British Journal of Obstetrics and Gynaecology October 1975. Vol 82. pp 840-842

ADVANCED SIMULTANEOUS INTRAUTERINE AND ABDOMINAL PREGNANCY A CASE REPORT BY

N. DAS Consultant Obstetrician and Gjviaecologist Chingola, Zambia Summary An unusual case of twin pregnancy is described. One fetus was inside and the other outside the uterus.

CASE HISTORY A 36-year-old woman was admitted to hospital on 26th November 1973 with vomiting and abdominal pain of three days duration when eight months pregnant. She had had three normal deliveries, the last in 1958, and three abortions. During her present pregnancy she had kept well but had not seen a doctor. On examination she appeared to be in pain. Mild dehydration was present. She was not anaemic and there was no ankle oedema. Her pulse was 100 per minute, blood pressure 100/70 mm Hg and temperature 37-8 "C. There was some tenderness in the upper abdomen. The uterus was 32 weeks by size with the head presenting, but not engaged. The fetal heart was regular. On vaginal examination there was a slight brownish discharge, and the cervix was closed. Intravenous fluid was commenced for vomiting and dehydration. A high vaginal swab showed trichomonads and a midstream urine specimen grew E. coli. A blood slide was positive for malarial parasites. Appropriate treatment was started with improvement in the patient's symptoms although she still vomited occasionally. Three days after admission twin pregnancy was suspected and her abdomen was X-rayed. Unfortunately the patient went into labour on the same night, before the X-ray film was seen 8 40

by a doctor. Early next morning she delivered normally a healthy female infant which did well. It weighed 1.89 kg, was 37 cm long and had a head circumference of 32 cm. The placenta and membranes were expelled complete and with minimal blood loss. On further examination it was suspected that there was another fetus and this was confirmed when the X-ray film was seen with a gas shadow between the fetuses (Fig. 1). At laparotomy, four hours after delivery, a second fetus was foundwith an intact sac, lying transversely in the upper abdomen. There was no haemorrhage or any free fluid in the peritoneal cavity and there were no adhesions in the abdomen. The fully developed placenta was attached to the left tube and ovary only and had not separated at all. The sac which contained very little liquor was opened and a living female baby was extracted who weighed 1.43 kg, was 40 cm long and had a head circumference of 31 cm. The child gasped occasionally and failed to respond to active resuscitation. The placenta was removed completely and easily by excising the left tube and ovary. There was hardly any blood loss and transfusion was not required. The postoperative period was complicated by mild pyrexia and a little swelling of the knees but the wound healed by first intention. The swelling of the knees slowly settled and the

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FIG.1 Abdominal X-ray.

patient was discharged 17 days after operation. She failed to attend the postnatal clinic.

COMMENT Abdominal pregnancy is very rare. Twin pregnancy, with one fetus inside and the other outside the uterus, is rarer still, and very difficult to diagnose. Fortunately, in this case, the radio-

logical picture was clear and conclusive, at least after the intrauterine fetus was born! There are arguments for and against removal of the placenta of an abdominal pregnancy. During the past 12 years I have dealt with five cases of advanced extrauterine pregnancy (one at term, two at 32 weeks, one at 27 weeks and one at 24 weeks) and the placenta was removed in four because it separated after division of the

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umbilical cord. It is surprising how the placenta gets separated partially or fully on its own at this stage even when it is attached to the Pouch of Douglas, bowel walls or uterus. If separation does not occur spontaneously, it is probably best to leave it in situ unless it can be removed as in this patient described by excising the ovary and tube to which it is attached. Of course if the placenta is left in situ the postoperative morbidity rate is high with lower abdominal pain, tenderness, mass formation and pyrexia.

It is remarkable that the intrauterine labour and delivery did not affect the abdominal pregnancy and that the second twin was delivered alive and almost equally developed as its fellow.

ACKNOWLEDGEMENTS I thank Dr. T. G. Geddes, Chief Medical Officer, N.C.C.M. Limited, Chingola Division, for permission to publish this case. I also thank Dr. D. Jenkinson for his assistance in the management of this case.

Advanced simultaneous intrauterine and abdominal pregnancy. A case report.

British Journal of Obstetrics and Gynaecology October 1975. Vol 82. pp 840-842 ADVANCED SIMULTANEOUS INTRAUTERINE AND ABDOMINAL PREGNANCY A CASE REPO...
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