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9.2 Ruptured Cornual Pregnancy
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Before cornuotomy, diluted vasopressin (20U
in 60–100mL of normal saline) is injected into
the surrounding myometrium. An incision along
the most bulging portion is performed with a
monopolar current (Fig.9.16a). Gestational tissue is evacuated with toothed forceps. Irrigation
inside the incision is performed using high hydrostatic pressure. Bipolar cautery ensures hemostasis at bleeding sites inside the incision. Vertical
mattress sutures (2-0 or 1-0 Vicryl) approximate
the myometrium (Fig.9.16b).
Variations of cornual resection exist. The most
common is a deep circumferential incision
around the interstitial pregnancy followed by
removal of the underlying myometrium and conceptual tissue. The second starts with a single linear incision cornuotomy. After removing the
conceptual tissue, suspicious myometrium on
both sides is excised at the base in an elliptical
fashion. Extension of myometrium removal is
based on the color and texture of the myometrium. The nal variation also starts with a single
linear incision cornuotomy. After removing the
conceptual tissue, an endoscopic linear cutter stapler simultaneously removes suspicious myometrium and sutures. This technique is used when
Fig. 9.15 (a) Laparoscopic view showing anatomic rela-
tionships of the gravid rudimentary horn; (b)
Fibromuscular attachment between the left unicornuate
uterus and the pregnancy in the rudimentary horn; (c)
Fibromuscular band being divided; (d) Lateral attach-
ments of the horn to round ligament; (e) Tubal attachment
divided; (f) Intact specimen of rudimentary horn pregnancy; (g) Cut section of resected specimen. (Reproduced
with permission from [124] under the CC BY 3.0)
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9 Ruptured Ectopic Pregnancy
e
f
g
Fig. 9.15 (continued)
Fig. 9.16 Cornuotomy procedure. (a) After a linear incision, the conceptual tissue is removed. (b) Incision is closed
with a vertical mattress suture. (Reproduced with permission from [126])
the bulging mass is small and supercially
implanted (Fig.9.17).
Uncontrollable bleeding during cornuotomy
or cornual resection necessitates temporary or
permanent bleeding control methods. These
include encircling sutures or placement of preformed knots around cornual pregnancy
(Fig.9.18) or temporary or permanent ligation or
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9.2 Ruptured Cornual Pregnancy
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Fig. 9.17 Cornual resection procedure. (a) Mass is grasped with forceps, and the incision is along the bulge. (b)
Myometrium is closed with the stapler. (Reproduced with permission from [126])
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Fig. 9.18 Endoloop placement before the evacuation of
the conceptus. (a) After endoloop placement around the
base of cornual pregnancy, the incision is made on cornu
with tension kept on the endoloop. (b) A conceptus is
removed. (c) slightly increased density (arrow) compared
to the liver parenchyma in (d) the venous phase that shows
a non-enhanced. (Reproduced with permission from
[128])
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9 Ruptured Ectopic Pregnancy
occlusion of the uterine artery or ascending
branch of the uterine artery [129].
Microsurgical Fallopian Tube Transposition
Elective microsurgical Fallopian tube transposition is recommended with a damaged contralateral tube [130, 131].
9.2.5.3 Anesthetic andPerioperative
Management
See Chap. 2. In nonurgent presentations, it is vital
to evaluate the type of rudimentary horn and the
possible presence of urological anomalies before
embarking on the surgical excision to avoid associated complications [115]. Hence, the interval
excision of the rudimentary horn after the complete preoperative evaluation is recommended
[121, 132]. The rudimentary horn carries a risk
for associated abnormalities. Therefore, an
abdominal MRI should be performed after complete recovery, primarily due to the high risk of
urinary tract anomalies [121].
9.2.6 Prognosis
The mortality rate has been reduced from 23% at
the turn of the twentieth century to 0.5% today
due to earlier preoperative diagnosis and earlier
intervention in ensuing hemorrhage.
Cornax described umbilical stulae discharging
fetal parts in 1545, Felix Platter in 1584, and
Jacob Noierus in 1595. Both the mother and child
survived. Walker von Solothurn, in 1887, made
one of the rst modern descriptions of this condition [133]. Galabin described the rst case of primary abdominal pregnancy in 1896.
