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<!-- Definition -->
'''Abdominal pregnancy''' is a form of [[ectopic pregnancy]] where the [[fetus]] is implanted within the [[peritoneal cavity|abdominal cavity]] outside the [[fallopian tube]], ovary and [[broad ligament]].<ref name=atrash>{{cite journal |author=Atrash HK, Friede A, Hogue CJR |title=Abdominal Pregnancy in the United States: Frequency and Mortality |journal=Obstetrics and Gynecology |date=March 1987 |volume=63 |pages=333–7| pmid=3822281| issue=3 }}</ref> While rare, abdominal pregnancies have a higher [[maternal mortality|mortality]] rate than ectopic pregnancies in general but, on occasion, can lead to a delivery of an infant who can survive independently.{{citation needed|date=May 2013}}
An '''abdominal pregnancy''' can be regarded as a form of an [[ectopic pregnancy]] where the [[embryo]] or [[fetus]] is growing and developing outside the [[uterus|womb]] in the [[abdomen]], but not in the [[Fallopian tube]], [[ovary]] or [[broad ligament]].
<ref name=Nunyalulendho>{{cite journal |author=Nkusu Nunyalulendho D, Einterz EM|title=Advanced abdominal pregnancy: case report and review of 163 cases reported since 1946 |journal=Rural Remote Health |date=2008 |volume=8 |pages=1087| pmid=19053177| issue=4 }}</ref>
<ref name=Agarwal>{{cite doi|10.1111/tog.12109}}</ref>


While rare, abdominal pregnancies have a higher chance of [[Maternal death|maternal mortality]], [[Perinatal mortality|perinatal mortality]] and [[Disease#Morbidity|morbidity]] compared to normal and ectopic pregnancies but, on occasion a healthy viable infant can be delivered.
==Risk factors==
<ref name=Masukume>{{cite journal |author=Masukume G|title=Live births resulting from advanced abdominal extrauterine pregnancy, a review of cases reported from 2008 to 2013 |journal=WebmedCentral OBSTETRICS AND GYNAECOLOGY |date=2014 |volume=5 |pages=WMC004510| issue=1| url=http://www.webmedcentral.com/article_view/4510 }}</ref>
Risk factors are similar to [[tubal pregnancy]] with [[sexually transmitted disease]] playing a major role.<ref name=hk>{{cite journal |url= http://www.hkmj.org/article_pdfs/hkm0012p425.pdf |title= Abdominal pregnancy presenting as a missed abortion at 16 weeks' gestation |author=KY Kun, PY Wong, MW Ho, CM Tai, TK Ng |journal=Hong Kong Medical Journal |accessdate=January 25, 2009|pmid= 11177167 |year= 2000 |volume= 6 |issue= 4 |pages= 425–7}}</ref>


Because tubal, ovarian and broad ligament pregnancies are as difficult to [[diagnose]] and [[treat]] as abdominal pregnancies, their exclusion from the most common definition of abdominal pregnancy has been debated.
==Anatomy==
<ref>{{cite doi|10.1016/j.ajog.2007.09.044}}</ref>
⚫
[[Implantation (human embryo)|Implantation]] sites include the [[peritoneum]] outside of the uterus, the [[rectouterine pouch]] (culdesac of Douglas), [[Greater omentum|omentum]], [[bowel]] and its [[mesentery]], [[mesosalpinx]], and the peritoneum of the pelvic wall and the abdominal wall.<ref name=atrash/><ref name=bonn/> The growing placenta may be attached to several organs including tube and ovary. Rare other sites have been the [[liver]] and [[spleen]],<ref name=ogi>{{cite journal |url=http://www.hindawi.com/journals/ogi/2009/247452.html |journal=Obstetrics and Gynecology International| year=2009 |doi=10.1155/2009/247452Case+Report |title=An Early Abdominal Wall Ectopic Pregnancy Successfully Treated with Ultrasound Guided Intralesional Methotrexate: A Case Report| author=Anderson PM, Opfer EK, Busch JM, Magann EF |pmid=}}</ref> giving rise to a '''hepatic pregnancy'''<ref>{{cite journal| author=Chui AK, Lo KW, Choi PC, Sung MC, Lau JW.|title=Primary hepatic pregnancy |journal=ANZ Journal of Surgery |pmid=11355741|date=April 2001 |volume=71 |issue=4| pages=260–1 |doi=10.1046/j.1440-1622.2001.02085.x}}</ref> or '''splenic pregnancy''', respectively.<ref>{{cite journal| author=Yagil Y, Beck-Razi N, Amit A, Kerner H, Gaitini D |title=Splenic Pregnancy: The Role of Abdominal Imaging |journal=Journal of Ultrasound Medicine | pmid=17957059| year=2007| volume=26| issue=11| pages=1629–32}}</ref> Even an early diaphragmatic pregnancy has been described in a patient where an embryo began growing on the underside of the [[Thoracic diaphragm|diaphragm]].<ref>{{cite journal| author=Norenberg DD, Gundersen JH, Janis JF, Gundersen AL. |title=Early pregnancy on the diaphragm with endometriosis |journal=Obstetrics and Gynecology |pmid=850582|date=May 1977| volume=49| issue=5| pages=620–2}}</ref>

Others - in the minority - are of the view that abdominal pregnancy should be defined by a [[placenta]] implanted into the [[peritoneum]].
<ref>{{cite doi|10.1016/j.ajog.2008.06.024}}</ref>

==Symptoms and signs==
Symptoms may include abdominal pain or vaginal bleeding during pregnancy.<ref name=Nunyalulendho/> As this is nonspecific in areas were ultrasound is not available the diagnosis was often only discovered during [[surgery]] to investigate the abnormal symptoms.<ref name=Nunyalulendho/> They are diagnosed later in the developing world than the developed.<ref name=Oneko>{{cite journal|last1=Oneko|first1=O|last2=Petru|first2=E|last3=Masenga|first3=G|last4=Ulrich|first4=D|last5=Obure|first5=J|last6=Zeck|first6=W|title=Management of the placenta in advanced abdominal pregnancies at an East african tertiary referral center.|journal=Journal of women's health (2002)|date=July 2010|volume=19|issue=7|pages=1369-75|pmid=20509789}}</ref> In about half of cases from a center in the developing world the diagnosis was initially missed.<ref name=Sunday/>

