Traore Aboubacar^1*, Sow Omar², Saidy Reymond², Ndiaye M. Diop¹, Diarra G. Baffing³, Dabo Ousmane¹, Fall Boubacar¹

¹Urology andrology department of peace hospital of Ziguinchor, Senegal

²General surgery department of peace hospital of Ziguinchor, Senegal

³Radiology department of peace hospital of Ziguinchor, Senegal

^*Corresponding Author: Traore Aboubacar, Urology andrology department of peace hospital of Ziguinchor, Senegal

Abstract: Abdominal pregnancy is a rare form of ectopic pregnancy. It is challenging to diagnose preoperatively and is often diagnosed incidentally during abdominal surgery. We report a case of abdominal pregnancy diagnosed while managing an acute intestinal obstruction.

case: This 30-year-old female patient was admitted with an acute intestinal obstruction. An exploratory laparotomy was performed after resuscitation measures, which allowed the extraction of a 14 cm fetus incarcerated in the Douglas and with uterine perforation. Postoperative management was favorable.

Conclusion: Abdominal pregnancy is challenging to diagnose and is associated with high maternal-fetal morbidity and mortality. Our patient's case raises the issue of legalized abortion with the suspicion of a clandestine abortion.

Introduction
Abdominal pregnancy is rare, accounting for around 1% of all ectopic pregnancies [1]. The fetus develops outside the uterus in the peritoneal cavity, with implantation sites in the omentum, liver, spleen, and peritoneum, but not in the fallopian tube, ovary, or broad ligament. In most cases, it is secondary to tubo-abdominal abortion, the rupture of a tubal pregnancy [2]. Preoperative diagnosis is complex and often accidental in the setting of abdominal pain or intestinal obstruction. We report a case of abdominal pregnancy revealed by acute intestinal obstruction.

Observation
The patient was 30 years old, married, G5 and P4, all alive and well. She was seen in the emergency department for intense abdominal pain, vomiting, and cessation of stool and gas, which had been evolving for 5 days. Her physical examination revealed preserved general condition, conjunctival mucosa was mild anicteric, abdomen distended and tympanic on percussion, and rectal exams showed an empty rectal ampulla. Blood pressure was 140/100 mm hg, tachycardia 122 beats/min, respiratory rate 24 cycles/min, and temperature 36 degrees. The results of further investigations are summarized in the following (table).

Table: Results of lab tests

We noted the presence of a dead fetus at the level of the Douglas sac, with its head wedged between the rectum and uterus, compressing the recto-sigmoid junction, and a foul-smelling blackish collection in the Douglas of around 200 cc from the perforated uterus (Figure 4).

We proceeded with the extraction of a 14cm fetus (Figure 3), aspiration of the Douglas fluid, followed by abdominal cleaning and closure of the uterine perforation.

Postoperative management was favorable, with bowel movement recovery in the form of stool and gas on the second postoperative day. The patient was discharged on day 05 postoperatively.

Figure 1: Air fluid levels mainly colic

Figure 2: intestinal dilatation

Figure 3: uterus perforation

Discussion
Abdominal pregnancies are divided into two groups according to mechanism: secondary abdominal pregnancies, which are more frequent, secondary either to tubo-abdominal abortion or rupture of tubal pregnancies, or migration of intrauterine pregnancy through a hysterectomy breach or uterine perforation or rudimentary horn; primary abdominal pregnancies due to implantation of the egg in the peritoneal cavity through delayed ovarian uptake [3]. The latter must satisfy Studdiford's criteria: healthy ovary and fallopian tubes, absence of retroperitoneal fistula, exclusive contact of the egg with the peritoneum. We classify our case in the first group, with an abdominal pregnancy secondary to uterine perforation. However, extensive questioning after surgery revealed no endo-uterine maneuvers for induced abortion to explain uterine perforation, and the patient did not know she was pregnant. We suspected a clandestine abortion, which the patient was afraid to confess to under the constraint of the law, a practice not legalized in our country. Acute intestinal obstruction complicating pregnancy is rare, with an incidence of 1/1500 to 1/66431, even less frequent if the cause is an abdominal pregnancy [4]. Maternal morbidity and mortality are high, as is the risk of fetal loss [5]. Risk factors for abdominal, extrauterine pregnancy include endometriosis, pelvic inflammatory disease, IVF, multiparity, intrauterine device, aspiration abortion, uterine scarring, and genital infection. Preoperative diagnosis of abdominal pregnancy is difficult due to its non-specificity and clinical polymorphism depending on the term and location of the pregnancy and can go undetected until late in pregnancy.

Abdominal pain is a standard feature, but the displacement of abdominal organs as pregnancy progresses leads to atypical localization of pain, resulting in delayed diagnosis [6,4]. It may also be revealed by an abdominal surgical emergency such as hemoperitoneum, peritonitis, or acute intestinal obstruction [7], as in the case of our patient, who was unaware of her pregnancy and whose diagnosis was fortuitous intraoperatively. Ultrasound allows us to suspect the diagnosis preoperatively in 50% of cases in the presence of an empty uterus associated with a gestational sac or a mass separated from the uterus, annex, and ovaries. CT and MRI can help confirm the diagnosis, distinguish the anatomical relationship and potential vascular connections, and assess placental adhesion [8]. In our patient, the clinical picture of frank intestinal obstruction, the absence of signs pointing to pregnancy, and, for financial reasons, an unprepared abdominal radiograph was preferred to a CT scan demonstrating air-fluid levels, which motivated exploratory laparotomy. Treatment of abdominal pregnancy depends on gestational age and fetal viability. While laparoscopy remains an option when the diagnosis is made early [9], it should be avoided if the pregnancy is implanted on a vascular surface due to the risk of hemorrhage.

In the case of late diagnosis, therapeutic termination of the pregnancy is an option, but it is possible with reinforced follow-up to extract a live, viable child by laparotomy. Placenta management is the main problem in laparotomy for advanced pregnancy. Some authors prefer to ligate the cord and leave the placenta in situ due to the risk of hemorrhage secondary to removal of the placenta, followed by untreated monitoring, arterial embolization, or methotrexate to accelerate placental resorption [10,4]. However, if possible, complete delivery of the placenta should be carried out after careful assessment of its relationship with the abdominopelvic organs. In our patient, we were not confronted with the difficulties of managing the placenta, which was utterly resorbed with a dead fetus.

Conclusion
Abdominal pregnancy is a rare form of ectopic pregnancy. Preoperative diagnosis is difficult, despite the critical contribution of ultrasound, and is often fortuitous, revealing itself during managing an abdominal surgical emergency such as an acute intestinal obstruction. The mechanism of our patient's abdominal pregnancy (uterine perforation) raises the question of the legalization of abortion, which, if performed clandestinely, can be life-threatening for the pregnant woman.

Conflicts of Interest: The authors declare no competing interest.

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