9.3.2 Classication
Abdominal pregnancies can be classied as primary when fertilization occurs outside the uter-
ine adnexa or as secondary (thought to be more
common), resulting from undetected rupture of
early tubal pregnancy with subsequent implantation onto the peritoneal surfaces. In rare cases of
uterine rupture (mostly rupture of a unicornuate
or bicornuate uterus), the fetus may be extruded
into the peritoneal cavity. At the same time, the
placenta remains functional within the uterus,
and the gestation continues as a uteroabdominal
pregnancy. According to Studdiford’s criteria,
primary peritoneal pregnancy can be clinically
distinguished from secondary peritoneal pregnancy (see Sect. 9.2.1).
Implantation can occur anywhere in the abdomen, including ligaments, liver, and spleen.
Abdominal pregnancy is not strictly dened as
early before 12–28 weeks of gestation and
advanced after.
9.3 Abdominal Pregnancy
9.3.1 Historical Perspective
The rst reference to abdominal pregnancy is
from the Talmud, in which rabbis reportedly
observed a child who emerged from the abdominal side of the mother. Hindu legend states that
Buddha was born through his mother’s right side
or armpit. The rst reported abdominal pregnancy was by Abulcasis in the tenth century, who
observed the discharge of fetal parts through the
abdominal wall in the umbilical region. The rst
documented report of a successful abdominal
pregnancy was in 1500 when a Swiss swinegelder performed abdominal surgery on his wife.
9.3.3 Incidence
Hellman and Simon from New York collected
316 reported cases from 1809 to 1935 [134].
They included a series of fetuses from 22weeks’
gestation to term. In 1935, the incidence was
1/9333 pregnancies [135].
The incidence varies widely with geographical location, the degree of antenatal attendance,
the level of medical care, socioeconomic status,
and different institutions in the same country
[136–138]. It is presumed that abdominal pregnancy is more common in developing countries
because of the high frequency of pelvic inammatory disease with suboptimal treatment [139,
9.3 Abdominal Pregnancy
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140]. Abdominal pregnancies make up a small
percentage of EP [141]. Moreover, 98% of extrauterine pregnancies are intratubal, 1% are ovarian, and the rest are primary or secondary
peritoneal implantations. Atrash etal., in 1987,
estimated the incidence of abdominal pregnancy
at 10.9/100,000 live births and 9.2/1000 EPs in
the USA [138] or between 1/3000 and 1/8000
deliveries in other studies [136, 137, 142, 143].
Ombelet etal. found an incidence of 1/402 pregnancies in developing countries and 1/10,000
pregnancies in developed countries [144].
Advanced abdominal pregnancy is rare and
accounts for 1/25,000 pregnancies [145]. Until
2016, 28 cases of abdominal pregnancy after IVF
were published [146].
9.3.4 Risk Factors
Risk factors include a history of tubal pregnancies, pelvic inammatory disease, tubal sterilization, tubal infertility, tubal reconstructive surgery,
endometriosis, transfer at the blastocyst stage, a
higher number of embryos transferred, decreased
endometrial thickness, variation in culture media,
and fresh embryo transfer [8, 147–149]. Other
women at risk include those who conceive despite
using an intrauterine contraceptive device
(IUCD) or progestagen-only contraceptive pills
[150]. Without these risk factors, the undetected
rupture of a tubal pregnancy is considered
HP.Cocaine abuse increases the risk of abdominal pregnancy up to 20-fold [151]. Oehninger
etal., in 1988, described the rst case of abdominal pregnancy after IVF [152]. Mechanisms for
abdominal pregnancy during IVF include [153]:
• uterine perforation during the transfer,
• spontaneous intra-abdominal fertilization,
• microstula at the interstitial portion of the
uterus.
quarter of the twentieth century, such as
Berkley, Bonney, Kelly, and Cullen, stated that
they had made mistakes in diagnosing this condition. In 1936, preoperative diagnosis was
35% [154]. Clinical ndings are extremely
variable; today, preoperative diagnosis is unsuspected in up to 60% [155]. Sometimes it is
found when abdominal exploration is indicated
for other causes such as AA or tubo-ovarian
abscess [156]. Spontaneous progression of
undetected IUP from surgical management of
acute or subacute ruptured EP on postoperative
follow-up is rare. On the contrary, spontaneous
abortion of an IUP has followed EP rupture
[157].
Early diagnosis depends on the clinician having a high index of suspicion. Reece etal. dened
four common symptoms and ndings as follows
[157]:
• Abdominal pain,
• Adnexal mass,
• Peritoneal irritation,
• Increase in uterine size.
