Successful anesthetic management of parturient with advanced abdominal pregnancy.

Introduction

Abdominal pregnancy is an extremely rare form of ectopic pregnancy where implantation of fertilized ovum occurs directly in the abdominal cavity. The prevalence of ectopic pregnancy is 1-2% with 95% occurring in the fallopian tube [1]. The incidence of ectopic pregnancy occurring in the abdomen is even more uncommon with incidence ranging from 1:1000 to 1:30,000 and mostly seen in developing nations [2]. First documented case of abdominal pregnancy was in 1708 where the diagnosis was made based on excessive hemorrhage during a laparotomy [3]. Similar case reports demonstrated the fatal risks associated with abdominal pregnancy as majority of cases resulted in extraction of the dead fetus with high rate of maternal mortality [4]. The mortality rate associated with abdominal pregnancy is seven times higher than general ectopic pregnancy and 90 times higher than delivery in the third trimester [5]. This presents a major challenge to anesthesia providers caring for these patients as the most common cause of death are hemorrhage and anesthetic complications [1]. However, due to the advancements and improved access to prenatal care, discovery of ectopic pregnancy earlier in the gestational period is more feasible allowing for careful planning and improved outcome. Given the rarity and lack of standard management for this condition, we present our anesthetic management of a patient diagnosed with abdominal pregnancy who underwent successful surgical delivery of a viable neonate.

Case Report

Our patient is a 48-year-old gravida 4 para 1-0-2-2 African-American female from Ghana with history of sickle cell trait, hypertension, and iron-deficiency anemia who was initially diagnosed with ectopic pregnancy at 5 weeks of gestation. The patient had two prior terminated pregnancies and one cesarean section with twins from in vitro fertilization. She was initially counseled and advised to undergo elective termination given the risks of high morbidity and mortality, but decided to continue with the pregnancy. The MRI showed an extrauterine gestational sac with oligohydramnios containing the fetus in the left hemipelvis that appeared to be attached to the left ovary. Abnormally shaped implanted placenta was located to the left of the gestational sac with heterogeneous necrotic changes. Adjacent bowel loops were displaced, left ureter was compressed resulting in hydronephrosis, and no signs of invasion to other adjacent structures were observed. Follow-up CTA to evaluate placental vasculatures showed primary supply by the left ovarian and left uterine arteries. The left uterine artery was noted to pass directly beneath the fetal cranium.

The patient was admitted to the obstetrics service at 24 weeks and 0 days of gestation for antepartum observation and to facilitate coordination of care. Trauma surgery, vascular surgery, interventional radiology, urology, and gynecology services were consulted for possible assistance during the operation. Trauma surgery was notified in case of emergency surgical intervention overnight without appropriate services present. Vascular surgery was notified in case of uncontrolled hemorrhage requiring vascular control via aortic cross clamps. Interventional radiology was notified for possible placenta vasculature embolization after the delivery of the fetus. Our anesthetic plan consisted of general anesthesia with rapid sequence endotracheal tube intubation, radial arterial line, single lumen 9-French internal jugular central line, two 8.5-French rapid infusion catheters in bilateral antecubital veins, and multiple typed and crossed blood products in anticipation of hemorrhage. After detailed planning and coordination, surgical delivery was scheduled for 28 weeks and 0 days of gestation in order to maximize fetal benefit while minimizing maternal risk.

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With Regards,

Mary jasmin

Editorial Assistant

Anesthesiology Case Reports