Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
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I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Case Series
Year : 2023 | Month : January | Volume : 17 | Issue : 1 | Page : QR01 - QR05 Full Version

Abdominal Ectopic Pregnancy: Challenging Obstetrical Paradox in Series of Three Cases


Published: January 1, 2023 | DOI: https://doi.org/10.7860/JCDR/2023/58872.17421
Animesh Naskar, Abantika Ghosh, Bharat Chandra Mandi, Suchita Mandal, Pritilata Show

1. Associate Professor, Department of Obstetrics and Gynaecology, R G Kar Medical College and Hospital, Kolkata, West Bengal, India. 2. Junior Resident, Department of Obstetrics and Gynaecology, R G Kar Medical College and Hospital, Kolkata, West Bengal, India. 3. Tutor, Department of Obstetrics and Gynaecology, R G Kar Medical College and Hospital, Kolkata, West Bengal, India. 4. Junior Resident, Department of Obstetrics and Gynaecology, R G Kar Medical College and Hospital, Kolkata, West Bengal, India. 5. Senior Resident, Department of Obstetrics and Gynaecology, R G Kar Medical College and Hospital, Kolkata, West Bengal, India.

Correspondence Address :
Dr. Animesh Naskar,
10, Baje Shibpur 2nd Bye Lane, Shibpur, Howrah-711102, West Bengal, India.
E-mail: animesh282@gmail.com

Abstract

Abdominal Ectopic Pregnancy (AEP), a rare life-threatening obstetrical complication, is defined as ectopic implantation within the peritoneal cavity outside the uterus, tubes, ovaries, or intra-ligamentous locations. A series of three rare cases of early AEP is presented: (First case: a 32-year-old, gravida 2, para 1; Second case: a 31-year-old, gravida 3, para 2; and Third case: a 39-year-old gravida 4, para 2). All the cases were of early (<20 weeks) primary AEP and they all presented with acute abdomen, unstable vitals, and haemoperitoneum. The first case had omental implantation with a gestational sac of (3×3) cm and was diagnosed by strong clinical suspicion with intraoperative confirmation for the same, whereas the second and third cases had implantation on Pouch of Douglas (POD) and sigmoid colon respectively; and was diagnosed by sonography with intraoperative confirmation during laparotomy. All three cases were successfully managed by a multidisciplinary team approach, blood transfusions, and emergency laparotomy with complete removal of the placenta. They had a good postoperative recovery. The reports of histopathology of tissues retrieved peroperatively from the implantation sites showed chorionic villi which confirmed the product of conceptions. Presentation of this case series provides an opportunity to illustrate a rare variant of ectopic pregnancy with a challenging obstetric dilemma and to discuss the importance of strong clinical suspicion for such a grave maternal condition, on the part of the attending obstetrician, to make an early diagnosis and prompt treatment, so that maternal morbidity and mortality can be avoided.

Keywords

Abdominal pregnancy, Haemoperitoneum, Laparotomy, Sonography

Abdominal pregnancy is a rare form of ectopic gestation and potentially life-threatening obstetrical complication in terms of maternal morbidity and mortality. This is thought to represent around 1-1.5% of all ectopic pregnancies with an estimated incidence varying from 1:10,000 to 1:30,000 pregnancies worldwide (1),(2).

Abdominal pregnancy refers to an ectopic pregnancy that has implanted in the peritoneal cavity, external to the uterine cavity and fallopian tubes (3). The placenta of abdominal pregnancy is often found to be attached to reproductive organs with subsequent rupture into the peritoneal cavity. Direct attachment of the placenta to the uterine serosa, omentum, bowel, and mesentery is also found (4). Though the most frequent sites of placental implantation are the Pouch of Douglas (POD), which accounts for 55% of cases. It can also occur in mesosalpinx, the omentum, the peritoneum of the abdominal or pelvic walls, and the space between the anterior uterine wall and the bladder (1),(5).