Frequent signs and symptoms include
crampy abdominal pain, vaginal spotting or
bleeding, nausea, vomiting, malaise, and painful fetal movement [137, 142, 143, 155]. The
most common physical ndings are abdominal
tenderness, an abnormal fetal position, and displacement of the cervix. Tal et al. reported
abdominal pain in 83%, abdominal tenderness
with hypovolemic shock in 13% of the HPs,
and vaginal bleeding in 50%. Vaginal bleeding
common with EP is rare in HPs because of the
intact endometrium of IUP [158]. When the
fetus dies, it will cause the cessation of all signs
of pregnancy, such as enlargement of the
breasts, etc. [159].
9.3.6 Diagnosis
9.3.5 Clinical Presentation
Diagnosis of HP/abdominal pregnancy is challenging. Even brilliant surgeons from the rst
In the USA, up to 1987, only one of nine women
who reached the hospital alive had an accurate
preoperative diagnosis of abdominal pregnancy
[138].
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9 Ruptured Ectopic Pregnancy
9.3.6.1 Laboratory Findings
Laboratory tests such as abnormally increasing
βHCG are not sufciently reliable for the diagnosis, as are signs and symptoms such as abdominal
pain and tenderness, persistent transverse or
oblique lie, and palpable fetal parts [141].
Quantitative measurements of serum βHCG levels are of no use because the IUP will be producing normal and increasing levels of serum βHCG
[160]. The absence of uterine contractions during
oxytocin challenge testing suggests abdominal
pregnancy [137].
9.3.6.2 Transabdominal Ultrasound
When coupled with clinical evaluation, transabdominal US (Figs.9.19 and 9.20) has a 50–75%
success rate [141]. US ndings of abdominal
pregnancy are as follows [162, 163]:
• demonstration of a fetus in a gestational sac
outside the uterus or the depiction of an
abdominal or pelvic mass identiable as the
uterus separate from the fetus,
• failure to see a uterine wall between the fetus
and urinary bladder,
• recognition of a close approximation of the
fetus to the maternal abdominal wall,
• localization of the placenta outside the connes of the uterine cavity.
The most frequent and reliable nding is a sepa-
ration of the uterus from the fetus (90%).
Extrauterine placenta (75%) and oligohydramnios
(45%) are next in frequency. Other features include
fetal parts close to the maternal abdominal wall
(25%), failure to visualize myometrium between
the fetus or placenta and maternal bladder (15%),
abnormal fetal lie (25%), poor visualization of the
placenta (25%), and maternal bowel gas impending
fetal visualization (25%) [163]. Clear identication
of an empty uterus as a separate structure is essential for the diagnosis. This can be accomplished by
giving close attention to the lower pelvis to ensure
continuity between normally appearing vaginal and
endometrial echoes. Findings that mimic abdominal pregnancy include pregnancy in a bicornuate
uterus, pedunculated uterine broids associated
with a gravid uterus, and a normal early pregnancy
in a sharply retroexed or anteexed uterus.
9.3.6.3 Abdominal MRI
An MRI conrms abdominal pregnancy, showing
the same characteristics as abdominal US
(Fig.9.20) with a more precise denition of the
location of the placenta and placental invasion of
the surrounding structures (Fig.9.21).
9.3.7 Treatment
The effort to separate the placenta is attended with
a great risk of fatal hemorrhage.
(Edward Parker Davis, 1904)
Fig. 9.19 Transabdominal US: pregnancy outside of the
uterus. (Reproduced with permission from [161])
Fig. 9.20 Abdominal pregnancy: live fetus at 17weeks
with normal amniotic uid. (Reproduced with permission
from [161])
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Fig. 9.21 (a) MRI of abdominal pregnancy—the pla-
centa is inserted on the posterior wall of the uterus.
(Reproduced with permission from [161]). (b)
T2-weighted sagittal MRI of the lower abdomen demon-
Management depends on maternal hemody-
namic status, congenital fetal abnormality, fetal
strating the placental invasion. Placenta (a), invasion area
(b), sigmoid colon (c), uterine cavity (d). (Reproduced
with permission from [164] under the CC BY 3.0)
However, in some circumstances, it could be pos-
sible to await fetal maturity [168].
viability, gestational age at presentation, and the
availability of neonatal facilities. Surgical intervention is indicated with a dead fetus due to the
risk of infection and disseminated intravascular
coagulation. Some recommend 3–8 weeks of
observation to allow atrophy of placental vessels
[165]. If the diagnosis is uncertain and EP/
>20 Weeks Gestation
If a conservative approach is considered for
abdominal pregnancy at >20 weeks’ gestation,
the following prerequisites have been proposed
[170, 171]:
abdominal pregnancy is suspected, laparoscopy
can be diagnostic and therapeutic (Fig.9.22).
