Research articles

By Dr. Gwinyai Masukume
Corresponding Author Dr. Gwinyai Masukume
Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, - South Africa
Submitting Author Dr. Gwinyai Masukume

Abdominal pregnancy, Extrauterine pregnancy, Live birth, Placenta, Sex ratio at birth

Masukume G. Live births resulting from advanced abdominal extrauterine pregnancy, a review of cases reported from 2008 to 2013. WebmedCentral OBSTETRICS AND GYNAECOLOGY 2013;4(12):WMC004477
doi: 10.9754/journal.wmc.2013.004477

This is an open-access article distributed under the terms of the Creative Commons Attribution License(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Submitted on: 30 Dec 2013 08:54:39 PM GMT
Published on: 31 Dec 2013 07:11:33 AM GMT


Introduction: Advanced abdominal pregnancy is classically defined as a pregnancy that has progressed beyond 20 weeks of gestation in which the fetus is growing and developing in the mother’s abdominal cavity. An advanced abdominal pregnancy resulting in a live birth is rare. Cases of pre-eclampsia occurring with advanced abdominal pregnancy (non-distended uterus) helped to dispel the hypothesis that excessive stretching of the myometrium was involved in pre-eclampsia’s etiology. Thus advanced abdominal pregnancies, in particular those with live births can provide a unique and useful opportunity to understand certain reproductive biologic phenomena.

Methods: PubMed, Scopus and Google Scholar were searched for English language articles that reported a live birth resulting from an advanced abdominal pregnancy from 2008 (the year of the last major review on advanced abdominal pregnancy) to 2013.

Results: 38 cases of an advanced abdominal pregnancy resulting in a live birth were identified from 16 countries. 37.5% males at birth (normal average 51.5%) were observed in this study.

Conclusion: Physiologically males are more vulnerable than females from conception; the presumed hostile extrauterine environment of advanced abdominal pregnancy may cause excess in-utero demise of males compared to females. Live births from advanced abdominal pregnancy serve as a useful model to elucidate certain reproductive biologic mechanisms.


Advanced abdominal pregnancy (AAP) is classically defined as a pregnancy that has progressed beyond 20 weeks of gestation in which the fetus is growing and developing in the mother’s abdominal cavity, or the fetus shows signs of having been in the mother’s abdominal cavity [1].

Ovarian, broad ligament and tubal pregnancies are excluded from AAPs definition; however this omission has been contested because from a clinical perspective these pregnancies pose similar diagnostic and therapeutic challenges as AAPs [2]. Furthermore, the greater than 20 weeks of gestation cutoff is arbitrary.

An AAP resulting in a live birth is rare. This is because abdominal pregnancy has an incidence of about 1 in 400 to 50 000 deliveries [3]; the variable incidence depends on the characteristics of a particular geographic region. In addition, because the fetus is outside the uterus, AAP has a high maternal and perinatal morbidity and mortality. It is estimated that a woman with an abdominal pregnancy is 90 times more likely to die in comparison to a woman with an intrauterine pregnancy [4]. On average, more than half of AAP babies die [1]. About 20% of AAP infants have malformations or deformations [5].

AAP can be primary or secondary (see Illustration 1). Primary AAP where there is direct implantation of the conceptus into the abdominal cavity is the less common type; certain criteria have to be met for an AAP to be classified as being primary [6]. Secondary AAP due to fimbrial abortion, tubal rupture, ruptured uterus or a ruptured uterine rudimentary horn is the more common type; ruptured tubal pregnancies account for the majority of AAPs.

An over distended uterus (with excessive stretching of the myometrium) for example occurring with twins was at one stage considered to be involved in the etiology of pre-eclampsia [7]. Cases of pre-eclampsia occurring with AAP (non-distended uterus) helped to dispel the hypothesis that excessive stretching of the myometrium was involved in pre-eclampsia’s etiology [7]. Thus AAPs in particular those with live births provide a unique and useful opportunity to understand certain reproductive biologic phenomena. In addition AAP serves as a prototype of pregnancy in males, who lack a uterus, however such a pregnancy would be difficult and dangerous.


PubMed, Scopus and Google Scholar were searched with the term ‘advanced abdominal pregnancy’ from January 1 2008 (the year of the last major review on AAP [1]); the last search date was November 30 2013. The title and abstract of articles was used to select articles that could have a live birth resulting from an AAP (AAP was classically defined). Articles citing these identified articles were also considered. The full text of identified English language articles were read to identify a live birth resulting from an AAP. Articles which had a viable birth resulting from an AAP were included.

A single investigator extracted from the identified articles the variables of year reported, country, maternal age, gestational age at delivery, etc. The full list of extracted variables (33) is available in the data set (see Additional file).