The symptoms and signs vary according to the implantation site. If the implantation site is in the pelvic cavity, early diagnosis is easily confused with tubal ectopic pregnancy (6), and only 20-40% of cases are diagnosed before surgery (7). It increases the risk of fatal intraperitoneal haemorrhage, primarily because of the risk of massive bleeding from partial or total placental separation (8). Therefore, it is important to diagnose and effectively manage this rare type of pregnancy in order to reduce maternal morbidity and mortality.

Case Report

Case 1

A 32-year-old, gravida 2, para 1, at six weeks of pregnancy attended the obstetric emergency unit with complaints of severe pain in the abdomen of two days duration, and mild occasional bleeding per vaginum for seven days. She had a history of irregular intake of oral contraceptive pills. She had no history of endometriosis, Pelvic Inflammatory Disease (PID); nor any Sexually Transmitted Diseases (STD). On examination, the patient was pale, her pulse rate was 140 beats per minute and feeble, blood pressure was 80/60 mm Hg. Her abdomen was moderately distended with remarkable generalised tenderness and guarding, which prevented adequate palpation. Per vaginal examination revealed that the uterus was tender and almost 10 weeks in size. Bilateral fornices could not be assessed well. Cervical motion tenderness was elicited. Abdominal tapping was done and showed a bloody tap (positive tap test). No Ultrasonography (USG) report was available. The patient was resuscitated with intravenous fluids with noradrenaline support; Foley’s catheterisation and packed Red Blood Cells (RBC) requisition were done. A clinical diagnosis of ruptured ectopic pregnancy was made and she was prepared for emergency exploratory laparotomy.

The abdomen was opened with a low-midline incision under general anaesthesia. About two litres of haemoperitoneum and almost 500 g of clots were noted. Uterus was found to be of normal size, and bilateral tubes and ovaries were healthy. An ectopic gestational sac (3×3) cm was found to be implanted over the gut omentum close to the sigmoid colon (Table/Fig 1). The omentum was ligated by silk sutures. The ectopic mass was clamped, and a partial omentectomy was performed to remove the gestational sac. A general surgeon was present during the laparotomy. After securing haemostasis, the peritoneum was washed with one litre of normal saline. An intraperitoneal drain was inserted and the abdomen was closed in layers. The specimen of ectopic mass with adhered omentum was sent for Histopathological Examination (HPE). The postoperative period of the patient was uneventful. She was transfused with three units of packed RBC and was discharged on postoperative day 5. Histopathological report of the ectopic mass showed a product of conception (Table/Fig 2).

Case 2

A 31-year-old pregnant lady, gravida 3, para 2, was transferred from a nearby district hospital to the obstetric emergency unit of the institution with complaints of severe pain in the abdomen for the last 24 hours and intermittent bleeding per vaginum for the last five days. This was a postcaesarean pregnancy with two living issues and her last childbirth was almost two years back. She had around six weeks of amenorrhea with irregular menstruation and could not remember her last menstrual period. The patient had neither history of PID nor STD. She did not use any contraception and had no history of endometriosis. On examination, she was moderate to severely pale, her pulse rate was 110 beats per minute with low volume, blood pressure was 100/60 mmHg. Muscle guard, rigidity, moderate distension, and tenderness were elicited on abdominal examination. Bimanual examination revealed a bulky uterus, tender boggy mass palpable in the posterior fornix. Abdominal paracentesis revealed a frank bloody tap. Transabdominal USG revealed an empty endometrial cavity with a heterogenous mass measuring 5.5×5.4 cm. with a foetal pole of 8 weeks gestation inside the gestational sac and located in the POD close to the right adnexa. There was free fluid in the paracolic gutter and pelvic cavity. The patient was resuscitated with intravenous fluid and an urgent requisition of three units of packed RBC was sent for emergency blood transfusion.