==Mechanism==
⚫
[[Implantation (human embryo)|Implantation]] sites can be anywhere in the abdomen but can include the [[peritoneum]] outside of the uterus, the [[rectouterine pouch]] (culdesac of Douglas), [[Greater omentum|omentum]], [[bowel]] and its [[mesentery]], [[mesosalpinx]], and the peritoneum of the pelvic wall and the abdominal wall.<ref name=Atrash/><ref name=bonn/> The growing placenta may be attached to several organs including tube and ovary. Rare other sites have been the [[liver]] and [[spleen]],<ref name=ogi>{{cite journal |url=http://www.hindawi.com/journals/ogi/2009/247452.html |journal=Obstetrics and Gynecology International| year=2009 |doi=10.1155/2009/247452Case+Report |title=An Early Abdominal Wall Ectopic Pregnancy Successfully Treated with Ultrasound Guided Intralesional Methotrexate: A Case Report| author=Anderson PM, Opfer EK, Busch JM, Magann EF |pmid=}}</ref> giving rise to a '''hepatic pregnancy'''<ref>{{cite journal| author=Chui AK, Lo KW, Choi PC, Sung MC, Lau JW.|title=Primary hepatic pregnancy |journal=ANZ Journal of Surgery |pmid=11355741|date=April 2001 |volume=71 |issue=4| pages=260–1 |doi=10.1046/j.1440-1622.2001.02085.x}}</ref> or '''splenic pregnancy''', respectively.<ref>{{cite journal| author=Yagil Y, Beck-Razi N, Amit A, Kerner H, Gaitini D |title=Splenic Pregnancy: The Role of Abdominal Imaging |journal=Journal of Ultrasound Medicine | pmid=17957059| year=2007| volume=26| issue=11| pages=1629–32}}</ref> Even an early diaphragmatic pregnancy has been described in a patient where an embryo began growing on the underside of the [[Thoracic diaphragm|diaphragm]].<ref>{{cite journal| author=Norenberg DD, Gundersen JH, Janis JF, Gundersen AL. |title=Early pregnancy on the diaphragm with endometriosis |journal=Obstetrics and Gynecology |pmid=850582|date=May 1977| volume=49| issue=5| pages=620–2}}</ref>


===Primary versus secondary implantation===
===Primary versus secondary implantation===
A primary abdominal pregnancy refers to a pregnancy that implanted directly in the abdominal cavity and its organs, save for the tubes and ovaries; such pregnancies are very rare, only 24 cases had been reported by 2007.<ref name=dahiya>{{cite journal |title=Advanced Abdominal Pregnancy: A Diagnostic and Management Dilemma| author=Krishna Dahiya, Damyanti Sharma |journal= Journal of Gynecologic Surgery |doi=10.1089/gyn.2007.B-02259-1 |url= http://www.liebertonline.com/doi/abs/10.1089/gyn.2007.B-02259-1?cookieSet=1&journalCode=gyn |pmid= |date=June 2007 |volume=23 |issue=2 |pages=69–72 }}</ref> Typically an abdominal pregnancy is a secondary implantation which means that it originated from a tubal (less common an ovarian) pregnancy and re-implanted.<ref name=bonn>{{cite web |url= http://www.meb.uni-bonn.de/dtc/primsurg/docbook/html/x5173.html |title=Primary Surgery; Volume One: Non-trauma. Chapter 8, Abdominal pregnancy |author= Maurice King, Peter C. Bewes, James Cairns, Jim Thornton (editors) |publisher=[[Bonn University]] |accessdate=2010-01-25}}</ref> To diagnose the rare primary abdominal pregnancy, Studdiford's criteria need to be fulfilled: tubes and ovaries should be normal, there is no abnormal connection ([[fistula]]) between the uterus and the abdominal cavity, and the pregnancy is related solely to the peritoneal surface without signs that there was a tubal pregnancy first.<ref name=ogi/>
A primary abdominal pregnancy refers to a pregnancy that first implanted directly in the [[peritoneum]], save for the tubes and ovaries; such pregnancies are very rare, only 24 cases had been reported by 2007.<ref name=dahiya>{{cite journal |title=Advanced Abdominal Pregnancy: A Diagnostic and Management Dilemma| author=Krishna Dahiya, Damyanti Sharma |journal= Journal of Gynecologic Surgery |doi=10.1089/gyn.2007.B-02259-1 |url= http://www.liebertonline.com/doi/abs/10.1089/gyn.2007.B-02259-1?cookieSet=1&journalCode=gyn |pmid= |date=June 2007 |volume=23 |issue=2 |pages=69–72 }}</ref> Typically an abdominal pregnancy is a secondary implantation which means that it originated from a tubal (less common an ovarian) pregnancy and re-implanted.<ref name=bonn>{{cite web |url= http://www.meb.uni-bonn.de/dtc/primsurg/docbook/html/x5173.html |title=Primary Surgery; Volume One: Non-trauma. Chapter 8, Abdominal pregnancy |author= Maurice King, Peter C. Bewes, James Cairns, Jim Thornton (editors) |publisher=[[Bonn University]] |accessdate=2010-01-25}}</ref> Other mechanisms for secondary abdominal pregnancy include [[Uterine rupture|uterine rupture]], rupture of a [[Unicornuate uterus#Rudimentary_horn|uterine rudimentary horn]] and [[Fimbriae of uterine tube|fimbrial abortion]]. <ref name=Masukume/>


==Diagnosis==
==Diagnosis==
A patient with an abdominal pregnancy may just display the normal signs of pregnancy or have [[non-specific symptom]]s such as [[abdominal pain]], [[vaginal bleeding]], and/or gastrointestinal symptoms.<ref name=bonn/> Frequently the diagnosis of an abdominal pregnancy is missed.<ref name=Sunday/> However, it is a dangerous condition as it can bleed intraperitoneally resulting in a [[medical emergency]] with [[hemorrhagic shock]] and can be fatal; other causes of maternal death in patients with an abdominal pregnancy include [[toxemia]]{{disambiguation needed|date=March 2013}}, [[anemia]], [[pulmonary embolus]], [[coagulopathy]], and infection.<ref name=hk/>
A person with an abdominal pregnancy may feel there is "something not right" or just display the normal signs of pregnancy or have [[non-specific symptom]]s such as [[abdominal pain]], [[vaginal bleeding]], and/or [[Human gastrointestinal tract#Symptoms|gastrointestinal symptoms]]. <ref name=bonn/> Frequently the diagnosis of an abdominal pregnancy is missed, even with the use of [[Obstetrical ultrasonography|sonography]] (which depends on the operator's skill).<ref name=Sunday/> <ref name=Roberts>{{cite doi|10.1111/j.1479-828X.2005.00489.x}}</ref> However, it is a dangerous condition as it can bleed intraperitoneally resulting in a [[medical emergency]] with [[hemorrhagic shock]] and can be fatal; other causes of maternal death in patients with an abdominal pregnancy include [[anemia]], [[pulmonary embolus]], [[coagulopathy]], and [[infection]].<ref name=hk/>


