28.05.2020 Cases I've never seen Part III - Abdominal Pregnancy in the 19th week!

This case has left me feeling and knowing that God works miracles.  A patient around 19 weeks pregnant according to last menstruation (not from our area and therefore not part of any of our pre-natal care) came in the early morning hours with pain in the belly right.  The midwives drew a picture and sent to me on my phone:

Its pretty clear and my first though it HELLP but given her early week that is pretty unlikely 

The first scan I do makes me hardly believe what I am looking at.  Those not familiar with obstetric scans, this is an abdominal scan that shows lots of free fluid (black) and bladder (fluid filled sac on the right) and most importantly:

a completely empty uterus!

I find the baby, right next to the liver and no longer alive

Conclusion: An abdominal pregnancy with a significant amount of free fluid (blood) in the abdomen

The upper abdomen is swollen due to the baby there

Emergency!!  Transfer to PSF in downtown Antananarivo and emergency laparotomy are performed.  It is a miracle she got there in time and did not bleed to death.  It was a ruptured tubal pregnancy near the uterus and when it burst it ruptured part of the uterus along with it.  The blood loss miraculously was compensated with only 2 bags of blood.  The surgeons there were able to stop the bleeding and save the woman's life.  I cannot believe what happened.  These situations are avoided by early pregnancy scans that confirm the location of the pregnancy.

Wow after this case the scheduled re-re-C-section for today seemed a small feat.  Nonetheless all went well here despite the fact that the previous operations had again sutured together the rectus abdominal muscles which required quite some effort to get in.  No trouble though for the rest of the 28th Caesarean delivery here for me!