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Minimally Invasive Management of 14.5-Week Abdominal Pregnancy Without Laparotomy

A Novel Approach Using Percutaneous Sonographically Guided Feticide and Systemic Methotrexate

Department of Obstetrics and Gynecology, Carolinas Medical Center, Charlotte, North Carolina USA (A.G.M.); and Montgomery Radiology Associates, Montgomery, Alabama USA (M.H.L.).

Address correspondence and reprint requests to Avick G. Mitra, MD, Department of Obstetrics and Gynecology, Carolinas Medical Center, PO Box 32861, Charlotte, NC 28232 USA; e-mail: avick.mitra{at}carolinashealthcare.org.

Objective. To evaluate the possible role of a novel, minimally invasive approach to the management of abdominal pregnancy. Methods. We hypothesized that sonographically guided feticide without subsequent laparotomy for removal of the fetus and placenta could minimize potential blood loss and would be a reasonable approach in the care of a patient who had a viable 14.5-week abdominal pregnancy with placental implantation directly over the bifurcation of the left common iliac artery. An extensive MEDLINE literature review revealed 1 case of sonographically guided feticide followed 10 days later by uneventful laparotomy for removal of the fetus and placenta. Thus, we used sonographically guided feticide without subsequent laparotomy for removal of the products of conception. Results. The sonographically guided feticide was uneventful, and the patient had no major postprocedure morbidity; a mild ileus was treated conservatively without the need for nasogastric suctioning. No major postprocedure bleeding was encountered. Human chorionic gonadotropin levels dropped precipitously. During the 1.5 years of postprocedure follow-up, the patient reported no major complications. The gestational sac involuted very slowly; amniotic fluid volume appeared normal at 6 months after the procedure but was diminished at the 9-month postprocedure examination. Conclusions. In cases of previable intra-abdominal pregnancy, sonographically guided feticide may lessen the risk of extensive hemorrhage that can be associated with exploratory laparotomy. Sonographically guided feticide without subsequent exploratory laparotomy can result in a gradual resorption of the products of conception and an uncomplicated recovery. This treatment option should be considered in the management of this potentially life-threatening condition.

Key Words: abdominal pregnancy • management • treatment

Abbreviations: hCG, human chorionic gonadotropin • MRI, magnetic resonance imaging • MS-AFP, maternal serum -fetoprotein

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