AFJOG

African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 3 | 2025 | 26 CASE REPORT African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 3 | 2025 | Advanced abdominal twin pregnancy – A case report removal of the placenta at the time of surgery (Muroni et al., 2021; Dassah et al., 2009). However, when the placenta is adherent to highly vascular or vital structures (e.g., bowel, mesentery, abdominal wall), attempts at removal carry an extreme risk of uncontrolled hemorrhage. In such cases, the placenta is often left in situ with the umbilical cord ligated, and the patient is managed conservatively postoperatively (Muroni et al., 2021; Dahab et al., 2011). This approach avoids exsanguination but comes with trade-offs: leaving the placenta can lead to secondary complications such as infection, abscess formation, coagulopathy, or secondary hemorrhage during the involution process. Given similarities to the management of placenta accreta spectrum (where the placenta is abnormally invasive), an individualized approach is warranted for AAP. The decision to remove the placenta or leave it in situ should be made intraoperatively based on placental location, the feasibility of securing its blood supply, and the patient’s hemodynamic stability. In our case, even minimal manipulation of the placenta provoked significant bleeding, and we judged that removal would likely be fatal; thus, we opted for in situ management with close postoperative monitoring. Resource-limited settings present additional challenges. Limited access to advanced imaging and specialist care often contributes to delayed diagnosis and intervention in abdominal pregnancy (Sunday-Adeoye et al., 2011). A recent case series from a tertiary center in South Africa emphasized that early identification and timely referral, coupled with multidisciplinary management, substantially improve maternal outcomes even in these high-risk pregnancies (Harries et al., 2025). Our experience with this case reinforces several key points. First, clinicians should remain vigilant for possible abdominal pregnancy when imaging results are inconsistent or when physical findings (like superficial fetal parts or an abnormally displaced uterus) raise suspicion. Second, advanced imaging modalities such as MRI should be employed to clarify the diagnosis and guide surgical strategy whenever standard ultrasound is equivocal. Third, the management of the placenta must be carefully individualized: while leaving the placenta in situ can avert immediate hemorrhage, it necessitates intensive follow-up to manage the residual tissue. Finally, coordination of a multidisciplinary team (including obstetricians, radiologists, anaesthesiologists, and surgeons, as well as blood bank support) is essential for optimal outcomes in these complex cases. Looking forward, more research is needed to guide management of advanced abdominal pregnancies. Reports of successful expectant management in select cases suggest that under certain conditions (e.g., pre-viable gestation, stable maternal status, accessible monitoring), non-immediate intervention could be considered. However, there are no clear guidelines, and decisions must be made on a case-by- case basis. Multicenter collaboration and data pooling may help establish consensus on criteria for safe surveillance versus intervention in AAP. Until then, early diagnosis, careful planning, and individualized care remain the cornerstones of managing this rare and life-threatening condition. CONCLUSION This case illustrates the importance of confirming pregnancy location early and maintaining a high index of suspicion for ectopic gestations when clinical or ultrasound features are atypical. Advanced abdominal pregnancy carries grave risks, and optimal outcomes depend on early diagnosis, meticulous surgical planning, and individualized management. In particular, management of the placenta should be tailored to minimize haemorrhagic risk, with a multidisciplinary team in place. Early referral to a specialized center and careful postoperative follow-up (including serial imaging and β-hCG monitoring) are essential to improving maternal prognosis in these rare and complex cases. REFERENCES ¦ £ ¤ £ ¦ £ £ ¦ ¥ § ¦ ¦ £ ££ § Â ¤ ¤ § ¯ § £ £ ¥ § ¯ ¥ § ¦ § ® § ¨ ¥ £ ¢ £ £ ® ® £ £