the authors report the case of a 17-week intact abdominal pregnancy diagnosed in the course of an investigation of lower abdominal pain .
subsequent angiography was performed to occlude the supportive artery of the pregnancy by selective embolization .
the placenta was left in the abdominal cavity because of the high risk of massive and often uncontrollable bleeding , and treatment with methotrexate was applied postoperatively .
preoperative embolization and the postoperative methotrexate therapy facilitate the safe surgical treatment of abdominal pregnancy .
reports on its frequency vary , ranging from 1 in 3371 deliveries to greater than 1 in 10 200 deliveries [ 13 ] .
the maternal mortality risk from abdominal pregnancy is 7.7 times greater than that of tubal ectopic pregnancy .
the treatment of these cases requires attention due to the risk of life - threatening bleeding arising from the rupture of the fetus .
maternal morbidity can also be substantial , with high incidence of pelvic abscess , peritonitis , and sepsis caused by retained placental remnants .
a 28-year - old patient ( gravida 3 , para 2 , with 1 caesarean section in the history ) was referred to our department by her general practitioner , with lower abdominal pain developed 3 weeks before .
the physical examination verified abdominal tenderness , principally at the right side of the lower abdomen and around the umbilicus .
transvaginal sonography described the uterus 7089 mm in size with no visible fetus in the cavity . above the uterus at the right side
an amniotic cavity was seen , in which the fetus was visible in an oblique - breech presentation .
biometric data ( biparietal diameter ( bpd ) : 44 mm , head circumference ( hc ) : 145 mm , abdominal circumference ( ac ) : 104 mm , femur length ( fl ) : 24 mm ) corresponded to a 1718-week - old fetus without any signs of malformation .
the quantity of the amniotic fluid was normal , the placenta was attached to the right back side , and both ovaries were normal .
laboratory evaluation ( red blood cell count , hemoglobin , hematocrit , white blood cell count , platelet count , westergren ) did not show any clinically significant abnormality .
pelvic mri ( with native multiplane , multisequential imaging ) showed that above the urinary bladder in the pelvis minor a 60 mm thick uterus was visible with stir ( short tau inversion recovery ) sequence and t2 enhancement . above
the uterus risen from the right iliac region there was a 5060 mm thin walled cystic object with embryonic elements inside ( skull , orbit , lambda suture could be observed ) which were also visible with long - period sequences .
without contrast material the exact location of the placentation was not precisely determinable , but it was found that the outer surface of the uterus did not communicate with the fetus .
the patient was referred to the department of cardiovascular surgery , semmelweis university , for a selective angiography and embolization .
selective angiography verified a normal upper and lower as well as internal iliac artery . in the height of the right renal artery
a winding artery was noticed running towards the pelvis minor , which was suspected to be the ovarian artery .
this artery was hypertrophic , thicker than usual , with a winding shape , and seemed to supply a parenchymal bulge situated to the right of the uterus .
a selective embolization of this artery was performed with pva ( polyvinyl alcohol ) particles . during the control angiography ,
the control ultrasound examination showed no signs of fetal life . in the perioperative period , antibiotic treatment
was administered : 31.5 g cefuroxime intravenously , and 2250 mg metronidazole orally . a day after the selective angiography and embolizations ,
after adhesiolysis , it became visible that the fetus was situated in the lower right region of the abdominal cavity , adhered to the colon descendens and to the small intestine .
the membranes were separated until the edge of the placenta . as the complete removal of the whole fetus without the risk of life - threatening bleeding was not possible ,
in the postoperative course , intramuscular methotrexate therapy was administered ( 20 mg / m twice a week , a total of 5 times ) .
ablactation was started with bromocriptine therapy and the antibiotic treatment was completed with intramuscular gentamicin with the dose of 1240 mg each day . on the 7 postoperative day ultrasound examination was performed . at the right side of the lower abdomen a 5949 mm solid bulge  the retained placenta 
the majority of pregnancies located in the abdominal cavity result from reimplantation of tubal abortions ; thus they can not be considered as real ( primary ) abdominal pregnancies .
the reported case matches the criteria defined by studdiford in 1942   as being a primary abdominal pregnancy . to be considered as such , the pregnancy must meet the following criteria : intact tubes and ovaries must be normal , without evidence and signs of recent or remote injury ; no evidence of uteroperitoneal fistula should be found ; the gestation must be related exclusively to the peritoneal surface and be early enough to eliminate the possibility that it is a secondary implantation . early diagnosis of an abdominal pregnancy is critical because a catastrophic hemorrhage can result from separation of the placenta .
ultrasonography is considered to be the criterion standard for obtaining exact information about the location of the pregnancy and its relation to the surrounding organs . in cases where ultrasonography is equivocal
selective catheterisation and subsequent embolization of the pelvic blood vessels was introduced in the early 1980 s in gynecological practice .
the main indication was massive pelvic hemorrhage ( eg , in certain cases of advanced , bulky cervical cancers ) . in our case ,
embolization of the main supporting vessel leading to the placenta was performed in order to avoid a massive intraoperative bleeding and to promote the absorption of the retained placenta .
retaining the placenta in its original place is a common method during operative procedures of abdominal pregnancies .
the drainage of the placental bed is highly recommended in order to detect bleeding in the postoperative stage .
methotrexate therapy is a well - known alternative treatment in certain cases of ectopic pregnancies in order to hasten trophoblastic degeneration . in this case , it was administered in the postoperative interval to promote the absorption of the retained placenta .
involution of the gestational tissue can be controlled by monitoring postoperative beta - hcg serum levels .
reviewing the literature regarding the management of genuine abdominal pregnancies , it is hard to find a publication explaining the same method reported by us , perhaps due to the rarity of the cases and the limited accessibility of angiography .
numerous cases are recognized only when symptoms of abdominal bleeding are present ; therefore , laparotomy must be performed instantly .
as in the majority of cases in the literature , the outcome of our case was successful . therefore , preoperative selective angiography and embolization followed by laparotomy and adjuvant methotrexate therapy can be a safe and effective method in the treatment of abdominal pregnancies in the second trimester .
 summarybackgroundabdominal pregnancy is a rare condition that may lead to severe complications.case reportthe authors report the case of a 17-week intact abdominal pregnancy diagnosed in the course of an investigation of lower abdominal pain . 
 ultrasonography and mr examination revealed an intact abdominal pregnancy . 
 subsequent angiography was performed to occlude the supportive artery of the pregnancy by selective embolization . 
 the pregnancy was terminated safely by laparotomy a day later . 
 the placenta was left in the abdominal cavity because of the high risk of massive and often uncontrollable bleeding , and treatment with methotrexate was applied postoperatively.conclusionspreoperative embolization and the postoperative methotrexate therapy facilitate the safe surgical treatment of abdominal pregnancy . 