Suspicion of an abdominal pregnancy is raised when the baby‘s parts can be easily felt, or the [[Lie (obstetrics)|lie]] is abnormal. [[Obstetrical ultrasonography|Sonography]] is extremely helpful in the diagnosis as it can demonstrate that the pregnancy is outside an empty uterus, there is no [[amniotic fluid]] between the placenta and the fetus, no uterine wall surrounding the fetus, fetal parts are close to the abdominal wall, and the fetus is in abnormal lie.<ref name=hk/> [[MRI]] has also been used with success to diagnose abdominal pregnancy.<ref name=dahiya/> Elevated [[alpha-fetoprotein]] levels are another clue of the presence of an abdominal pregnancy.<ref>{{cite journal | author=Tromans PM, Coulson R, Lobb MO, Abdulla U |title= Abdominal pregnancy associated with extremely elevated serum alphafetoprotein: case report |journal= British Journal of Obstetrics and Gynaecology |pmid=6200135 | year=1984 | volume=91 | issue=3 | pages=296–8 | doi=10.1111/j.1471-0528.1984.tb04773.x}}</ref>
Suspicion of an abdominal pregnancy is raised when the baby‘s parts can be easily felt, or the [[Lie (obstetrics)|lie]] is abnormal, the [[Cervix|cervix]] is displaced, or there is failed [[Labor induction|induction of labor]]. <ref name=Nunyalulendho/> [[X-ray#Medical uses|X-rays]] can be used to aid diagnosis. <ref name=bonn/> Sonography can demonstrate that the pregnancy is outside an empty uterus, there is reduced to no [[amniotic fluid]] between the placenta and the fetus, no uterine wall surrounding the fetus, fetal parts are close to the abdominal wall, the fetus has an abnormal lie, the placenta looks abnormal and there is [[Ascites|free fluid in the abdomen]]. <ref name=hk/> <ref>{{cite doi|10.1186/1752-1947-7-10}}</ref> [[MRI]] has also been used with success to diagnose abdominal pregnancy and plan for surgery. <ref>{{cite journal | author=Lockhat F, Corr P, Ramphal S, Moodly J |title=The value of magnetic resonance imaging in the diagnosis and management of extra-uterine abdominal pregnancy |journal= Clin Radiol |pmid=16488208 | year=2006 | volume=61 | issue=3 | pages=264-9 | doi=}}</ref><ref name=dahiya/> Elevated [[alpha-fetoprotein]] levels are another clue of the presence of an abdominal pregnancy.<ref>{{cite journal | author=Tromans PM, Coulson R, Lobb MO, Abdulla U |title= Abdominal pregnancy associated with extremely elevated serum alphafetoprotein: case report |journal= British Journal of Obstetrics and Gynaecology |pmid=6200135 | year=1984 | volume=91 | issue=3 | pages=296–8 | doi=10.1111/j.1471-0528.1984.tb04773.x}}</ref>

To diagnose the rare primary abdominal pregnancy, Studdiford's 1942 criteria need to be fulfilled: tubes and ovaries should be normal, there is no abnormal connection ([[fistula]]) between the uterus and the abdominal cavity, and the pregnancy is related solely to the peritoneal surface without signs that there was a tubal pregnancy first.<ref name=Studdiford>{{cite journal |title=Primary peritoneal pregnancy| author=Studdiford WE |journal= Am J Obstet Gynecol |doi= |url= |pmid= |date=1942 |volume=44 |issue= |pages=487–91 }}</ref> Studdiford's criteria were refined in 1968 by Friedrich and Rankin to include [[Histopathology|microscopic]] findings. <ref name=Friedrich>{{cite journal |title=Primary pelvic peritoneal pregnancy| author=Friedrich EG Jr, Rankin CA Jr |journal= Obstet Gynecol |doi= |url= |pmid=5646396 |date=1968 |volume=31 |issue=5 |pages=649–53 }}</ref>

===Differential diagnosis===
Depending on [[Gestational age|gestational age]] the [[Differential diagnosis|differential diagnoses]] for abdominal pregnancy include [[Miscarriage|miscarriage]], [[Stillbirth|intra-uterine fetal death]], [[Placental abruption|placental abruption]], an [[Acute abdomen|acute abdomen with an intra-uterine pregnancy]] and a [[Uterine fibroid|fibroid uterus with an intra-uterine pregnancy]] . <ref name=Oneko/>


==Treatment==
==Treatment==
[[File:Intra-abdominal fetus being delivered.png|thumb|Abdominal pregnancy being delivered]]
Potential treatments consist of surgery with termination of the pregnancy (removal of the fetus) via [[laparoscopy]] or [[laparotomy]], use of [[methotrexate]], [[embolization]], and combinations of these. Sapuri and Klufio indicate that conservative treatment is also possible if the following criteria are met: 1. there are no major congenital malformations; 2. the fetus is alive; 3. there is continuous hospitalization in a well-equipped and well-staffed maternity unit which has immediate blood transfusion facilities; 4. there is careful monitoring of maternal and fetal wellbeing; and 5. placental implantation is in the lower abdomen away from the liver and spleen.<ref>{{cite journal |url= http://www.pngimr.org.pg/png_med_journal/Advanced%20viable%20-%20%20Mar%2097.pdf |author=Sapuri M, Klufio C |title=A case of advanced viable extrauterine pregnancy |journal= Papua New Guinea Medical Journal | volume=40 |pages=44–47 |date=March 1997 |pmid=10365569| issue=1 }}</ref> The choice is largely dictated by the clinical situation. Generally, treatment is indicated when the diagnosis is made; however, the situation of the advanced abdominal pregnancy is more complicated.
Ideally the management of abdominal pregnancy should be done by a [[team]] that has medical personnel from [[Specialty (medicine)|multiple specialties]]. <ref>{{cite doi|10.1136/bcr-2013-200495}}</ref> Potential treatments consist of surgery with termination of the pregnancy (removal of the fetus) via [[laparoscopy]] or [[laparotomy]], use of [[methotrexate]], [[embolization]], and combinations of these. Sapuri and Klufio indicate that conservative treatment is also possible if the following criteria are met: 1. there are no major congenital malformations; 2. the fetus is alive; 3. there is continuous hospitalization in a well-equipped and well-staffed maternity unit which has immediate blood transfusion facilities; 4. there is careful monitoring of maternal and fetal well being; and 5. placental implantation is in the lower abdomen away from the liver and spleen.<ref>{{cite journal |url= http://www.pngimr.org.pg/png_med_journal/Advanced%20viable%20-%20%20Mar%2097.pdf |author=Sapuri M, Klufio C |title=A case of advanced viable extrauterine pregnancy |journal= Papua New Guinea Medical Journal | volume=40 |pages=44–47 |date=March 1997 |pmid=10365569| issue=1 }}</ref> The choice is largely dictated by the clinical situation. Generally, treatment is indicated when the diagnosis is made; however, the situation of the advanced abdominal pregnancy is more complicated.


