AFJOG

REVIEW African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 2 | 2024 | Full-term abdominal ectopic pregnancy surgery, and pregnancy after assisted reproductive techniques. Other risk factors include a history of dilation and curettage or hysterotomy [1,11]. MATERNALCOMPLICATIONS The maternal complications of AP include massive bleeding resulting from early separation of the abnormal placenta or spontaneous rupture of the gestational sac, the risk of which increases significantly after 34 weeks. The most common site of placental attachments are the uterus, adnexa, broad ligament, omentum, and bowel [2,5] . When the abdominal placenta grows on the omentum, liver, spleen, ovaries, pelvic ligaments, or other vascular structures such as iliac vessels, there is a high risk of bleeding, whereas when it grows on the uterus, there is relatively less risk of bleeding. Massive bleeding that often occurs during surgery is due to the lack of occlusion of blood vessels after placental separation, unlike in intrauterine pregnancy where myometrial contraction of uterus after delivery results in vascular occlusion [5] . Surgical injury to the bowel and bladder due to placental invasion is not an uncommon complication [6,9,10] . In cases of abdominal pregnancy, where fetus dies and gets calcified (known as lithopedion) the patient may present with intestinal obstruction or perforation [2] . Patients with AP are also at high risk for thromboembolism [6] . Pre-eclampsia (PET) has been reported in AAP. The most plausible theory for development of PET is the abnormal placentation and inadequate invasion of the arteries by the trophoblast, which can explain the high incidence of PET in AAP [5] . FETALCOMPLICATIONS Fetal complications include intrauterine growth restriction, fetal death, fetal compression deformities, bronchopulmonary hypoplasia and neonatal death. According to the literature, the incidence of fetal pressure deformities is as high as 40%, and only 50% of neonates survive beyond the first week of life [1,6, 10, 13] . MANAGEMENTOFABDOMINALPREGNANCY If the diagnosis is established before 24 weeks of gestation, the recommended treatment is termination of pregnancy by laparotomy. If the diagnosis is made after 24 weeks of gestation, expectant management is an option. The timing of delivery should be individualised. The risk of fetal prematurity should be balanced against the risk of maternal well-being. The fetus can be delivered anytime from 32 weeks gestation and it is not recommended to continue with the pregnancy beyond 34 weeks of gestation. During expectant management, comprehensive maternal counselling isnecessary. Inthepresenceofoligohydramnios, the mother should be advised of the significant risk of pulmonary hypoplasia and compression deformities in the fetus [6] . The minimum requirements for expectant management include localizationofplacentaanditsattachmenttoadjacentstructures and patients should be admitted to hospital as there is a risk of life-threatening intra-abdominal haemorrhage. Regular evaluation of maternal well-being should be performed using the modified early obstetric warning score. Full blood count assessment should be performed at regular intervals and the mother should receive thromboprophylaxis. The availability of blood and blood products should be ensured at any given time. Regular fetal surveillance should be include daily non- stress cardiotocography (CTG) test and fortnightly ultrasound for fetal growth, liquor volume and umbilical artery Doppler evaluation [6] . Surgical management of AP can be performed laparoscopically only if it is an EAP of less than 12 weeks gestation [3] . AAP can be delivered only by laparotomy. Delivery can be emergent or elective. Ideally, laparotomy should be performed in a tertiary hospital where a multidisciplinary team and blood transfusion services are available. Surgery should be performed by a senior obstetrician, and a senior anaesthesiologist should administer the anaesthesia. If elective delivery is planned, depending on the location of the placenta, timely consultation from other disciplines, such as gynecological oncologist, urologist, colorectal, or vascular surgeon should be sought. The neonatologist should be present at the time of delivery [6] . Intra-operatively, after delivery of the fetus, the surgeon should evaluate the feasibility of complete or partial removal of the placenta, which will depend on whether the placenta is attached to vital structures and the separability of the placenta from the organ(s) it is attached to [1] . In well-resourced settings, massive intra-operative bleeding can be prevented by intra-arterial embolization of the placental bed. Although, this method does not always yield good results, because the placental blood supply is not well defined and may be shared with other vital organs [1,9] . If a large part of the placenta is left in situ, serumbeta human chorionic gonadotropin (ᵦ-HCG) levels should be monitored post-operatively. Use of methotrexate is controversial and should be delayed for 2-3 weeks, as early use of methotrexate immediately after surgery can lead to early placental separation and haemorrhage, as well as increased risk of infection due to rapid necrosis of the placenta. Post- operatively, it is prudent to keep the patient on extended antibiotics for 2 weeks [9] . When blood flow in the residual placenta has stopped, usually two to three months after delivery, a relook laparotomy can be performed to remove the residual placenta to prevent late postoperative bleeding and a large volume of inactive placental tissue [9] .However, if the placenta is left in situ and is not fully absorbed, the residual placenta does not respond to new pregnancy hormones in the subsequent pregnancy [9] . CONCLUSIONS Advanced abdominal pregnancy is rare and difficult to diagnose. A high index of suspicion is required in women who report symptoms such as persistent abdominal pain, painful fetal movement, and abnormal fetal lie or presentation. Ultrasound examination is a reliable tool for diagnosing AP especially EAP. All pregnant women should be encouraged to present early for antenatal care and ultrasound examination. This will assist to make the diagnosis and allow for treatment of AP at an early stage, thus avoiding the complications associated with AAP. Furthermore, with advanced gestation it gets more difficult to diagnose AP, and in such cases MRI is an appropriate tool to make the diagnosis and to locate the placental attachments. Management depends on the gestational age at which the diagnosis is made with options of termination of pregnancy, preterm delivery, or expectant management until further fetal maturation. In elective cases, multidisciplinary pre-operative planning is important for optimal outcome. Delivery is recommendedinatertiarycentre.Whenincidentallyencountered during surgery at a primary or secondary level of the healthcare, patients should be transferred without delivery with intact amnioticmembranes toa tertiary centre for furthermanagement. Ethical approval: The local Human Research Ethics Committee ruled that a literature review is a low-risk research activity and African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 2 | 2024 | 12