AFJOG

African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 2 | 2025 | 25 CASE REPORT African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 3 | 2025 | Advanced abdominal twin pregnancy – A case report pregnancy located entirely within the peritoneal cavity, separate from the empty uterus. The placenta was shown to infiltrate the posterior uterine wall and involve the right broad ligament and adnexa, with extensive vascularity. Both gestational sacs had markedly reduced amniotic fluid volumes (Figure 1, Figure 2). Figure 1: Axial T2-weighted MRI image showing the orbits and cranial structures of both fetuses. The abnormal placenta is visible between them; note the extra-uterine position of the amniotic sacs and the markedly reduced amniotic fluid (oligohydramnios). Figure 2. Coronal T2-weighted MRI image demonstrating the extra-uterine abdominal location of both fetuses, with the empty uterus displaced to the left of the abnormal placenta. The endometrial cavity is clearly empty, and the placenta infiltrates the posterolateral uterine wall. Operative Management: After multidisciplinary team review—including obstetrics, radiology, anesthesiology, and blood bank—an emergent laparotomy was undertaken due to the high risk of catastrophic hemorrhage and lack of fetal viability. Intraoperatively, the uterus was visualized anteriorly and to the left, separate from the gestational sacs. Two live fetuses weighing 420 g and 410 g were delivered, but unfortunately both expired shortly after birth due to extreme prematurity and complications of oligohydramnios. The placenta was extensively attached to the posterior uterine wall, right adnexa, and surrounding pelvic structures, withmultiple large-caliber vessels. Evenminimal manipulation provoked brisk bleeding. Complete placental removal was deemed unsafe. The umbilical cords were ligated and cut, leaving the placenta in situ, and a closed-suction drain was placed in the pelvis. Six units of packed red blood cells were transfused intra- and postoperatively. Postoperative Course: The patient initially recovered well and was discharged on postoperative day 10. However, she was readmitted three days later with fever, tachycardia, and rigors. Blood cultures and procalcitonin levels remained negative, suggesting a sterile inflammatory reaction rather than overt sepsis. She improved after six days of broad- spectrum intravenous antibiotics and was discharged in stable condition. Follow-up included serial β-hCG measurements and clinical monitoring of placental involution. Complete resorption of the placental tissue was confirmed over the ensuing weeks. The patient was also initiated on antiretroviral therapy for HIV and remained well at her three-month follow-up visit. DISCUSSION Advanced abdominal pregnancy remains one of the most dangerous forms of ectopic gestation. Maternal mortality rates as high as 0.5–18% have been reported, and fetal or perinatal loss exceeds 75% in most series (Harries et al., 2025; Nkusu Nunyalulendho & Einterz, 2008; Ramphal et al., 2023). These high stakes underscore the need for timely diagnosis and appropriate management. Diagnostic challenges are a hallmark of AAP. Symptoms are often vague (e.g., abdominal discomfort, gastrointestinal upset, or atypical presentations of fetal movement), leading to frequent misdiagnosis even in advanced gestation (El Hajjar et al., 2024; Sunday-Adeoye et al., 2011). Ultrasound remains the frontline diagnostic tool; classic sonographic findings include a fetus outside the uterus, no myometrium surrounding the fetus, and a placenta located separate from the uterine cavity (Allibone et al., 1981; Rohilla et al., 2018). Despite these clues, the sensitivity of ultrasound for abdominal pregnancy is limited. An estimated 20–45% of advanced abdominal pregnancies are correctly identified before laparotomy (Mpogoro et al., 2013; Sunday-Adeoye et al., 2011). Thus, maintaining a high index of suspicion is critical, especially when ultrasound findings are incongruent or unclear. In equivocal cases, MRI can greatly enhance diagnostic precision. Beyond confirming an extrauterine pregnancy, MRI delineates placental attachment sites and vascular anatomy, information that is crucial for surgical planning (Huang et al., 2014; Dempsey et al., 2022). In our case, for example, MRI clearly mapped the relationship between the gestational sacs, the empty uterus, and the infiltrative placenta, which informed the surgical approach. The optimal timing of intervention in AAP can be controversial. Somehaveadvocated for expectantmanagement in carefully selected cases of advanced abdominal pregnancy, with intensive monitoring to prolong the pregnancy and improve fetal outcomes when possible (Ramphal et al., 2023). A recent review has shown that under vigilant surveillance — including serial ultrasounds and MRI — reasonable maternal outcomes can be achieved, albeit fetal survival remains poor in most cases (Ramphal et al., 2023). Similarly, Huang et al. (2014) reported that performing weekly MRI scans after about 32–34 weeks’ gestation can help detect early signs of sac compromise, prompting timely intervention before catastrophic rupture. Surgical considerations in AAP largely revolve around placental management. The operative strategy hinges on the placental attachment site. If the placenta is attached to surfaces where its blood supply can be safely ligated (such as the uterine serosa or broad ligament), some authors advocate