===Advanced abdominal pregnancy===
===Advanced abdominal pregnancy===
Advanced abdominal pregnancy refers to situations where the pregnancy continues past 20 weeks of [[gestation]].<ref>{{cite journal |url= http://resources.metapress.com/pdf-preview.axd?code=0q502jvng20024u6&size=largest |author=White RG |title=Advance Abdominal Pregnancy – A Review of 23 Cases |journal= Irish Journal of Medical Science | volume=158 |pages=77–8 |date=March 1989 |pmid=2753657| issue=3 |doi= 10.1007/BF02942151}}</ref> In those situations, live births have been reported, so in a report from Nigeria with four live births out of a series of 20 abdominal pregnancies.<ref name=Sunday/> Often, however, with advancement of the pregnancy the support for the fetus becomes compromised and the fetus dies. A patient may carry a dead fetus but will not go into labor. Over time, the fetus calcifies and becomes a [[lithopedion]].
Advanced abdominal pregnancy refers to situations where the pregnancy continues past 20 weeks of [[gestation]] (versus early abdominal pregnancy < 20 weeks).<ref name=White>{{cite journal |url= http://resources.metapress.com/pdf-preview.axd?code=0q502jvng20024u6&size=largest |author=White RG |title=Advanced Abdominal Pregnancy – A Review of 23 Cases |journal= Irish Journal of Medical Science | volume=158 |pages=77–8 |date=March 1989 |pmid=2753657| issue=3 |doi= 10.1007/BF02942151}}</ref> <ref name=Agarwal/> In those situations, live births have been reported in [[Academic journal|academic journals]] <ref name=Masukume/> and also in the [[News media|lay press]] where the babies are not uncommonly referred to as 'Miracle babies'. <ref>BBC News Health. [http://news.bbc.co.uk/2/hi/health/443373.stm "Doctors hail 'miracle' baby"], ''[[BBC News]]'', London, 10 September 1999. Retrieved on 11 November 2014.</ref> <ref>Jessica Salter. [http://www.telegraph.co.uk/news/uknews/2658086/Miracle-baby-who-grew-outside-the-womb.html "'Miracle baby' who grew outside the womb"], ''[[The Daily Telegraph]]'', London, 31 August 2008. Retrieved on 11 November 2014.</ref> Often, however, with advancement of the pregnancy the support for the fetus becomes compromised and the fetus dies. <ref>{{cite doi|10.4172/scientificreports.434}}</ref> A patient may carry a dead fetus but will not go into labor. Over time, the fetus calcifies and becomes a [[lithopedion]]. <ref>{{cite doi|10.1186/2193-1801-3-151}}</ref>


It is generally recommended to perform a laparotomy when the diagnosis of an abdominal pregnancy is made.<ref name=bonn/> However, if the pregnancy is past 24 weeks and the baby alive and medical support systems are in place, careful watching could be considered to bring the baby to [[Viability (fetal)|viability]] (34–36 weeks).<ref name=bonn/> Women with an abdominal pregnancy will not go into labor. Delivery in a case of an advanced abdominal pregnancy will have to be via [[laparotomy]]. The survival of the baby is reduced and high [[perinatal mortality]] rates between 40-95% have been reported.<ref>{{cite journal |author=Martin JN Jr, Sessums JK, Martin RW, Pryor JA, Morrison JC| title=Abdominal pregnancy: current concepts of management |journal=Obstetrics and Gynecology |pmid=3281075 |year=1988 |volume=71 |issue=4 |pages=549–57}}</ref>
It is generally recommended to perform a laparotomy when the diagnosis of an abdominal pregnancy is made.<ref name=bonn/> However, if the baby is alive and medical support systems are in place, careful watching could be considered to bring the baby to [[Viability (fetal)|viability]].<ref name=bonn/> Women with an abdominal pregnancy will not go into labor. Delivery in a case of an advanced abdominal pregnancy will have to be via [[laparotomy]]. The survival of the baby is reduced and high [[perinatal mortality]] rates between 40-95% have been reported.<ref>{{cite journal |author=Martin JN Jr, Sessums JK, Martin RW, Pryor JA, Morrison JC| title=Abdominal pregnancy: current concepts of management |journal=Obstetrics and Gynecology |pmid=3281075 |year=1988 |volume=71 |issue=4 |pages=549–57}}</ref>


Babies of abdominal pregnancies often have [[birth defect]]s due to compression in the absence of the [[amniotic fluid]] buffer. The rate of [[malformation]]s and deformations is estimated to be about 21%; typical deformations are facial and cranial asymmetries and joint abnormalities and the most common malformations are limb defects and central nervous malformations.<ref>{{cite journal| author=Stevens CA| title=Malformations and deformations in abdominal pregnancy |journal=American Journal of Medical Genetics | pmid=8291554| year=1993| volume=47| issue=8| pages=1189–95| doi=10.1002/ajmg.1320470812}}</ref>
Babies of abdominal pregnancies are prone to [[birth defect]]s due to compression in the absence of the [[Uterus#Layers|uterine wall]] and the often reduced amount of [[amniotic fluid]] surrounding the unborn baby. <ref name=Stevens>{{cite journal| author=Stevens CA| title=Malformations and deformations in abdominal pregnancy |journal=American Journal of Medical Genetics | pmid=8291554| year=1993| volume=47| issue=8| pages=1189–95| doi=10.1002/ajmg.1320470812}}</ref> The rate of [[malformation]]s and deformations is estimated to be about 21%; typical deformations are facial and cranial asymmetries and joint abnormalities and the most common malformations are limb defects and central nervous malformations. <ref name=Stevens/>


Once the baby has been delivered [[placenta]]l management becomes an issue. In normal deliveries the contraction of uterus provides a powerful mechanism to control blood loss, however, in an abdominal pregnancy the placenta is located over tissue that cannot contract and attempts of its removal may lead to significant blood loss. Generally, unless the placenta can be easily tied off or removed, it may be preferable to leave it in place and allow for a natural regression.<ref name=hk/><ref name=bonn/> This process may take about four months and can be monitored by checking [[human chorionic gonadotropin]] levels. Use of [[methotrexate]] to accelerate placental regression is controversial as the large amount of necrotic tissue is a potential site for infection.<ref name=hk/> Placental vessels have also been blocked by angiographic [[embolization]].<ref>{{cite journal |author=Cardosi RJ, Nackley AC, Londono J, Hoffman MS |title=Embolization for advanced abdominal pregnancy with a retained placenta. A case report |journal=Reproductive Medicine |pmid=12418072 |year=2002 |volume=47 |issue=10 |pages=861–3}}</ref>
Once the baby has been delivered [[placenta]]l management becomes an issue. In normal deliveries the contraction of uterus provides a powerful mechanism to control blood loss, however, in an abdominal pregnancy the placenta is located over tissue that cannot contract and attempts of its removal may lead to life-threatening blood loss. Thus [[Blood transfusion|blood transfusion]] is frequent in the management of patients with this kind of pregnancy, with others even using [[Tranexamic acid|tranexamic acid]] and [[Recombinant factor VIIa|recombinant factor VIIa]], which both minimize blood loss. <ref name=Nunyalulendho/> <ref>{{cite doi|10.1186/1752-1947-5-531}}</ref>

