetric referrals during the study period, rate of IPPM was 8% (20/248, 18 fresh stillbirths and 2 asphyxia-specific neonatal deaths). District hospitals and community health-centers/first referral units contributed three-fourths of all referrals. On logistic regression analysis significant risk factors for IPPM were presence of obstructed labor (OR: 23, 95% CI: 1.9-275.8), father engaged in unskilled labor (OR: 10, 95% CI: 1.3-77.7) and absence of urine examination during antenatal period (OR: 5.5, 95% CI: 1.8-16.3). CONCLUSIONS: Low socioeconomic status, inadequate antenatal care and poor intrapartum care due to unskilled birth attendance are risk factors of IPPM.

Second trimester pregnancy termination with 400 µg vaginal misoprostol: efficacy and safety.

The present study was designed to evaluate the efficacy and safety of misoprostol (400 µg) given intravaginally repeated at 6 hourly intervals for a maximum of 6 doses for second-trimester pregnancy terminations. The study was conducted on women who had to undergo pregnancy termination between 13 and 26 weeks of gestation for various indications but mainly intrauterine death over a period of 2 years. A standard regime of 400 µg of misoprostol 6 hourly intravaginally was given until a maximum of 6 doses. Sixty women underwent second trimester terminations. The mean induction abortion interval was 11.8 h. The success rate at the end of 48 h was 96.6%. Side-effects were in the form of incomplete abortion, excessive blood loss, and fever. No patient had a uterus rupture. Intravaginal misoprostol 400 µg given 6 hourly seems to be an effective, safe, and acceptable method for second trimester pregnancy terminations.

Secondary abdominal pregnancy and its associated diagnostic and operative dilemma: three case reports.

INTRODUCTION: Abdominal pregnancy is extremely rare and has historically been defined as an implantation in the peritoneal cavity, exclusive of tubal, ovarian or intraligamentary pregnancy. CASE PRESENTATIONS: Three cases are reported. All came from a lower middle-income group and all of them were subjected to surgery. The first patient was a 30-year-old woman, who was pregnant for the fourth time, who presented at 16 weeks with an abdominal pregnancy. She was admitted with constant abdominal pain and retention of urine. She was hemodynamically stable and was administered a pre-operative intramuscular injection of methotrexate. During laparotomy she had only minor blood loss, the major part of the placenta was removed easily and she did not require any blood transfusion. Serum beta human chorionic gonadotrophin values and ultrasound follow-up revealed a normal study four weeks after surgery. The second patient was a 26-year-old woman, pregnant for the third time, admitted at 14 weeks with an abdominal pregnancy with hemoperitoneum, and the third patient was a 24-year-old woman, pregnant for the first time, who presented at 36 weeks gestation. She was only diagnosed as having an abdominal pregnancy during surgery, experienced excessive blood loss and required a longer hospital stay. CONCLUSIONS: We hypothesize that treatment with pre-operative systemic methotrexate with subsequent laparotomy for removal of the fetus and placenta may minimize potential blood loss, and would be a reasonable approach in the care of a patient with an abdominal pregnancy with placental implantation to the abdominal viscera and blood vessels. This treatment option should be considered in the management of this potentially life-threatening condition. During surgery, if the placenta is attached to vital organs it should be left behind. Early diagnosis can help in reducing associated maternal morbidity and mortality.