|Year : 2016 | Volume
| Issue : 1 | Page : 46-49
Hydrocephalic newborn in a missed advanced abdominal pregnancy - diagnostic challenges in a rural setting: A case report
Ibrahim Aliyu1, Adewale Ashimi2
1 Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria
2 Department of Obstetrics and Gnaecology, Federal Medical Centre, Birnin Kudu, Jigawa, Nigeria
|Date of Web Publication||4-Mar-2016|
Department of Paediatrics, Aminu Kano Teaching Hospital, Kano
Source of Support: None, Conflict of Interest: None
Advanced abdominal pregnancy (AAP) is a rare event associated with high maternal and perinatal morbidity and mortality. It is commonly seen among patients in the low socioeconomic class, those with previous history of infertility, and women with pelvic infection that seems to be more in the developing countries like Nigeria. It could, however, pose a diagnostic challenge, especially in resource-limited settings where there is lack or restriction of healthcare professionals and medical diagnostic facilities; hence diagnosis is often clinical that is fraught with errors. This may result in misdiagnosis as was observed in our case. Abdominal pregnancy is often associated with congenital deformation anomalies such as talipes and spinal dysraphism. However, the case of a live newborn delivered at term with combination of talipes and hydrocephalus, which are deformation and malformation anomalies respectively is reported.
Keywords: Abdominal pregnancy, hydrocephalus, talipes
|How to cite this article:|
Aliyu I, Ashimi A. Hydrocephalic newborn in a missed advanced abdominal pregnancy - diagnostic challenges in a rural setting: A case report. J Mahatma Gandhi Inst Med Sci 2016;21:46-9
|How to cite this URL:|
Aliyu I, Ashimi A. Hydrocephalic newborn in a missed advanced abdominal pregnancy - diagnostic challenges in a rural setting: A case report. J Mahatma Gandhi Inst Med Sci [serial online] 2016 [cited 2021 Feb 28];21:46-9. Available from: https://www.jmgims.co.in/text.asp?2016/21/1/46/178105
| Introduction|| |
Advanced abdominal pregnancy (AAP) is defined as a pregnancy of over 20 weeks with a fetus living or showing signs of having once lived and developed in the mother's abdominal cavity.  It is an unusual type of ectopic pregnancy that is implanted on structures in the abdomen other than the uterus, fallopian tubes, ovaries, and ligaments.  It is associated with a high morbidity and mortality for both the mother and fetus. The maternal mortality is 0.5-18% and the perinatal mortality rate may be as high as 40-95%; , common maternal morbidities include anemia, septicemia, disseminated intravascular coagulopathy and fistula formation.  The fetal morbidities are often deformation related to the compact nature of the abdominal space such as talipes, jaw and spinal deformities.  Nevertheless, there are some reports on other uncommon congenital anomaly in abdominal pregnancy like pulmonary hypoplasia and hydroceplalus ,, but our case had combination of hydrocephalus and talipes equinovarus surviving to term.
| Case Report|| |
A 30-year-old unbooked G5P4 (all alive) woman, who was uncertain of her last menstrual period but was 9 months amenorrhoeic presented to the obstetric emergency room of our hospital. She was referred from a general hospital with complaints of sudden severe abdominal pain associated with bleeding per vaginam of 10 h duration. Two weeks prior to presentation, she was admitted twice at the referring center on account of recurrent painless bleeding per vaginam, and she had an ultrasound scan done that revealed a singleton fetus presenting cephalic with hydrocephalus and placenta praevia. She was managed conservatively and scheduled for an elective cesarean section. Two days before the surgery, she developed the above complaints and was referred. There was no history of trauma to the abdomen and she had not perceived fetal movements 12 h prior to presentation. Her last confinement was 4 years prior to presentation and her delivery was at home. This was complicated by retained placenta that was manually removed at a nearby hospital. She had never received antenatal care and all her deliveries were supervised by traditional birth attendants at home. She is not a known hypertensive and the first of the two wives of a petty trader. She had no formal education.
Examination revealed an anxious lady, not pale, afebrile (36.8 o C), anicteric and not in respiratory distress. The severe abdominal pain prevented her from walking upright although the bleeding had subsided. Her pulse rate was 116 beats/min and the blood pressure was 120/70 mmHg. The abdomen was distended and tender. A suprapubic mass about 18-weeks size was palpated separate from another mass presumed to be the uterus that was 38 cm above the symphysis pubis. The fetal lie was longitudinal; the presentation and heart tones could not be ascertained due to the tenderness. Pelvic examination revealed blood-stained vulva, the cervical os was about 2-cm dilated and uneffaced. There was no active bleeding.