Generally, unless the placenta can be easily tied off or removed, it may be preferable to leave it in place and allow for a natural regression.<ref name=hk/><ref name=bonn/> This process may take several months and can be monitored by [[Physical examination|clinical examination]], checking [[human chorionic gonadotropin]] levels and by [[Medical ultrasonography|ultrasound scanning]] (in particular using [[Medical ultrasonography#Doppler_ultrasonography|doppler ultrasonography]]. <ref name=Roberts/> Use of [[methotrexate]] to accelerate placental regression is controversial as the large amount of necrotic tissue is a potential site for infection <ref name=hk/>, [[Mifepristone|mifepristone]] has also be used to promote placental regression. <ref name=Huang>{{cite journal |author=Huang K, Song L, Wang L, Gao Z, Meng Y, Lu Y|title=Advanced abdominal pregnancy: an increasingly challenging clinical concern for obstetricians |journal=Int J Clin Exp Pathol |pmid=25337188 |date=2014 |volume=7 |pages=5461-72| issue=9 }}</ref> Placental vessels have also been blocked by angiographic [[embolization]].<ref>{{cite journal |author=Cardosi RJ, Nackley AC, Londono J, Hoffman MS |title=Embolization for advanced abdominal pregnancy with a retained placenta. A case report |journal=Reproductive Medicine |pmid=12418072 |year=2002 |volume=47 |issue=10 |pages=861–3}}</ref> Complications of leaving the placenta can include residual [[bleeding]], [[infection]], [[Bowel obstruction|bowel obstruction]] (which may all necessitate further surgery) <ref name=Huang/> and failure to [[Breastfeeding|breast feed]] due to [[Placenta#Endocrine function|placental hormones]]. <ref>{{cite doi|10.1089/bfm.2011.0131}}</ref>

Outcome with abdominal pregnancy can be good for the baby and mother, Lampe described an abdominal pregnancy baby and her mother who were well more than 22 years after surgery. <ref>{{cite doi|10.1016/j.ejogrb.2006.11.023}}</ref>


==Epidemiology==
==Epidemiology==
Less than 1% of ectopic pregnancies in the United States are abdominal, or about 1 out of every 10,000 pregnancies.<ref name=atrash/> A report from Nigeria places the frequency in that country at 34 per 100,000 deliveries.<ref name=Sunday>{{cite journal| author= Sunday-Adeoye I, Twomey D, Egwuatu EV, Okonta PI |title=A 30-year review of advanced abdominal pregnancy at the Mater Misericordiae Hospital, Afikpo, southeastern Nigeria (1976-2006)| journal=Archives of Gynecology and Obstetrics |pmid=19876640| year= 2011| volume= 283| issue= 1| pages=19–24| doi= 10.1007/s00404-009-1260-4}}</ref> The [[maternal mortality|risk of death]] is estimated to be about 5 per 1,000 cases, about seven times the rate for ectopics in general, and about 90 times the rate for a delivery (US data).<ref name=atrash/>
Less than 1% of ectopic pregnancies in the United States are abdominal, or about 1 out of every 10,000 pregnancies.<ref name=Atrash>{{cite journal| author= Atrash HK, Friede A, Hogue CJ |title=Abdominal pregnancy in the United States: frequency and maternal mortality| journal=Obstet Gynecol |pmid=3822281| year= 1987| volume=69| issue= 3 Pt 1| pages=333–7| doi= }}</ref> A report from [[Nigeria]] places the frequency in that country at 34 per 100,000 deliveries and a report from [[Zimbabwe]], 11 per 100,000 deliveries.<ref name=Sunday>{{cite journal| author= Sunday-Adeoye I, Twomey D, Egwuatu EV, Okonta PI |title=A 30-year review of advanced abdominal pregnancy at the Mater Misericordiae Hospital, Afikpo, southeastern Nigeria (1976-2006)| journal=Archives of Gynecology and Obstetrics |pmid=19876640| year= 2011| volume= 283| issue= 1| pages=19–24| doi= 10.1007/s00404-009-1260-4}}</ref> <ref name=White/> Risk factors are similar to [[tubal pregnancy]] with [[sexually transmitted disease]] playing a major role.<ref name=hk>{{cite journal |url= http://www.hkmj.org/article_pdfs/hkm0012p425.pdf |title= Abdominal pregnancy presenting as a missed abortion at 16 weeks' gestation |author=KY Kun, PY Wong, MW Ho, CM Tai, TK Ng |journal=Hong Kong Medical Journal |accessdate=January 25, 2009|pmid= 11177167 |year= 2000 |volume= 6 |issue= 4 |pages= 425–7}}</ref>; however about half of those with ectopic pregnancy have no known risk factors - known risk factors include damage to the Fallopian tubes from [[Ectopic pregnancy#Surgical|previous surgery]] or from previous ectopic pregnancy and [[Tobacco smoking|tobacco smoking]]. <ref>{{cite doi|10.1056/NEJMcp0810384}}</ref> The [[maternal mortality]] rate is estimated to be about 5 per 1,000 cases, about seven times the rate for ectopics in general, and about 90 times the rate for a delivery (1987 US data).<ref name=Atrash/>

==History==
[[Abu al-Qasim al-Zahrawi|Albucasis]] (936–1013), the [[Arab]] [[Muslim]] [[physician]] is credited with first recognizing abdominal pregnancy which was apparently unknown to [[Greek]] and [[Roman]] physicians and was not mentioned in the writings of [[Hippocrates]]; [[Jacopo Berengario da Carpi]] (1460–1530) the Italian physician is credited with the first detailed anatomical description of abdominal pregnancy.
<ref name=Cotlar>{{cite journal |author=Cotlar AM|title=Extrauterine pregnancy: a historical review(3) |journal=Curr Surg |date=2000 |volume=57 |pages=484–492| pmid=11064074 |issue=5 }}</ref>

==Natural experiment==
Because pregnancy is outside the uterus, abdominal pregnancy serves as a [[Natural experiment|model]] of [[Male_pregnancy|human male pregnancy]] or for females who lack a uterus, although such pregnancy would be dangerous. <ref>Meryl Rothstein. [http://www.popsci.com/scitech/article/2005-07/male-pregnancy-dangerous-proposition "Male Pregnancy: A Dangerous Proposition"], ''[[Popular Science]]'', [[Bonnier Corporation]], 31 July 2005. Retrieved on 12 November 2014.</ref>
<ref>Dick Teresi. [http://www.nytimes.com/1994/11/27/magazine/how-to-get-a-man-pregnant.html "HOW TO GET A MAN PREGNANT"], ''[[The New York Times]]'', 27 November 1994. Retrieved on 12 November 2014.</ref> Abdominal pregnancy has served to further clarify the disease [[Pre-eclampsia|pre-eclampsia]] which was previously thought (1980's) to require a uterus for it to occur, however pre-eclampsia's occurrence in abdominal pregnancy (with the [[Conceptus|conceptus]] outside the uterus) helped throw light on pre-eclampsia's [[etiology]]. <ref name=Moodley>{{cite journal |author=Moodley J, Subrayen KT, Sankar D, Pitsoe SB |title= Advanced extra-uterine pregnancy associated with eclampsia. A report of 2 cases. |journal=S Afr Med J |pmid= 3563800 |year= 1987 |volume= 71 |issue= 7 |pages= 460-1}}</ref> The [[Human sex ratio|ratio of live males to females at birth]] (normal, 107 males to 100 females <ref>[[CIA|Central Intelligence Agency]]. [https://www.cia.gov/library/publications/the-world-factbook/geos/xx.html "WORLD - Sex ratio"], ''[[The World Factbook]]'', 2014. Retrieved on 12 November 2014.</ref>) is apparently reduced with abdominal pregnancy to as low as 60 males to 100 females (as reported by Masukume) because males are more likely to die in harsh environments (for example in abdominal pregnancy) compared to females. <ref name=Masukume/>
Cases of combined simultaneous abdominal and intra-uterine pregnancy have been reported. <ref name=Huang/> <ref>{{cite doi|10.1016/j.ejogrb.2010.10.015}}</ref>


