title: A case report of an asymptomatic late term abdominal pregnancy with a live birth at 41 weeks of gestation.
abstract: BACKGROUND
  Despite advances in diagnostic imaging and focused antenatal care, cases of undiagnosed abdominal pregnancies at term are still reported in obstetric practice. It is atypical and very rare for a patient to be asymptomatic late in pregnancy and for the pregnancy to result in a live birth with no evidence of intrauterine growth restriction despite the unfavourable implantation site. This late term asymptomatic presentation despite routine antenatal care demonstrates a diagnostic challenge.
  
  
  METHODS
  We report a case of a 26 year old Primigravida with an asymptomatic and undiagnosed abdominal pregnancy carried beyond 41 weeks of gestation espite routine antenatal care and serial ultrasound reports. She presented for a routine antenatal care visit at 41 weeks of gestation. Induction of labour was initiated due to the late term gestation but was unsuccessful. At this point the fetus developed severe tachycardia and CTG confirmed persistent non-reassuring foetal heart rate patterns. The mother was then prepared for an emergency caesarean delivery. Abdominal pregnancy was only diagnosed at laparotomy where a term male baby weighing 3108 g was delivered with an Apgar Score of 7 and 8 at 1 and 5 min respectively. The placenta which was implanted into the omentum, ileal mesentery and extending to the pouch of Douglas was removed following active bleeding from its detached margins. She was transfused with two units of blood and four units of fresh frozen plasma. Postoperative morbidity was minimal with transient paralytic ileus on the second post-operative day. Her recovery was otherwise uneventful and she was discharged on the seventh post-operative day in good condition. The neonate developed meconium aspiration syndrome and passed away on the 2nd day of life despite having undergone standard care. A post-mortem examination was not performed because the family did not consent to the procedure. Follow up of the mother at 2, 6 weeks and 6 months postpartum was uneventful.
  
  
  CONCLUSIONS
  This atypical presentation of an asymptomatic abdominal pregnancy carried tolate term and only diagnosed at laparotomy despite routine antenatal care demonstrates a significant lapse in diagnosis. Clinicians and radiologists must always bear this possibility in mind during routine client evaluation. Skills training in Obstetric ultrasound and in the clinical assessment of obstetric patients should emphasize features suggestive of abdominal pregnancy. This will improve diagnosis, ensure appropriate management and minimise complications. Immediate termination of pregnancy can be offered if the diagnosis is made before 20 weeks of gestation. Patients diagnosed with advanced abdominal pregnancies and are stable can be monitored under close surveillance and delivered at 34 weeks of gestation after lung maturity is achieved. Although removal of the placenta carries a higher risk of haemorrhage, a partially detached placenta can be delivered with minimal morbidity and a good maternal outcome. Given the documented low survival rates of neonates in such cases, neonatal units must be adequately equipped and staffed to support them. Post-mortem examination is important to confirm cause of death and exclude other complications and congenital anomalies. Communities need to be educated about the importance of this procedure.
authors.affiliation: Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Botswana, Private Bag 00713, Gaborone, Botswana. nassalim2@gmail.com.
authors.forename: Mercy Nkuba
authors.initials: MN
authors.lastname: Nassali
authors.affiliation: Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Botswana, Private Bag 00713, Gaborone, Botswana. Tadele.Benti@mopipi.ub.bw.
authors.forename: Tadele Melese
authors.initials: TM
authors.lastname: Benti
authors.affiliation: Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Botswana, Private Bag 00713, Gaborone, Botswana. Badani25@yahoo.co.uk.
authors.forename: Moreri
authors.initials: M
authors.lastname: Bandani-Ntsabele
authors.affiliation: Department of Obstetrics and Gynaecology, Princess Marina Hospital, P.O. Box 258, Gaborone, Botswana. Ellymails@gmail.com.
authors.forename: Elly
authors.initials: E
authors.lastname: Musinguzi
mesh_terms: D000328:Adult; D058070:Asymptomatic Diseases; D002585:Cesarean Section; D057210:Delayed Diagnosis; D005260:Female; D005865:Gestational Age; D006801:Humans; D007231:Infant, Newborn; D050498:Live Birth; D008297:Male; D008471:Meconium Aspiration Syndrome / Q000175:diagnosis* / Q000473:pathology; D066087:Perinatal Death; D011247:Pregnancy; D011269:Pregnancy, Abdominal / Q000175:diagnosis* / Q000473:pathology