After proper counselling, an emergency exploratory laparotomy was planned in view of massive intraperitoneal haemorrhage due to separation of abdominal ectopic and impending shock. Under general anaesthesia, a median laparotomy was performed. There was moderate haemoperitoneum (one litre) with almost 500 g of clots in the abdomen. The uterus was bulky, and bilateral adnexa were normal and healthy, but there was an irregular bleeding tissue (partially separated placenta) around 4×3 cm in the POD, close to the right posterior surface of the uterus (Table/Fig 3). The placental tissues were removed by dissecting them carefully, by digital separation from POD and posterior surface of the uterus, and sent for HPE. Bleeding from the implantation site was secured by bipolar cautery and compression by a local haemostatic agent. After abdominal closure, uterine curettage was done and the specimen was sent for HPE to rule out retained product of conception. She was transfused with two units of packed RBC and her postoperative period was uneventful. The patient was discharged on the seventh postoperative day. Histopathology report revealed that the tissue removed from POD was the product of conception (Table/Fig 4), and the specimen of uterine curettage was decidual cast.

Case 3

A 39-year-old, gravida 4, para 2, was referred from a district hospital after being diagnosed with Abdominal Ectopic Pregnancy (AEP) and presented with dull aching pain and huge haemoperitoneum. On examination, the patient was alert, conscious, and cooperative; blood pressure was 100/70 mmHg, pulse rate-130 beats per minute; severe pallor. Physical examination revealed huge distension of the whole abdomen with tenderness, rigidity and muscle guarding. Per vaginal examination showed os closed, cervix tubular, slightly drawn up, no bleeding per vaginum. Abdominal paracentesis revealed a positive ‘tap’ test for haemoperitoneum. Ultrasonography revealed a single, live foetus, 13 weeks 2 days, with gross intraperitoneal haemorrhage and implantation that seemed to occur outside the uterus, adjacent to gut loops in the right adnexal region. The patient was resuscitated with intravenous fluids and an urgent blood requisition was done and the patient was prepared for emergency exploratory laparotomy after proper counselling.

Laparotomy was performed by infraumbilical median incision and about three litres of haemoperitoneum was revealed. An ensac foetus of about 14 weeks in size was found in the peritoneum with cord and placenta firmly adhered to the appendices epiploic of the sigmoid colon and partial adhesion with left conu and adnexa (Table/Fig 5). Blunt dissection and adhesiolysis was performed to release amnion-omental adhesion. General surgery, urology, and vascular surgery services were consulted during the laparotomy. The uterus was 10-week size, both sided tube and bilateral ovaries were found to be normal and healthy, and preserved. No rent was found in the uterus.

There was continuous oozing from the placental bed adhered to the gut wall. The general surgery team ligated the site of appendices epiploicae with ‘1-0’ silk sutures to arrest the active bleeding sites on the gut and omentum. Bipolar cautery was also used to achieve haemostasis. About two litres of normal saline peritoneal wash was given. An intraperitoneal drain was placed in the POD and the abdomen was closed in layers. A specimen of ectopic mass with placenta was sent for HPE. The postoperative period of the patient was uneventful. The patient received four units of packed RBCs and was discharged on the 14th postoperative day.

Discussion

Abdominal pregnancy is an alien variation of ectopic pregnancy with high incidence, reported in women of developing countries with limited-resource settings, probably due to low socioeconomic status, increased incidence of PID, endometriosis, history of infertility, tubal reconstruction surgery, pregnancy with an intrauterine device. Although these risk factors can predispose to AEP, only 50% of women with AEP are found to have any associated risk factors (1). Cases of the present series did not have any of these risk factors. The risk of maternal and perinatal death from abdominal pregnancy is very high. The maternal mortality in abdominal pregnancy may range from 0.5% to 18% (1). The risk of maternal death in abdominal ectopic is 7-8 times more than the mortality that occurs in tubal ectopic and 90 times higher than the mortality found in intrauterine gestation. The risk of perinatal mortality rate is 40-95% (1),(9).