An assessment of ruptured uterus was made and she was counseled for exploratory laparotomy. Her packed cell volume was 31% and the electrolytes were within normal limit. Two units of blood were grouped and cross-matched. The abdomen was opened with a lower midline incision and the findings at surgery were as follows: The placenta was posterior to the fetus with the fetal head partly compressing on it. It was attached to the omentum. There was no evidence of placental adherence to the bowel or uteroperitoneal fistula. The uterus was bulky, intact and about 18-weeks size. The tubes, ovaries and urinary bladder were grossly normal. There was about 600 ml of hemoperitoneum. The placenta was attached to the omentum. It was ligated with a suture close to the omentum and was completely delivered while hemostasis was ensured. Similarly, a live male baby presenting cephalic in an intact amniotic sac in the peritoneal cavity [Figure 1] with Apgar scores of 5 and 7 in the first and fifth minute respectively was found; he had a big head with craniofacial disproportion. The birth weight was 3.4 kg and the baby had occipitofrontal circumference of 41 cm [Figure 2] and talipes equinovarus of the right foot [Figure 3]. He had normal spine and other systemic examinations were not remarkable. The abdomen was closed in layers and the baby was admitted in the special care baby unit. She had two units of blood transfused postoperatively and was placed on ceftriaxone and metronidazole. There was no family history of a similar disorder in other children and there was no obvious risk factor for such malformation. The newborn had a transfontanel ultrasound and a brain computer tomography (CT) scan was done at a tertiary center [Figure 4] showing communicating hydrocephalus.
The mother made remarkable progress and was discharged home on the seventh postoperative day, whereas the baby was referred to the pediatric neurosurgical department of the closest tertiary hospital for further evaluation and management.
| Discussion|| |
AAP is a rarity that most obstetricians would not see in their practice. It is common in women of low socioeconomic group, those with history of infertility and pelvic inflammatory disease which are prevalent in developing countries. , The diagnosis and management still remains a challenge, especially in developing countries where there is lack or restriction of healthcare professionals and medical diagnostic facilities; hence diagnosis is often clinical, which is fraught with errors that may be as high as 50-90%.  Although signs and symptoms of AAP are inconsistent, the clinical presentation however depends on the gestational age. For instance after the second trimester or in late third trimester, excessive fetal movements, persistent abdominal pain, vaginal bleeding and abnormal presentations may be noticed. In addition, palpation of an abdominal mass distinct from the uterus or the inability to delineate the uterus may be noted. 
Oftentimes, the rarity of AAP and the inconsistency in the few symptoms and signs makes diagnosis either missed or delayed until at laparotomy.
In the reported case, the patient had presented to a peripheral general hospital where a diagnosis of placenta praevia was considered based on her high parity and a history of recurrent painless bleeding per vaginam. To confirm their diagnosis and exclude abruptio placenta, the referring hospital performed an obstetric scan which revealed a singleton live hydrocephalic baby presenting cephalic and also showed that the placenta was in the lower uterine segment; findings that were later discovered to be erroneous. Although transabdominal ultrasonography which is the test of choice for confirming placenta praevia was done for this patient, it was inconclusive on the location of the internal os. The sonologist assumed the diagnosis because the presenting part was lying on the placenta. A transperineal or transvaginal approach to sonography might have complemented the process without risk of further hemorrhage.  Nevertheless, with meticulous scanning the fetal body would have been identified outside the uterus and the diagnosis of abdominal pregnancy confirmed, but when a well-trained sonologist is not available, the use of inflated intrauterine Foley's catheter during scanning may assist the inexperienced sonologist in arriving at the diagnosis.  In recent times, the use of computed tomography (CT) scan and magnetic resonance imaging (MRI) has also complemented sonography but these may not be readily available in resource-constrained settings like ours. In the case presented immediate cesarean section was not planned because the attending doctor at the referring hospital was not skilled enough to perform the surgery in view of possible complications that may be associated with placenta praevia; also the sudden abdominal pain and tenderness raised the possibility of a uterine rupture which would also require an experienced obstetrician. The abdominal findings of normal tubes and ovaries, no uteroperitoneal fistula was in keeping with Studdiford's criteria  which supports a primary abdominal pregnancy. Abdominal pregnancy may present with nonspecific complaints like abdominal pain and tenderness, vomiting and nausea and vaginal bleeding  which are also witnessed in cases of ectopic pregnancy and ruptured uterine pregnancy; therefore, the tendency of misdiagnosis is heightened if its possibility is not entertained. Hence, a high index of suspicion should be entertained in cases presenting with abdominal pain and tenderness, per vaginal bleeding, and easily palpable fetal parts with an abnormal fetal lie as was experienced in the index case.
