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Abdominal Pregnancy Resulting in Live Birth

Some babies survive. Can more be saved?
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Sometimes the death of the unborn child is the unwanted but tragically necessary side effect of treatment necessary to save the mother's life. A conscientious doctor will struggle with such cases, and will make all reasonable efforts to preserve the child's life if possible.

But one situation is so dire, even prolife physicians concede that there's no known way to save the baby: ectopic pregnancy.

Ectopic pregnancy is when the embryo implants outside the uterus. Primary ectopic pregnancy is the situation most of us are familiar with, in which the initial -- and final -- implant site is outside the uterus. Secondary ectopic pregnancy is a less common situation, in which the embryo starts out implanted in the uterus, but due to unusual circumstances such as uterine rupture the plancenta grows outside the uterus.

Since the typical ectopic pregnancy site is the fallopian tube, most people think of ectopic pregnancy being a tubal pregnancy. Tubal pregnancy is a medical emergency. If the embryo has already died, some physicians may allow the woman's body to deal with the situation naturally. If the embryo is still alive, even pro-life physicians take steps to prevent a potentially fatal rupture. The main difference in approaches is whether the physician takes direct steps to kill the embryo, usually with methotrexate, or whether he removes the tube and allows the embryo to die as a sad side-effect of this treatment.

However, there are documented cases of unborn children outside the uterus surviving to live birth. Reports of diagnosed abdominal pregnancies found fetal survival rates from 5% to 70%. And perhaps from these cases, we can learn approaches that can save other unborn children without unduly jeopardizing their mothers' lives. The maternal mortality rate is between 0.5 and 18% for abdominal pregnancy, a risk some mothers will be willing to take to save their children.

Prior to 20 weeks, the standard treatment is immediate termination in order to prevent maternal hemorrhage and death. After 20 weeks, evidently some physicians and mothers will opt for close monitoring until the fetus is able to survive delivery.

I found a case here with a write-up and photos of the delivery of the infant.

"Abdominal Pregnancy", in American Family Physician, desribes a case: The mother was 22 years old, and 38 weeks into her first pregnancy. She was admitted to the hospital in labor. The only unusual finding in her pregnancy was some vaginal bleeding in the first trimester. The physical exam found nothing abnormal, other than that the fetus was lying crosswise rather than head-down.

The mother's cervix dilated to 2 cm, but without any effacing, and there was no sign of the fetus presenting in the cervix. Because of this, the mother was prepped for a c-section. Upon opening her abdomen, the surgical team discovered the gestational sac, complete with fetus, atop the uterus. The sac was opened and a 5 lb, 12 oz baby girl delivered, with Apgar scores of 2 and 6.

The placenta was attached to the top of the uterus, right fallopian tube and ovary, and the broad ligament. The placenta was removed. The mother bled a lot, nearly 4 liters, and required a transfusion. She suffered a reaction to the transfusion. Both she and her daughter were discharged 16 days after the birth.

Term Asymptomatic Abdominal Pregnancy with Good Maternal Outcome: A Case Report described a case of a 28-year-old woman approaching her first delivery. She was from a rural area and had only had limited prenatal care consisting of four ultrasounds and a hospitalization for pyelonephritis three weeks before her arrival. She was admitted to Zeinabieh Hospital in labor.

The first three ultrasounds had shown a single fetus, with adequate amniotic fluid, done at 16, 30, and 34 weeks. The final ultrasound, performed while the mother was hospitalized for the pyelonephritis, showed decreased amniotic fluid at 35 weeks. Doctors recommended that she remain hospitalized, but she went home.

Upon final admission, the estimated gestational age was 37 to 38 weeks. She had regular contractions, and a good fetal heart rate at 140 beats per minute. Pelvic examination showed that her cervix was 20% effaced and 1 cm dilated. The fetal presentation was breach. The mother's abdomen was also unusally tense and rigid. The attending resident feared placental abruption, and summoned the attending physician to perform an emergency c-section.

When the mother's abdomen was opened, a full-term live infant was found in the amdominal cavity. The baby was a girl, weighed 3000 grams, and had Apgar scores of 9 and 10. The mother's uterus was 12 weeks of gestational size and pushed to the right. The mother's tubes and ovaries were normal.

The placenta was attached over a large area, and was lacerated. It was left in place, with the laceration treated several times to finally control the bleeding. The mother lost about 5000 cc of blood and required 6 units of whole blood, 10 packs of platelet, and 4 units of fresh frozen plasma.

The baby was healthy, with no abnormalities or deformaties.

The mother was dischaged two weeks post-operatively.

Abdominal Pregnancies includes a case report of a 19-year-old called Mary. At 7 months, the fetus developed a transverse lie rather than head-down. The doctor tried to move the fetus to a head-down position, but that didn't work. At 40 weeks, Mary had abdominal pain, and the fetus was still crosswise rather than head-down. A pelvic exam was performed, and found the cervix in an odd position in front of the fetal head. Mary's abdomen was opened for a c-section. It looked as if she had no uterus, because the membranes were up against the abdominal wall. The baby, a girl was delivered live, and the placenta was found to be attached to Mary's left fallopian tube. The surgical team removed as much of the amniotic membrane as possible, and left the placenta in place. Mary recovered uneventfully.

This case is of an embryo that implanted in the mother's broad ligament, rather than in her abdomen. The mother was 32 years old, and this was her second pregnancy. She experienced a spontaneous rupture of membranes at term, and a c-section was performed. The baby, a boy, weighed 3600 grams and experienced a brief period of difficulty breathing but was otherwise normal. But the mother was found to have a tuberculosis of her reproductive organs, which resulted in her death a few days later. The baby developed tuberculosis but survived.

BBC News reports on a case in which an abdominal pregnancy was not diagnosed until the child was being delivered. The 42-year-old mother required blood transfusions after the baby was removed through an abdominal incision that had been initiated for a scheduled c-section. The baby had implanted on the woman's omentum, the fatty layer covering the bowel.

BBC News also reported on the birth of Millie-An Pittman, whose 27-year-old mother required transfusions. Millie-An was discovered to be abdominally implanted during a scheduled c-section.

On some occasions, a tubal pregnancy may dislodge and reimplant in the abdominal cavity. Understanding the mechanism that allows this to happen might provide a way of deliberately moving the embryo to a more favorable implantation site.

Lay sites, such as this one and this one, say that ectopic pregnancies can not be carried to term. This may be leading to unnecessary pregnancy loss. On the other hand, glib assurances that some women have carried successfully to term can give a woman a false sense of security and lead to unnecessary maternal death. Only by getting out accurate information to mothers and medical professionals can we start empowering women to choose the management of their ectopic pregnancies that meet their own moral standards.

Personally, now that I have this information, I would insist on some attempt to salvage the pregnancy, even if the embryo had implanted in the fallopian tube. And I would not consent to anything that would end the embryo's life, since there would be hope, however remote. And I'm probably not alone in that.

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