• the absence of fetal malformation,
• the absence of maternal or fetal
9.3.7.1 Conservative Treatment
Sole treatment with MTX is ineffective in abdominal pregnancy with an embryo [167], but is
added to surgical treatment [168]. Preoperative
MTX treatment minimizes blood loss during
surgery and facilitates maximal placental removal
[169]. Because of the risks of placental separation, surgical intervention should immediately
follow the conrmed diagnosis of abdominal
decompensation,
• continued surveillance of fetal
well-being,
• placental implantation low in the abdomen, far away from the liver or spleen,
• adequate amniotic uid,
• continuous hospitalization in an appropriate facility,
• informed consent from the patient.
pregnancy, regardless of the fetal condition [138].
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9 Ruptured Ectopic Pregnancy
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Fig. 9.22 (a) A reddish and edematous mass on the left
infundibulopelvic ligament of early abdominal pregnancy.
(Reproduced with permission from [166] under the CC BY
Maternal surveillance comprises physical
examinations, serial US assessments, measurement of fetal growth, and daily fetal heart rate
monitoring. Laparotomy can be planned for
34weeks’ gestation without complications.
<20 Weeks Gestation
Continuing the pregnancy should be exceptional
when the diagnosis is before 20weeks of gestation. The importance of informed consent is paramount [168].
9.3.7.2 Surgical Treatment
If the fetus is alive, laparotomy should be
performed regardless of gestational age or
fetal condition [138, 139]. The reason is
mainly based on the unpredictability of
placental separation and consequential
massive hemorrhage.
Perioperative Embolization
Embolization of the placental vascular supply can
be performed before surgery to minimize blood
loss, during surgery to facilitate maximal placental
removal [172–174], and after surgery to stop post-
3.0). (b) Products of conception implanted in the posterior
cuč
-de- sac after intrauterine embryo transfer. (Reproduced
with permission from [146] under the CC BY 4.0)
operative bleeding [175]. Removal of an abdominal pregnancy by laparoscopy after embolization
has been described [173]. Although no consensus
regarding the treatment of the placenta in abdominal pregnancy has been established, most authors
advocate leaving the placenta in situ unless the
surgeon can be condently assured that the entire
blood supply to the placental bed can be surgically
ligated without loss of excessive amounts of blood
and the need for extensive blood replacement therapy. Unfortunately, if left in the abdominal cavity,
the placenta commonly causes complications in
the form of infection, abscesses, adhesions, intestinal obstruction, and wound dehiscence.
Preoperatively, the primary task is to identify
all sources of blood supply to the placenta
(Fig.9.23) and to embolize vessels that could be
difcult to ligate, such as the hypogastric artery.
Another option is MTX administration to inactivate the trophoblast when the placenta has been
left in situ [176]. It should be used before operation if fetal death is conrmed.
Routine angiographic evaluation includes
abdominal aortography with renal, celiac, superior mesenteric, and internal iliac arteriography.
Operative Procedure
Laparotomy should be performed through a midline incision [141]. It is advisable to make the
9.3 Abdominal Pregnancy
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Fig. 9.23 Catheterization of the right ovarian artery,
which supplied the placenta in abdominal pregnancy.
(Reproduced with permission from [161])
incision in the amniotic sac as far as possible
from the placental attachment and large enough
to extricate the fetus without trauma and permit
the subsequent drainage of amniotic uid [170].
Because of the high risk of bleeding, leaving the
placenta in place is preferable by ligating the
umbilical cord at its base. There is no effective
method of controlling bleeding in the placental
bed by clamping or cautery. Prolonged pressure,
hot packs, and topical thrombin-containing compresses have been used with variable success.
Using temporary aortic compression or an
abdominal balloon pressure pack in the pelvis
can be life-saving [170]. Leaving a drainage tube
in place should be avoided, as this increases the
risk of abscess formation and septicemia [177].
