Authors: Ahmad R G et al.
Cureus 17(11): e97818 DOI: 10.7759/cureus.97818
Summary:
This case report describes the anesthesia management of a rare advanced abdominal pregnancy discovered only after beginning an emergency cesarean section. A 30-year-old primigravida arrived with abdominal pain, fever, anemia, and fetal distress. Spinal anesthesia was initiated per protocol. Once the abdomen was opened, surgeons could not identify a gravid uterus; instead, they found a live extrauterine fetus in an intact gestational sac implanted along the left posterior uterine surface, ovary, tube, and infundibulopelvic ligament. The placenta was extremely vascular and adherent to bowel and pelvic structures. After delivery of a live infant, bleeding began, necessitating rapid conversion to general anesthesia, central and arterial line placement, and initiation of massive transfusion.
The placenta was intentionally left in situ to avoid catastrophic hemorrhage. Total estimated blood loss was approximately 1.5 L, and the patient received 9 units PRBCs, 4 units FFP, and 10 units cryoprecipitate during her full course of care. Postoperatively she remained intubated for 24 hours due to metabolic derangements and high risk of reoperation. ICU care included broad-spectrum antibiotics, ventilatory support, correction of coagulopathy, hemodynamic monitoring, and serial imaging. Placental tissue involuted gradually on CT angiography. She recovered well and was discharged home in stable condition.
Advanced abdominal pregnancy is exceedingly rare and carries high maternal and fetal risk. This case emphasizes the anesthetic challenges of unexpected extrauterine implantation, rapid transition to hemorrhage control, the need for immediate escalation from neuraxial to general anesthesia, and the importance of multidisciplinary coordination for optimal maternal survival.
Key Points:
• Abdominal pregnancy is extremely rare (1 per 10,000–30,000 pregnancies) and often diagnosed only during surgery.
• When discovered unexpectedly, anesthesiologists must anticipate massive hemorrhage and be prepared to convert from spinal to general anesthesia.
• The placenta is frequently unresectable; leaving it in situ can be lifesaving when vascular involvement is extensive.
• Invasive monitoring, massive transfusion protocols, postoperative ventilation, and close ICU care are essential.
• Multidisciplinary collaboration is critical to successful maternal outcomes.
What You Should Know:
Abdominal pregnancy discovered intraoperatively is one of the most dangerous obstetric scenarios. This case underscores that rapid anesthetic decision-making—including abandoning neuraxial anesthesia, securing the airway, obtaining central and arterial access, and activating massive transfusion—is fundamental to maternal survival. Conservative placental management, though unconventional, is often the safest strategy when extensive vascular attachment is present. Continuous postoperative monitoring and imaging are crucial to ensure safe placental involution and prevent delayed hemorrhage.
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