We take it for granted that pregnancies are supposed to be last 40 weeks, be generally manageable save for mild nausea and a possible waddle near term, crowned by a successful delivery. This is not always true, as a mother of four, who has had uneventful pregnancies and deliveries recently found out.
Mueni* was due to deliver on Christmas day but her baby seemed to have other ideas. 10 days past her due date, she was admitted for induction of labour.
All was well with mother and baby during the admission examination and she received a pessary inserted vaginally to trigger her labour. As this was expected to take hours, she was transferred to the antenatal ward. Sometimes after repeat induction doses, and eventual failure of induction, a caesarean delivery is recommended.
This was the case with Mueni, 24 hours after her admission, she had no signs of labour and was signed up for surgery. She also requested for a tubal ligation to be done during the caesarean section.
Surgery went smoothly until we got to the abdominal cavity when we all got thrown off kilter. Right in the abdominal cavity was a complete amniotic bag with the baby in it. There was no sign of the uterus. For a normal caesarean delivery, once the surgeon gets into the abdomen, the uterus is the first organ encountered. It is usually almost 15 times its normal size by the time a baby is full term. It obscures all other organs behind it. After it is cut open and the baby and placenta are extracted, it immediately contracts to less than half its previous size.
Baby in the abdomen
Finding an amniotic bag with no uterine walls was quite confusing before we figured out that we were dealing with a full term abdominal pregnancy. As described in last week’s article, an abdominal pregnancy is an ectopic pregnancy which, instead of happening in the fallopian tube, as commonly expected, falls out into the abdominal cavity and attaches itself to whatever organ it finds and essentially continues to grow.
The apprehension in the room was at an all-time high and Mueni picked up on it. The anaesthetist had the difficult task of keeping a straight face and reassuring her while we figured out how we were going to deal with this extremely rare finding, documented only in a handful of deliveries around the world.
Getting the baby out was the easy part. At 2600g, he came, checked out the world, let out a lusty cry and started suckling his fingers. This took Mueni’s mind off the things happening to her as she audibly rejoiced in Kikamba and enrolled the anaesthetist in her prayer of thanks. She had no idea just how right she was in referring to her little one as her miracle.
Mueni had to be sedated for the rest of the surgery while we explored her abdomen. The placenta was attached to intestines and the lower surface of the liver. We were extremely grateful that it was fully intact. We left it as it was, shortened the umbilical cord to leave only a small stump. We then carefully cleaned up the rest of the abdomen as best as we could and almost forgot to do the tubal ligation.
While over 40 per cent of babies carried as abdominal pregnancy have overt congenital abnormalities, our little miracle was completely normal!
Mueni stayed with us for a week before we sent her home with a list of instructions.
They included not doing anything strenuous, avoiding any forceful contact with her abdomen, religiously visiting the postnatal clinic, doing weekly blood tests to ensure her beta-hCG (pregnancy hormone) levels were subsiding appropriately. She also had to have two-weekly ultrasound scans to monitor the placenta we left in her body to ensure it was shrinking off.
In a normal pregnancy, the uterus contracts, causing detachment and expulsion of the placenta after the birth of the baby. The contraction further serves to hold the bleeding vessels that travel through the muscle of the uterine wall, stopping blood loss. In an abdominal pregnancy, the placenta is attached to organs that cannot function like the uterus. This means that in the event it detaches, the raw area would bleed torrentially. This is why it is left undisturbed and one must avoid any force on the abdomen that may detach it.
This is the most feared complication of an abdominal pregnancy as it would easily lead to imminent death. The placenta is left intact to die and is slowly cleaned out by the body over time. A progressive drop in the beta-hCG levels is an indication that things are on track. It takes about six weeks to disappear. All babies are little miracles but some are more miraculous than others!