Nevertheless, it is ideal to remove the placenta if
its blood supply can be secured, if the diagnosis
is made early in pregnancy, or in cases with the
fetal demise of more than 4 weeks’ duration
[178]. In these circumstances, removing the pla-
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Fig. 9.24 Fetus and placenta attached to the sigmoid
colon (see Fig.9.21b). (Reproduced with permission from
[164] under the CC BY 3.0)
centa has been followed by fewer complications,
less need for repeat surgery, and fewer repeat
hospitalizations [179, 180]. In fact, placental
removal has been associated with low morbidity
but high mortality [181]. The actual procedure
consists of an initial ligation of the placental
blood supply and, afterward, the removal because
massive life-threatening bleeding can occur due
to the absence of a contracting uterus, which generally would occlude the placental bed [182].
Other treatment options regarding the placenta
include partial removal or leaving the placenta in
situ. In the case of partial removal of the placenta,
a complete blood supply ligation is needed. If
not, massive uncontrollable bleeding may occur
[167]. Leaving the placenta in situ with the
umbilical cord ligation can be associated with
expectant management or other measures, which
can accelerate placental trophoblast involution
like MTX therapy or embolization [155, 172]. If
the placenta is not removed completely, it has
been estimated that the remnant can remain functional for approximately 50days after the operation. Total regression of placental function is
usually complete within 4months [183].
Some have advised delay to allow the fetus to
die and the placenta to become partly separated.
When the fetus has been removed and the placenta found to be rmly attached to the bowel
(Fig.9.24), the membranes should be stitched to
the abdominal wall and the placenta allowed to
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9 Ruptured Ectopic Pregnancy
remain while the amniotic sac is packed with
sterile gauze. The pressure prevents bleeding,
and the placenta gradually becomes loose, sometimes piecemeal and sometimes almost entirely.
If the organ to which the placenta is attached
is removable, then the placenta should be
removed together with that organ [184]. In cases
where placental implantation has occurred in vascular areas such as the mesentery and vital
organs, it has been recommended that the placenta should be left in situ because surgical excision can result in uncontrollable and
life-threatening bleeding [185]. If discovery is
not made until attempted CS, a safer alternative
would be to defer delivery if possible, close the
abdominal incision, and transfer the woman to an
appropriate hospital. This could be done even
after fetal delivery with the placenta left in situ if
there is no bleeding [169].
Intraoperative steps of the abdominal wall and
attachment to the uterus are presented in
Fig.9.25.
Postoperative Management
Patients remain in intensive care for 24–72 h
postoperatively. Complications could occur for
several weeks. A retained placenta can persist in
situ for several weeks and has remained detectable for 5years [170].
Postoperative MTX use expedites placental
absorption. However, its use is controversial. It
might increase infective complications from
rapid tissue necrosis, while some authors argue
for complete placental regression. MTX as a
folate antagonist causes an acute intracellular
deciency of folate coenzymes, thus affecting the
synthesis of DNA, especially in rapidly multiplying cells. MTX acts on rapidly dividing cells,
likely with limited effects on the mature placenta
with its limited proliferative activity. With or
without its utilization, the retained placenta will
frequently undergo suppuration and require sur-
gical removal [155, 173]. Risks of secondary
hemorrhage could be diminished while keeping
the infection risk low. A case of placental infusion with MTX via the umbilical arteries has also
been described [187]. Its use preoperatively, or
actinomycin D, has been proposed to destroy trophoblastic activity with established fetal death
[188].
9.3.8 Prognosis
9.3.8.1 Maternal Outcome
Maternal mortality ranges from 0.5% to 30%
[136, 138, 142, 170]. From 1809 to the 1970s, it
was 18.2% [189], principally from massive
bleeding from incomplete or entire placental separation during the pregnancy (see Sect. 9.3.7.2).
The mortality rate of abdominal pregnancy is
sevenfold higher than that of a non-abdominal EP
[138].
9.3.8.2 Fetal Outcome
Mortality
The fetal outcome is poorer than the maternal
outcome. The perinatal mortality is 40–95%
[171, 190]. Through a survey of the literature
from 1809 to 1919 and questionnaires from 200
obstetricians, Beck collected only 262 cases of
extrauterine pregnancy after the fth month with
a living infant.
Morbidity/Deformations
Fetal abnormalities (congenital malformations)
range from 20–40% to 90%, primarily from associated oligohydramnios [190]. Early amnion rupture can explain the band-related defects, the
compression-related defects, or its combination
[191]. With the fetus surrounded by an average
amniotic uid volume in advanced pregnancy,
the fetal outcome tends to be better [170].
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