An ectopic pregnancy refers to any pregnancy that occurs outside of the endometrial cavity. Abdominal pregnancy is the most uncommon type of ectopic pregnancy with a reported incidence of 1 in 2200 to 1 in 10,200 of all pregnancies [1]. Presenting symptoms range from abdominal pain, mild vaginal bleeding , or painful and excessive fetal movements to hemoperitoneum and hemorrhagic shock in the most severe cases. Rarely, abdominal pregnancy occurs after hysterectomy and, in these cases, an early pregnancy was likely in existence prior to hysterectomy.

There are two proposed etiologies for abdominal pregnancies which include direct implantation on the peritoneum or secondary implantation resulting from tubal abortion or rupture with extrusion of the trophoblastic tissue [2]. Unfortunately, ultrasound sensitivity has been reported at best to be 50 % for identification of abdominal pregnancies, making this a difficult diagnosis to assign [2].Additionally, serial beta-hCG levels may rise appropriately further confounding the diagnosis [3]. Magnetic resonance imaging (MRI) may be a better imaging modality due to the ability to distinguish between tissue layers based on signal density [4].In resource-poor settings, a Foley catheter inflated within the lower uterine segment can help ascertain whether the fetus is within the uterus or not [5].

Due to the risk of infection, peritonitis, and intra-abdominal hemorrhage with maternal exsanguination, surgical intervention is recommended in cases of abdominal pregnancy . There have been rare case reports of conservative management at periviability with inpatient monitoring but this cannot be routinely recommended [6]. Ultrasound and/or MRI can be useful for preoperative planning in demonstrating placental location and vasculature to minimize maternal hemorrhage at time of surgery. Several units of packed red blood cells should be available prior to surgery in the event of hemorrhage requiring transfusion. Hemoglobin and clotting factors should be monitored proactively and aggressively repleted as necessary.

There have been rare reports of successful laparoscopic management of abdominal pregnancy; however, this is only possible if the diagnosis is made at an early stage in the gestational age [7]. At later gestational ages, laparotomy is required for fetal delivery. The more difficult management decisions lie around placental management. There are three options pertaining to the placenta. The first is to attempt removal; however, this should only be pursued if the placenta separates easily and there is no collateral blood supply to adjacent vital organs. The second option is to leave the placenta in situ and await spontaneous resorption. The last option is to leave the placenta in situ but to administer postoperative methotrexate with the goal of expediting placental involution. With this option, there are some concerns surrounding rapid necrosis that may increase bacterial growth and the risk of associated intra-abdominal infection [8]. Unless the placenta is easily removed after fetal delivery, the general recommendation is to leave the placenta in situ.