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.