It is classified as primary or secondary based on its implantation site. Primary implantation is rare, with the incidence being 0.6-1.6% of all cases reported worldwide [1,9]. According to Studdiford’s criteria (1942), the diagnosis of primary abdominal pregnancy is based on the following: 1) normal tubes and ovaries; 2) absence of an utero-placental fistula; and 3) attachment exclusively to a peritoneal surface early enough in gestation to eliminate the likelihood of secondary implantation from primary site (10). Secondary abdominal pregnancy is the most common and frequent following rupture of tubal ectopic (9). The most common sites of placental implantation are the POD, which accounts for 55% of cases, followed by the mesosalpinx, the omentum, the peritoneum of the abdominal or pelvic walls, and the space between the anterior uterine wall and the bladder (1). The least common form of abdominal pregnancy is the omental pregnancy (11). The first case of our series, was located in the omentum, the second case was in POD and the third case was found in the peritoneum and gut wall (sigmoid colon). In this series, the uterus, bilateral tubes, and ovaries appeared normal and we could not find any utero-peritoneal fistula and all three cases were detected in the early gestational period (<20 weeks). Therefore, the cases of the present series seemed to be early primary abdominal pregnancies. In 2021, one similar case was reported by Dorjey Y et al., in Bhutan (12).

Tabulated illustration with significant features of a few recent published case reports worldwide on early primary abdominal pregnancy has been depicted in (Table/Fig 6) (11),(12),(13),(14),(15),(16).

Besides, classification based on the site of implantation, abdominal pregnancy can also be classified as early or late depending on the gestational age at which it presents. Early Abdominal Pregnancy (EAP) presents at or before 20 weeks of gestation and late or advanced abdominal pregnancy presents after 20 weeks of gestation (4). Similar to case one of the current series, omental implantation of abdominal pregnancy was reported by George R et al., Jayanthi R et al., Yip SL et al., Yasin NZHM et al., Ozdemir I et al., (2),(11),(14),(16),(17).

In concordance with case two of the present series, implantation of the placenta at POD in abdominal pregnancy was reported by Cagino K et al., Yang X and Ma K, Wong JQE and Lim YH (18),(19),(20). Two cases of abdominal pregnancies reported from Dubai in 2018, also had a placental attachment to POD (5). Placental attachment to the mesentery of the sigmoid colon like case three of our series was also observed in the cases of abdominal pregnancy reported by Dubey S et al., and Yildizhan R et al., (3),(8). An ectopic mass adherent to the rectal wall was reported recently by Thang NM et al., from Vietnam (21).

The clinical presentations of abdominal pregnancy are uncertain. In a recent study, most patients had abdominal pain and vaginal bleeding and some patients needed admission for haemorrhagic shock caused by placental separation or rupture of ectopic pregnancy lesions (22). This finding is consistent with our cases because all patients in our series had abdominal pain and haemoperitoneum. Massive haemoperitoneum was recently reported in a case of abdominal pregnancy from a resource-limited setting in Ghana (13). Intraperitoneal haemorrhage was also noticed in AEP reported by others (23),(24). A case of primary omental pregnancy presented with shock due to severe intraperitoneal haemorrhage was reported from Turkey (17).

Despite wide variation in presentations, severe lower abdominal pain is one of the most consistent findings (6),(13), like the cases of our series. The clinical pictures vary according to the implantation site. If the implantation site is in the pelvic cavity, early diagnosis is easily confused with tubal ectopic pregnancy (6), and only 20-40% of cases are diagnosed before surgery (7). Our first case seemed to be ruptured tubal ectopic preoperatively but a confirmatory diagnosis was made intraoperatively and by HPE.

Practically, diagnosis of AEP may be late and difficult because patients may remain asymptomatic, or if symptomatic, the symptoms are nonspecific (25). So, a high index of clinical suspicion is of paramount importance for its early diagnosis (3). This is consistent with the diagnosis of the first case of our series where there was no imaging study except clinical suspicion and laparotomy findings. In many cases, the diagnosis of AEP is not confirmed until a laparotomy or laparoscopy is performed (26). In a resource-poor setting, the diagnosis can be made peroperatively (27). Although serial monitoring of serum beta Human Chorionic Gonadotropin (HCG) level is a useful tool for clinically suspected tubal ectopic, it is not consistent enough to make the diagnosis of abdominal pregnancy (3). Transvaginal USG is considered the frontline diagnostic imaging tool with a sensitivity of 99% for the diagnosis of abdominal pregnancy (1),(5). Diagnosis of AEP is often difficult and missed during routine USG (3). Sonography gives only 50% accuracy for diagnosis of EAP when it is used along with clinical evaluation (4). The classical USG finding of abdominal pregnancy is an empty uterus, with a gestational sac or mass outside of the uterus, fallopian tubes, and ovaries confirming the diagnosis of abdominal pregnancy (4),(5). Magnetic Resonance Imaging (MRI) serves as an adjunct in cases when sonography is inconclusive or equivocal (5). To confirm the location of placental and foetal tissue, MRI can be used (1). MRI may also help in surgical planning by estimating the depth of placental tissue involvement in mesenteric and uterine attachment (28).