==References==
==References==
{{reflist}}
{{reflist|3}}


==External links==
==External links==
*[http://www.thefetus.net/page.php?id=1032 Pictures]
*[http://www.thefetus.net/page.php?id=1032 Pictures]
* [http://www.ectopic.org.uk The Ectopic Pregnancy Trust] - Information and support for those who have suffered the condition by a medically overseen and moderated [[united Kingdom|UK]] based charity, recognised by the National Health Service (UK) Department of Health (UK) and [http://www.rcog.org.uk/ the Royal College of Obstetricians and Gynaecologists]
* [http://www.ectopic.org.uk The Ectopic Pregnancy Trust] - Information and support for those who have suffered the condition by a medically overseen and moderated [[united Kingdom|UK]] based charity, recognized by the National Health Service (UK) Department of Health (UK) and [http://www.rcog.org.uk/ the Royal College of Obstetricians and Gynaecologists]


{{Pathology of pregnancy, childbirth and the puerperium}}
{{Pathology of pregnancy, childbirth and the puerperium}}


[[Category:Medical emergencies]]
[[:Category:Medical emergencies]]
[[Category:Pregnancy with abortive outcome]]
[[:Category:Pregnancy with abortive outcome]]
[[Category:Health issues in pregnancy]]
[[:Category:Health issues in pregnancy]]

Revision as of 02:33, 20 November 2014

Abdominal pregnancy
SpecialtyObstetrics Edit this on Wikidata

An abdominal pregnancy can be regarded as a form of an ectopic pregnancy where the embryo or fetus is growing and developing outside the womb in the abdomen, but not in the Fallopian tube, ovary or broad ligament. [1] [2]

While rare, abdominal pregnancies have a higher chance of maternal mortality, perinatal mortality and morbidity compared to normal and ectopic pregnancies but, on occasion a healthy viable infant can be delivered. [3]

Because tubal, ovarian and broad ligament pregnancies are as difficult to diagnose and treat as abdominal pregnancies, their exclusion from the most common definition of abdominal pregnancy has been debated. [4]

Others - in the minority - are of the view that abdominal pregnancy should be defined by a placenta implanted into the peritoneum. [5]

Symptoms and signs

Symptoms may include abdominal pain or vaginal bleeding during pregnancy.[1] As this is nonspecific in areas were ultrasound is not available the diagnosis was often only discovered during surgery to investigate the abnormal symptoms.[1] They are diagnosed later in the developing world than the developed.[6] In about half of cases from a center in the developing world the diagnosis was initially missed.[7]

Mechanism

Implantation sites can be anywhere in the abdomen but can include the peritoneum outside of the uterus, the rectouterine pouch (culdesac of Douglas), omentum, bowel and its mesentery, mesosalpinx, and the peritoneum of the pelvic wall and the abdominal wall.[8][9] The growing placenta may be attached to several organs including tube and ovary. Rare other sites have been the liver and spleen,[10] giving rise to a hepatic pregnancy[11] or splenic pregnancy, respectively.[12] Even an early diaphragmatic pregnancy has been described in a patient where an embryo began growing on the underside of the diaphragm.[13]

Primary versus secondary implantation

A primary abdominal pregnancy refers to a pregnancy that first implanted directly in the peritoneum, save for the tubes and ovaries; such pregnancies are very rare, only 24 cases had been reported by 2007.[14] Typically an abdominal pregnancy is a secondary implantation which means that it originated from a tubal (less common an ovarian) pregnancy and re-implanted.[9] Other mechanisms for secondary abdominal pregnancy include uterine rupture, rupture of a uterine rudimentary horn and fimbrial abortion. [3]

Diagnosis

A person with an abdominal pregnancy may feel there is "something not right" or just display the normal signs of pregnancy or have non-specific symptoms such as abdominal pain, vaginal bleeding, and/or gastrointestinal symptoms. [9] Frequently the diagnosis of an abdominal pregnancy is missed, even with the use of sonography (which depends on the operator's skill).[7] [15] However, it is a dangerous condition as it can bleed intraperitoneally resulting in a medical emergency with hemorrhagic shock and can be fatal; other causes of maternal death in patients with an abdominal pregnancy include anemia, pulmonary embolus, coagulopathy, and infection.[16]

Suspicion of an abdominal pregnancy is raised when the baby‘s parts can be easily felt, or the lie is abnormal, the cervix is displaced, or there is failed induction of labor. [1] X-rays can be used to aid diagnosis. [9] Sonography can demonstrate that the pregnancy is outside an empty uterus, there is reduced to no amniotic fluid between the placenta and the fetus, no uterine wall surrounding the fetus, fetal parts are close to the abdominal wall, the fetus has an abnormal lie, the placenta looks abnormal and there is free fluid in the abdomen. [16] [17] MRI has also been used with success to diagnose abdominal pregnancy and plan for surgery. [18][14] Elevated alpha-fetoprotein levels are another clue of the presence of an abdominal pregnancy.[19]

To diagnose the rare primary abdominal pregnancy, Studdiford's 1942 criteria need to be fulfilled: tubes and ovaries should be normal, there is no abnormal connection (fistula) between the uterus and the abdominal cavity, and the pregnancy is related solely to the peritoneal surface without signs that there was a tubal pregnancy first.[20] Studdiford's criteria were refined in 1968 by Friedrich and Rankin to include microscopic findings. [21]

Differential diagnosis

Depending on gestational age the differential diagnoses for abdominal pregnancy include miscarriage, intra-uterine fetal death, placental abruption, an acute abdomen with an intra-uterine pregnancy and a fibroid uterus with an intra-uterine pregnancy . [6]

Treatment

Abdominal pregnancy being delivered

Ideally the management of abdominal pregnancy should be done by a team that has medical personnel from multiple specialties. [22] Potential treatments consist of surgery with termination of the pregnancy (removal of the fetus) via laparoscopy or laparotomy, use of methotrexate, embolization, and combinations of these. Sapuri and Klufio indicate that conservative treatment is also possible if the following criteria are met: 1. there are no major congenital malformations; 2. the fetus is alive; 3. there is continuous hospitalization in a well-equipped and well-staffed maternity unit which has immediate blood transfusion facilities; 4. there is careful monitoring of maternal and fetal well being; and 5. placental implantation is in the lower abdomen away from the liver and spleen.[23] The choice is largely dictated by the clinical situation. Generally, treatment is indicated when the diagnosis is made; however, the situation of the advanced abdominal pregnancy is more complicated.

