AFJOG

African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 3 | 2025 | 24 CASE REPORT African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 3 | 2025 | Advanced abdominal twin pregnancy – A case report INTRODUCTION An advanced abdominal pregnancy (AAP) is an ectopic gestation that implants within the peritoneal cavity and continues beyond 20 weeks’ gestation. Although uncommon, AAP carries substantial maternal and fetal risks. Abdominal pregnancy overall constitutes <1% of ectopic pregnancies and is estimated to occur in roughly 1 in 10,000–30,000 pregnancies, but the true incidence varies by population and detection practices (Nkusu Nunyalulendho & Einterz, 2008; Sunday-Adeoye et al., 2011; Chen et al., 2023). Maternal morbidity is driven by catastrophic hemorrhage, coagulopathy, and sepsis, particularly when placental implantation involves vascular pelvic or abdominal organs. Contemporary reports place maternal mortality between ~0.5% and 18%, with fetal/perinatal mortality reported between 75% and 95% (Harries et al., 2025; Nkusu Nunyalulendho & Einterz, 2008; Ramphal et al., 2023). Delayed or missed diagnosis remains a major contributor to poor outcomes: in one series, only about 29% of abdominal pregnancies were correctly identified pre- operatively, with most initially misclassified as other conditions such as tubal ectopic pregnancy or placenta previa (Sunday- Adeoye et al., 2011). Diagnosis is challenging because symptoms are often non-specific and examination findings subtle. A systematic sonographic approach is essential—confirming continuity of the cervix, uterus, and intrauterine contents, and scanning the entire abdomen to exclude an extrauterine gestation when an empty uterus or abnormal fetal lie is seen. Hallmark ultrasound features include identification of a fetus outside the uterus, absence of a myometrial wall between the fetus and maternal organs, and an aberrantly located placenta (Allibone et al., 1981; Rohilla et al., 2018). However, the sensitivity of ultrasound remains limited, with an estimated only 20–45% of advanced abdominal pregnancies recognized before surgery (Mpogoro et al., 2013; Sunday-Adeoye et al., 2011). MRI is not required in every case, but it can be invaluablewhen ultrasound findings are equivocal and for pre-operative mapping of placental implantation and vascular relationships to guide surgical planning (Huang et al., 2014; Dempsey et al., 2022). Twin advanced abdominal pregnancies are exceptionally rare, with only a handful of cases described in the literature, and they pose added diagnostic and operative complexity, including a larger placental mass and heightened hemorrhagic risk (Mpogoro et al., 2013; Dassah et al., 2009). Here, we report a 22-week monochorionic diamniotic twin advanced abdominal pregnancy diagnosed with ultrasound and confirmed with MRI. We describe the operative management with delivery of the fetuses and planned placental retention, the postoperative course, and follow-up. This case contributes to the limited literature on advanced twin AAP and illustrates practical imaging pitfalls and considerations for individualized decision-making on placental management. CASEPRESENTATION A 24-year-old woman, gravida 3 para 2, was referred to our tertiary center at 22 weeks’ gestation with a provisional diagnosis of placenta previa after an episode of mild vaginal bleeding. Her first two pregnancies were uneventful, both resulting in spontaneous vaginal deliveries. She had not attended formal antenatal care during the current pregnancy, aside from a single clinic visit where she received empirical treatment for a urinary tract infection. The patient reported persistent loss of appetite, nausea, and vomiting over the preceding weeks. She denied significant abdominal pain but described intermittent abdominal discomfort and reduced perception of fetal movements. On examination, her vital signs were stable. Abdominal palpation revealed superficially palpable fetal parts and an indistinct uterine fundus, raising concern for an extrauterine gestation. Laboratory investigations demonstrated anemia (hemoglobin 8.3 g/dL) and HIV positivity with a CD4 count of 297×10 6 /L. She was not yet on antiretroviral therapy. An initial ultrasound at the referring hospital showed a low-lying, irregular placenta and was interpreted as “placenta previa”. Upon repeat ultrasound at our center, findings were inconclusive: one sonographer reported a live singleton intrauterine pregnancy, while another suspected an extrauterine pregnancy. This discrepancy prompted further evaluation by a senior ultrasonographer and a radiologist. Key sonographic findings included an empty uterus displaced anteriorly and to the left, with no clear continuity between the uterine cavity and cervix; a large, irregular placenta occupying most of the pelvic cavitywith a partially cystic appearance (raising suspicion of molar changes); and a live fetus in an abnormal lie with oligohydramnios and poorly defined amniotic membranes. Given the diagnostic uncertainty, an MRI was performed. The MRI clearly demonstrated a monochorionic diamniotic twin A Barnard Department of Obstetrics & Gynaecology, Stellenbosch University, Tygerberg Hospital, Tygerberg, South Africa CORRESPONDENCE: A Barnard | Email: barnarda@sun.ac.za Advanced abdominal twin pregnancy – A case report ABSTRACT Adnexal tumours constitute a wide range of conditions that are frequently faced in gynecological practice, and this include benign cysts, as well as malignant tumours. Although the majority of ovarian tumours are asymptomatic or have localized symptoms, very large adnexal tumours may have systemic effects because of their size and location. This report describes a rare case of a young woman with a very large adnexal tumour presenting with predominantly cardiovascular-related symptoms. A 21 year old nulligravid woman presented to our emergency department with progressive history abdominal distension, swelling of the lower limbs, and cardiorespiratory distress due to an adnexal tumour noted intra op to be measuring 30 x 40 cm. Initial investigations revealed a tumour originating from the pelvis extending to the epigastrium. Further investigations revealed cardiovascular compromise tumour with an ejection fraction of 43% on echocardiogram. A multidisciplinary team consisting of gynaecological oncologists, physicians and anaesthetists were involved in the management of the patient. Fertility sparing surgery was performed and serial echocardiograms post-operatively showed improvement in the patient’s cardiovascular status. Keywords: Advanced abdominal pregnancy; Twin pregnancy; Ectopic pregnancy; Placenta management; Maternal morbidity; MRI