Several published studies reported on the therapeutic regimen including conservative and surgical treatment options for abdominal ectopic. Conservative therapy includes selective placental vascular embolisation, ultrasound-guided drug injection (methotrexate) in the gestational sac, or maternal systemic drug therapy (29),(30). Expectant management has been attempted successfully in a few cases to achieve foetal maturity (31). But a long follow-up period may be required in this approach.

For the management of AEP, a surgical procedure in the form of laparotomy or laparoscopy is preferable, and an excellent outcome is achieved by the complete removal of the whole sac containing the foetus and membranes along with the placenta (32). Laparotomy is preferable in cases where there is a risk of haemorrhage (33). EAP with haemodynamically unstable mothers has been treated by laparotomy (14).

Laparoscopic surgery may be opted, if the cases are diagnosed early and do not carry vascular risks (26). In 2016 Yip SL et al., concluded in a case report on primary omental pregnancy that there are increasing reports of laparoscopically managed EAP among women who are haemodynamically stable (14). In fact, after the year 2000, the rate of operative laparoscopy for EAP was 100%, because of significant benefits in terms of minimal blood loss, fast recovery, and a short period of hospital stay in the laparoscopic surgery (4). Several cases were reported in recently published literature that even with haemoperitoneum, EAP was managed surgically by operative laparoscopy based on a great deal of surgical expertise and technological advances (24),(34). Pre-viable abdominal pregnancy (<24 weeks) is usually treated with laparotomy with removal of the ectopic pregnancy with or without placental removal (if low risk of maternal haemorrhage) (27). All our patients were treated surgically (laparotomy) in the present series.

Several cases reported globally in published literature in recent times on successful surgical management of early primary AEP either by laparotomy or by laparoscopy, has been depicted in (Table/Fig 7) (2),(3),(11),(12),(13),(14),(15),(16),(18),(19),(23),(24),(34),(35),(36),(37),(38),(39),(40),(41).

Massive bleeding from the placental site is a life-threatening and challenging complication of abdominal pregnancy. Generally, complete removal of the placenta is not recommended, and partial removal is required to control intraoperative haemorrhage. Sometimes, it is to be left in situ and wait for self-involution and resorption (27).

A multidisciplinary surgical approach including gynaecological oncology, vascular surgery, urology, and trauma surgery may be necessitated because of the risk of torrential bleeding, difficult pelvic surgery, and urological complication. The risk of postoperative complications like haemorrhage or infection is to be dealt with through continuous monitoring and follow-up (42). AEP carried to term is a rare possibility (27),(42).

As per the study report, congenital malformations in the newborn are common and the risk of foetal malformations is about 40%, out of these 50% of babies can survive the first week of life (43).

Conclusion

Abdominal pregnancy is a rare life-threatening obstetric condition. Its diagnosis and treatment are still great challenges, particularly in resource-poor settings. If detected early, laparotomy is the method of choice for its treatment. Based on a high index of clinical suspicion along with a multidisciplinary team approach and a great deal of surgical expertise, all the cases of AEP were successfully managed. Prompt diagnosis, judicious intervention by emergency exploratory laparotomy, and adequate blood transfusion were the keys to save all the mothers in this case series.

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DOI and Others

DOI: 10.7860/JCDR/2023/58872.17421

Date of Submission: Jul 04, 2022
Date of Peer Review: Oct 13, 2022
Date of Acceptance: Dec 07, 2022
Date of Publishing: Jan 01, 2023

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jul 06, 2022
• Manual Googling: Nov 24, 2022
• iThenticate Software: Dec 06, 2022 (16%)

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