Statistical analysis was done using Stata version 12IC (StataCorp LP College Station, TX). Continuous variables were tested for normality and where they were not normally distributed the median and interquartile range (IQR) were reported.


38 cases of an AAP with a live birth were identified from 16 countries (in Africa, Asia, the Caribbean, North America and South America) see Table 1 and Illustration 3.

The median age of women was 29 years, IQR 24 – 34 years. 50.0% of women were having their first pregnancy when they had an AAP.

36.5 weeks was the median gestation at delivery, IQR 33 – 39 weeks. The median birth weight was 2.4kg, IQR 1.35 – 2.85kg.

Of the 32 AAP cases with data on sex of the baby, 12 (37.5%) were males.

In 10 (26.3%) cases, the placenta was not removed, in four of these cases a re-laparatomy had to be done because of complications resulting from the retained placenta. In the remaining 28 (73.7%) cases, the placenta was either removed completely or partially.

18 (47.4%) of women received blood or blood product transfusion, but it is important to note that in some of the other cases it was not mentioned whether blood or blood products were administered.

In 18 (47.4%) of cases the diagnosis of AAP was made before delivery, in 15 (39.5%) cases the diagnosis was not made before delivery and in 5 (13.2%) cases it was not mentioned or unclear if the diagnosis was made before delivery.

30 (79.0%) of women had sonography before delivery, the remainder of the women either did not have sonography or this information was not mentioned in the articles.

19 (50.0%) cases had an abnormal lie; the lie was unknown in 16 (42.1%) cases; 10 (26.3%) of the cases had a breech presentation.


As has been previously noted with AAP, the following features were also present in this study; symptoms and signs of AAP are generally non specific, an abnormal lie or presentation is common, it is difficult to diagnose AAP despite the widespread use of sonography and there is frequent need for transfusion of blood or blood products [1].

On average, the sex ratio at birth is 51.5% males [39]. The 37.5% male births seen in this study can be attributed to the fact that physiologically males are more vulnerable than females from conception [40]; the presumed hostile extrauterine environment of AAP may cause excess in-utero demise of males compared to females. Although in this study some data on the sex of the newborn baby was missing, the sex ratio at birth would still be in favor of fewer males compared to females even if all the missing cases were males.

The median gestation and birth weight at delivery were pre-term (<37 completed weeks) and of low birth weight (<2.5kg) respectively; this is not unusual for a pregnancy in an unnatural location.

A case of bilateral [19] and unilateral talipes equinovarus [38] were observed in this study, both cases seemed to be non-syndromic. Crudely, this would yield a congenital talipes equinovarus (CTEV) birth prevalence of 52.6 per 1 000 live AAP births, which far exceeds the estimated CTEV prevalence of 1 to 4.5 per 1000 live births [41]. The etiology and mechanism of development of idiopathic CTEV is unknown [41] ; one can only speculate about the role of AAP in the development of CTEV. One infant had bronchopulmonary dysplasia [37] which was likely related to pre-maturity among other factors [42]. Another infant [27] had patent ductus arteriosus, inguinal hernia, undescended testes and phimosis which were very likely related to pre-maturity [43].

“The two key components in successful embryo implantation are the competent embryo and the receptive endometrium that together undertake intimate bilateral communication” [44] . Live births from AAP render this preceding statement debatable because the endometrium does not seem to be invariably essential for successful pregnancy. This has important implications.

It is worth noting that live births from AAP have been described in the setting of HIV infection [16,20], described with twins [36] and one case of abdominal pregnancy diagnosed at 14 weeks of gestation was managed expectantly until delivery at 32 weeks gestation [10].

The key controversy in the management of abdominal pregnancy has been whether to remove or not remove the placenta after delivery [16,19,32]. In this study, in the majority of cases, the placenta was removed successfully after delivery. Ultimately, removal of the placenta seems best done on a case by case basis.

Including only English language articles is a limitation, it is unclear what the impact of this limitation is. The quality of the reported cases differed, for example some articles lacked information on hemoglobin, the APGAR score and other variables which precluded analysis of these variables. Some full texts of articles meeting the inclusion criteria could not be accessed, namely these reports from Ethiopia, Greece and India [45–47]. Publication bias is possible where only well managed cases were reported. None of the cases mention information about the male partner (father of the newborn); the biologic father is increasingly recognized to play a pivotal role in pregnancy related conditions [48].


Live births from advanced abdominal pregnancy serve as a useful model to elucidate certain reproductive biologic mechanisms.


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Abdominal Pregnancy > 20 weeks: A review of live births 2008-2013
Posted by Dr. Everett F Magann on 03 Jan 2014 10:10:56 PM GMT Reviewed by WMC Editors

I thank Dr. Everett F Magann for his review of my article; his review is found her... View more
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