Advanced abdominal pregnancy

Advanced abdominal pregnancy refers to situations where the pregnancy continues past 20 weeks of gestation (versus early abdominal pregnancy < 20 weeks).[24] [2] In those situations, live births have been reported in academic journals [3] and also in the lay press where the babies are not uncommonly referred to as 'Miracle babies'. [25] [26] Often, however, with advancement of the pregnancy the support for the fetus becomes compromised and the fetus dies. [27] A patient may carry a dead fetus but will not go into labor. Over time, the fetus calcifies and becomes a lithopedion. [28]

It is generally recommended to perform a laparotomy when the diagnosis of an abdominal pregnancy is made.[9] However, if the baby is alive and medical support systems are in place, careful watching could be considered to bring the baby to viability.[9] Women with an abdominal pregnancy will not go into labor. Delivery in a case of an advanced abdominal pregnancy will have to be via laparotomy. The survival of the baby is reduced and high perinatal mortality rates between 40-95% have been reported.[29]

Babies of abdominal pregnancies are prone to birth defects due to compression in the absence of the uterine wall and the often reduced amount of amniotic fluid surrounding the unborn baby. [30] The rate of malformations and deformations is estimated to be about 21%; typical deformations are facial and cranial asymmetries and joint abnormalities and the most common malformations are limb defects and central nervous malformations. [30]

Once the baby has been delivered placental management becomes an issue. In normal deliveries the contraction of uterus provides a powerful mechanism to control blood loss, however, in an abdominal pregnancy the placenta is located over tissue that cannot contract and attempts of its removal may lead to life-threatening blood loss. Thus blood transfusion is frequent in the management of patients with this kind of pregnancy, with others even using tranexamic acid and recombinant factor VIIa, which both minimize blood loss. [1] [31]

Generally, unless the placenta can be easily tied off or removed, it may be preferable to leave it in place and allow for a natural regression.[16][9] This process may take several months and can be monitored by clinical examination, checking human chorionic gonadotropin levels and by ultrasound scanning (in particular using doppler ultrasonography. [15] Use of methotrexate to accelerate placental regression is controversial as the large amount of necrotic tissue is a potential site for infection [16], mifepristone has also be used to promote placental regression. [32] Placental vessels have also been blocked by angiographic embolization.[33] Complications of leaving the placenta can include residual bleeding, infection, bowel obstruction (which may all necessitate further surgery) [32] and failure to breast feed due to placental hormones. [34]

Outcome with abdominal pregnancy can be good for the baby and mother, Lampe described an abdominal pregnancy baby and her mother who were well more than 22 years after surgery. [35]

Epidemiology

Less than 1% of ectopic pregnancies in the United States are abdominal, or about 1 out of every 10,000 pregnancies.[8] A report from Nigeria places the frequency in that country at 34 per 100,000 deliveries and a report from Zimbabwe, 11 per 100,000 deliveries.[7] [24] Risk factors are similar to tubal pregnancy with sexually transmitted disease playing a major role.[16]; however about half of those with ectopic pregnancy have no known risk factors - known risk factors include damage to the Fallopian tubes from previous surgery or from previous ectopic pregnancy and tobacco smoking. [36] The maternal mortality rate is estimated to be about 5 per 1,000 cases, about seven times the rate for ectopics in general, and about 90 times the rate for a delivery (1987 US data).[8]

History

Albucasis (936–1013), the Arab Muslim physician is credited with first recognizing abdominal pregnancy which was apparently unknown to Greek and Roman physicians and was not mentioned in the writings of Hippocrates; Jacopo Berengario da Carpi (1460–1530) the Italian physician is credited with the first detailed anatomical description of abdominal pregnancy. [37]

Natural experiment

Because pregnancy is outside the uterus, abdominal pregnancy serves as a model of human male pregnancy or for females who lack a uterus, although such pregnancy would be dangerous. [38] [39] Abdominal pregnancy has served to further clarify the disease pre-eclampsia which was previously thought (1980's) to require a uterus for it to occur, however pre-eclampsia's occurrence in abdominal pregnancy (with the conceptus outside the uterus) helped throw light on pre-eclampsia's etiology. [40] The ratio of live males to females at birth (normal, 107 males to 100 females [41]) is apparently reduced with abdominal pregnancy to as low as 60 males to 100 females (as reported by Masukume) because males are more likely to die in harsh environments (for example in abdominal pregnancy) compared to females. [3] Cases of combined simultaneous abdominal and intra-uterine pregnancy have been reported. [32] [42]

