The Sigmoidal Pregnancy: A Rare Entity Complicated by an Ina
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The abdominal pregnancy is a rare form of ectopic gestation which occurs once in 10,000 live births and accounts for less than 1% of ectopic pregnancies. It is defined by the placental implantation into the peritoneal cavity, excluding the fallopian tubes, ovaries, and the inter ligamentous space. Primary abdominal pregnancy refers to the direct implantation of the fertilized ovum into the parietal or visceral peritoneum without previous attachments to the reproductive tract. Whereas the secondary abdominal pregnancy is the result of tubal abortion or the rupture of an intrauterine pregnancy into the peritoneal cavity. In general, the most common site of ectopic pregnancies in the fallopian tube as it accounts for 97% of the ectopic localizations.

A 41-year-old G1P0 woman was referred to the emergency department of our hospital because of severe vaginal bleeding. As the patient was unconscious, her medical history was taken from her accompanying sister. The patient's history was significant for 18 weeks of amenorrhea and positive pregnancy tests, in addition to constipation and a misdiagnosis of incomplete abortion.

As a result of the wrong diagnosis, an external obstetrician performed a dilatation and curettage (D&C) that ended up in perforating the uterus. Upon the clinical examination, the patient looked pale, her pulse was weak, her heart rate was 140 beats per minute, and her blood pressure was 80/40 mmHg. The transabdominal ultrasonography showed an empty heteromorphic uterus and excessive amount of free intra-abdominal fluid. Therefore the diagnosis of a perforated uterus was confirmed, and a ruptured ectopic pregnancy was suspected. The patient was moved immediately to the operating room to perform an emergent exploratory laparotomy and resuscitated with 6 full-blood units and 5 plasma units.

A Pfannenstiel incision was made; the abdominal muscles and fascia were dissected. Upon reaching the peritoneal cavity, a big amount of blood clots was taken out and a fetus with his placenta inserted exclusively into the sigmoid colon was observed. The uterus was perforated in different locations on the contralateral side of the placental insertion. In addition, ileal and appendicular injuries were also observed. So the diagnosis of abdominal pregnancy was achieved intraoperatively. The fetus was taken out, and the internal iliac arteries were ligated to reduce the hemorrhage.

A hysterectomy was done due to the multiple large defects of the uterine wall. Regarding the wide placental insertion on the sigmoid colon and the potential risk of inducing additional hemorrhage by dissecting it, a sigmoidectomy was considered as the ultimate management. Therefore, the incision was dilated longitudinally superior to the umbilicus, and the sigmoid colon was resected. The descending colon was isolated, and a skin colostomy was made.

Finally, the intestinal injury was repaired before skin closure. The operation lasted for 7 hours. The patient's vital signs returned to their normal limits after the surgery and she was stable during the eight days of follow-up. The pathologic examination of the resected specimen showed the presence of normal chorionic villi invading the sigmoid wall. However, due to the D&C, the endometrium was not fully evident when the uterus was examined microscopically. The endometrial remnants showed Arias-Stella reaction in the endometrial glands.

In conclusion, The primary abdominal pregnancy is a rare clinical finding that may be encountered once in a lifetime, but when it's encountered, it should be dealt with firmly. Although the majority of patients present with unspecific symptoms, the altered defecating habits like constipation may hide a sigmoidal pregnancy behind. The good correlation between the ultrasonographic findings and the β-HCG levels is crucial to achieving the diagnosis.

However, the entire abdomen should be scanned by either ultrasonography or computed tomography scan. The management should be minimally invasive and well planned in order to prevent the massive hemorrhage that may cost the patient her life. In emergencies, performing an exploratory laparotomy or laparoscopy combined with less traumatic hemostatic technique is favorable. Finally, when the D&C is needed, it should be delayed until the patient is stable again.