The management of the placenta is contentious but is generally now advocated that patient should be individualized and the placenta should be removed if safe to do so;  in our case the placenta was completely removed without any complication. She made remarkable progress and was discharged home.
The newborn had no other deformity other than the hydrocephalus and talipes. The talipes in this case was attributed to the compressive effect of the abdominal cavity, however, the exact mechanism of the hydrocephalus in this case is unknown, unlike in the case of Leikin et al.,  which had an associated spinal dysraphism, ours was an isolated finding.
| Conclusion|| |
The reported case shows that although AAP is rare, its diagnosis in settings such as ours can be improved upon with meticulous interpretation of symptoms and signs by the obstetrician and sonologist hinged upon a high index of suspicion; also the need for improvement in skills cannot be overemphasized. Though fetus of abdominal pregnancy may also have congenital deformations due to pressure effect, the mechanism of its association with hydrocephalus is not clear.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
| References|| |
Worley KC, Hnat MD, Cunningham FG. Advanced extrauterine pregnancy: Diagnostic and therapeutic challenges. Am J Obstet Gynaecol 2008;198:297.e1-7.
Laila A, Shiuly C, Mazhari SI. Diagnostic dilemma in abdominal pregnancy. A case report. J BCPS 2009;27:177-9.
Atrash HK, Friede A, Hogue CJ. Abdominal pregnancy in the United States: Frequency and maternal mortality. Obstet Gynecol 1987;69:333-7.
Costa SD, Presley J, Bastert G. Advanced abdominal pregnancy. Obstet Gynecol Surv 1991;46:515-25.
Jurkovic D. Ectopic pregnancy. In: Edmonds K, editor. Dewhurst Textbook of Obstetrics and Gynaecology. Vol. 7. Oxford: Blackwell; 2007. p. 115-200.
Ayinde OA, Aimakhu CO, Adeyanju OA, Omigbodun AO. Abdominal pregnancy at University College Hospital Ibadan: A ten year review. Afr J Reprod Health 2005;9:123-7.
Stevens CA. Malformations and deformations in abdominal pregnancy. Am J Med Genet 1993;47:1189-95.
Catwright PS, Brown JE, Davis RJ, Thieme GA, Boehm FH. Advanced abdominal pregnancy associated with pulmonary hypoplasia: Report of a case. Am J Obstet Gynecol 1986; 155:396-7.
Leikin E, Randall HW Jr. Hydrocephalic fetus in an abdominal pregnancy. Obstet Gynecol 1987;69:498-500.
Westrom L. Effect of acute pelvic inflammatory disease on infertility. Am J Obstet Gynecol 1975;121:707-13.
Mbura JS, Mgaya HN. Advanced abdominal pregnancy in Muhimbili Medical Centre, Tanzania. Int J Gynaecol Obstet 1986;24:169-76.
Adeyomoye AA, Ola ER, Arogundade RA, Awosanya GO, Abudu OO. Comparison of trans-abdominal sonography (TAS) and transperineal sonography (TPS) in the diagnosis of Placenta Praevia. Niger Postgrad Med J 2006;13:21-5.
Aliyu LD, Ashimi AO. A multicenter study of advanced abdominal pregnancy: A review of 6 cases in low resource settings. Eur J Obstet Gynaecol Reprod Biol 2013;170:33-8.
Studdiford WE. Primary peritoneal pregnancy. Am J Obstet Gynecol 1942;44:487-91.
Rahman MS, Al-Suleiman S, Rahman J, Al-Sibai MH. Advanced abdominal pregnancy - observations in 10 cases. Obstet Gynecol 1982;59:366-72.
Sunday-Adeoye I, Twoney D, Egwuatu EV, Okonta PI. A 30-year review of advanced abdominal pregnancy at the Mater Misericordiae Hospital, Afikpo, south-eastern Nigeria (1976-2006). Arch Gynecol Obstet 2011;283:19-24.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]