References

  1. ^ a b c d e Nkusu Nunyalulendho D, Einterz EM (2008). "Advanced abdominal pregnancy: case report and review of 163 cases reported since 1946". Rural Remote Health. 8 (4): 1087. PMID 19053177.
  2. ^ a b Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.1111/tog.12109, please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with |doi=10.1111/tog.12109 instead.
  3. ^ a b c d Masukume G (2014). "Live births resulting from advanced abdominal extrauterine pregnancy, a review of cases reported from 2008 to 2013". WebmedCentral OBSTETRICS AND GYNAECOLOGY. 5 (1): WMC004510.
  4. ^ Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.1016/j.ajog.2007.09.044, please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with |doi=10.1016/j.ajog.2007.09.044 instead.
  5. ^ Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.1016/j.ajog.2008.06.024, please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with |doi=10.1016/j.ajog.2008.06.024 instead.
  6. ^ a b Oneko, O; Petru, E; Masenga, G; Ulrich, D; Obure, J; Zeck, W (July 2010). "Management of the placenta in advanced abdominal pregnancies at an East african tertiary referral center". Journal of women's health (2002). 19 (7): 1369–75. PMID 20509789.
  7. ^ a b c Sunday-Adeoye I, Twomey D, Egwuatu EV, Okonta PI (2011). "A 30-year review of advanced abdominal pregnancy at the Mater Misericordiae Hospital, Afikpo, southeastern Nigeria (1976-2006)". Archives of Gynecology and Obstetrics. 283 (1): 19–24. doi:10.1007/s00404-009-1260-4. PMID 19876640.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  8. ^ a b c Atrash HK, Friede A, Hogue CJ (1987). "Abdominal pregnancy in the United States: frequency and maternal mortality". Obstet Gynecol. 69 (3 Pt 1): 333–7. PMID 3822281.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  9. ^ a b c d e f g Maurice King, Peter C. Bewes, James Cairns, Jim Thornton (editors). "Primary Surgery; Volume One: Non-trauma. Chapter 8, Abdominal pregnancy". Bonn University. Retrieved 2010-01-25. {{cite web}}: |author= has generic name (help)CS1 maint: multiple names: authors list (link)
  10. ^ Anderson PM, Opfer EK, Busch JM, Magann EF (2009). "An Early Abdominal Wall Ectopic Pregnancy Successfully Treated with Ultrasound Guided Intralesional Methotrexate: A Case Report". Obstetrics and Gynecology International. doi:10.1155/2009/247452Case+Report.{{cite journal}}: CS1 maint: multiple names: authors list (link) CS1 maint: unflagged free DOI (link)
  11. ^ Chui AK, Lo KW, Choi PC, Sung MC, Lau JW. (April 2001). "Primary hepatic pregnancy". ANZ Journal of Surgery. 71 (4): 260–1. doi:10.1046/j.1440-1622.2001.02085.x. PMID 11355741.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  12. ^ Yagil Y, Beck-Razi N, Amit A, Kerner H, Gaitini D (2007). "Splenic Pregnancy: The Role of Abdominal Imaging". Journal of Ultrasound Medicine. 26 (11): 1629–32. PMID 17957059.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  13. ^ Norenberg DD, Gundersen JH, Janis JF, Gundersen AL. (May 1977). "Early pregnancy on the diaphragm with endometriosis". Obstetrics and Gynecology. 49 (5): 620–2. PMID 850582.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  14. ^ a b Krishna Dahiya, Damyanti Sharma (June 2007). "Advanced Abdominal Pregnancy: A Diagnostic and Management Dilemma". Journal of Gynecologic Surgery. 23 (2): 69–72. doi:10.1089/gyn.2007.B-02259-1.
  15. ^ a b Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.1111/j.1479-828X.2005.00489.x, please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with |doi=10.1111/j.1479-828X.2005.00489.x instead.
  16. ^ a b c d e KY Kun, PY Wong, MW Ho, CM Tai, TK Ng (2000). "Abdominal pregnancy presenting as a missed abortion at 16 weeks' gestation" (PDF). Hong Kong Medical Journal. 6 (4): 425–7. PMID 11177167. Retrieved January 25, 2009.{{cite journal}}: CS1 maint: multiple names: authors list (link)
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  18. ^ Lockhat F, Corr P, Ramphal S, Moodly J (2006). "The value of magnetic resonance imaging in the diagnosis and management of extra-uterine abdominal pregnancy". Clin Radiol. 61 (3): 264–9. PMID 16488208.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  19. ^ Tromans PM, Coulson R, Lobb MO, Abdulla U (1984). "Abdominal pregnancy associated with extremely elevated serum alphafetoprotein: case report". British Journal of Obstetrics and Gynaecology. 91 (3): 296–8. doi:10.1111/j.1471-0528.1984.tb04773.x. PMID 6200135.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  20. ^ Studdiford WE (1942). "Primary peritoneal pregnancy". Am J Obstet Gynecol. 44: 487–91.
  21. ^ Friedrich EG Jr, Rankin CA Jr (1968). "Primary pelvic peritoneal pregnancy". Obstet Gynecol. 31 (5): 649–53. PMID 5646396.
  22. ^ Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.1136/bcr-2013-200495, please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with |doi=10.1136/bcr-2013-200495 instead.
  23. ^ Sapuri M, Klufio C (March 1997). "A case of advanced viable extrauterine pregnancy" (PDF). Papua New Guinea Medical Journal. 40 (1): 44–47. PMID 10365569.
  24. ^ a b White RG (March 1989). "Advanced Abdominal Pregnancy – A Review of 23 Cases". Irish Journal of Medical Science. 158 (3): 77–8. doi:10.1007/BF02942151. PMID 2753657.
  25. ^ BBC News Health. "Doctors hail 'miracle' baby", BBC News, London, 10 September 1999. Retrieved on 11 November 2014.
  26. ^ Jessica Salter. "'Miracle baby' who grew outside the womb", The Daily Telegraph, London, 31 August 2008. Retrieved on 11 November 2014.
  27. ^ Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.4172/scientificreports.434, please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with |doi=10.4172/scientificreports.434 instead.
  28. ^ Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.1186/2193-1801-3-151, please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with |doi=10.1186/2193-1801-3-151 instead.
  29. ^ Martin JN Jr, Sessums JK, Martin RW, Pryor JA, Morrison JC (1988). "Abdominal pregnancy: current concepts of management". Obstetrics and Gynecology. 71 (4): 549–57. PMID 3281075.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  30. ^ a b Stevens CA (1993). "Malformations and deformations in abdominal pregnancy". American Journal of Medical Genetics. 47 (8): 1189–95. doi:10.1002/ajmg.1320470812. PMID 8291554.
  31. ^ Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.1186/1752-1947-5-531, please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with |doi=10.1186/1752-1947-5-531 instead.
  32. ^ a b c Huang K, Song L, Wang L, Gao Z, Meng Y, Lu Y (2014). "Advanced abdominal pregnancy: an increasingly challenging clinical concern for obstetricians". Int J Clin Exp Pathol. 7 (9): 5461–72. PMID 25337188.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  33. ^ Cardosi RJ, Nackley AC, Londono J, Hoffman MS (2002). "Embolization for advanced abdominal pregnancy with a retained placenta. A case report". Reproductive Medicine. 47 (10): 861–3. PMID 12418072.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  34. ^ Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.1089/bfm.2011.0131, please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with |doi=10.1089/bfm.2011.0131 instead.
  35. ^ Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.1016/j.ejogrb.2006.11.023, please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with |doi=10.1016/j.ejogrb.2006.11.023 instead.
  36. ^ Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.1056/NEJMcp0810384, please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with |doi=10.1056/NEJMcp0810384 instead.
  37. ^ Cotlar AM (2000). "Extrauterine pregnancy: a historical review(3)". Curr Surg. 57 (5): 484–492. PMID 11064074.
  38. ^ Meryl Rothstein. "Male Pregnancy: A Dangerous Proposition", Popular Science, Bonnier Corporation, 31 July 2005. Retrieved on 12 November 2014.
  39. ^ Dick Teresi. "HOW TO GET A MAN PREGNANT", The New York Times, 27 November 1994. Retrieved on 12 November 2014.
  40. ^ Moodley J, Subrayen KT, Sankar D, Pitsoe SB (1987). "Advanced extra-uterine pregnancy associated with eclampsia. A report of 2 cases". S Afr Med J. 71 (7): 460–1. PMID 3563800.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  41. ^ Central Intelligence Agency. "WORLD - Sex ratio", The World Factbook, 2014. Retrieved on 12 November 2014.
  42. ^ Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.1016/j.ejogrb.2010.10.015, please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with |doi=10.1016/j.ejogrb.2010.10.015 instead.

External links

Category:Medical emergencies Category:Pregnancy with abortive outcome Category:Health issues in pregnancy

Retrieved from "https://en.wikipedia.org/w/index.php?title=Abdominal_pregnancy&oldid=634636377"