European Journal of Obstetrics & Gynecology and

Reproductive Biology 109 (2003) 106107

Case report
Surgical packing as a means of controlling massive haemorrhage in
association with advanced abdominal pregnancy
Galal E.E. Farag*, Susmita Ray, Angela Ferguson
Department of Obstetrics and Gynaecology, North Manchester General Hospital, Delaunays Road, Crumpsall, Manchester M8, UK
Received 31 July 2002; received in revised form 10 October 2002; accepted 14 November 2002

Abstract

A case of advanced abdominal pregnancy was diagnosed at laparotomy. During surgery, there was massive haemorrhage from the placenta
which was controlled using surgical gauze packing.
# 2002 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Abdominal pregnancy; Ectopic pregnancy; Surgical packing; Obstetric haemorrhage

1. Case report
A 30-year-old primigravida was referred to antenatal
booking clinic at 15 weeks. She had multiple admissions
and ultrasound scans for abdominal pain and vaginal spot-
ting at 15, 20, 32 and 36 weeks. At 38 weeks she was
admitted with constant backache and shingles at the level of
T10. The foetal lie was oblique. She was treated with
acyclovir and a decision was made to deliver by elective
Caesarean section 5 days later. At laparotomy, an intra-
abdominal pregnancy was discovered. The baby was lying
transversely in the peritoneal cavity. The sac was incised and
the liquor was clear. A live male baby was delivered and
showed no gross malformations. The APGAR scores were 2
at 1 min and 7 at 5 min and the birth weight was 3130 g.
Almost immediately moderate to severe bleeding started
within the peritoneal cavity. The placental site was explored,
but no attempt was made to remove the placenta. The
placenta was adherent to the sigmoid mesentery and des-
cending colon. The placenta appeared to be separating with
massive haemorrhage; however, some of the bleeding came
from bursting vessels on the foetal surface of the placenta.
An attempt at surgical dissection and removal of the placenta
was unsuccessful. Haemostatic sutures were inserted into
the substance of the placenta but the bleeding continued.
Finally, the abdominal cavity was packed with 14 large
sterile swabs. The haemorrhage was substantially controlled
*
Corresponding author. Tel.: 44-161-720-2025;
fax: 44-161-720-2141.
E-mail address: galalfarag@aol.com (G.E.E. Farag).
and the open wound was covered with dressings. The packs
were removed 48 h later and there was no active bleeding.
The placenta was left in situ and the abdomen was closed
without drainage. The patient was hospitalised in the inten-
sive care unit for 6 days. She received in total 36 units of
blood, 4 bags of platelets and 24 units of fresh frozen plasma.
She left hospital with her healthy baby 3 weeks post-
delivery. During that time, she had an incision and drainage
of an infected rectus sheath haematoma followed a week
later by a successful repair of partial wound dehiscence.
Both mother and baby remained well at follow up.
2. Discussion
Abdominal pregnancy is a rare though serious obstetric
condition with an incidence of 1:10 000 pregnancies. It
constitutes 1% of ectopic pregnancies [1]. The risk of dying
from abdominal pregnancy is 7.7 times greater than from a
tubal pregnancy and 90% higher than from intrauterine
pregnancy [2]. Perinatal mortality is approximately 70
80% at gestations of
30 weeks with a 3090% chance
of congenital malformation in the surviving infant [3]. Most
authors have reported a diagnostic error in 5090% of the
cases.
A high index of suspicion is the cornerstone to diagnosis.
Cocaine abuse has been identified as a risk factor specific
for abdominal pregnancy and increases the risk up to
20-fold [4]. Clinical clues are abnormal vaginal bleeding
in early pregnancy, unusual abdominal pain, painful
foetal movements, easily palpable superficial foetal parts,

0301-2115/02/$ see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved.
doi:10.1016/S0301-2115(02)00483-9
 G.E.E. Farag et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 109 (2003) 106107
malpresentation, excessive nausea and vomiting, evidence
of intrauterine growth retardation, oligohydramnios, unef-
faced closed cervix, and failure to respond to prostaglandin
or syntocinon.
Ultrasonography has been a useful diagnostic tool parti-
cularly in early pregnancy, although absolute diagnosis by
ultrasound is an uncommon event. Magnetic resonance
imaging (MRI) is the investigation of choice in suspected
cases due to better clarity of images in multiple planes and
absence of irradiation to the live foetus. The placenta and
its vasculature can be well defined and where the placenta
is left in situ, MRI is useful in the follow up of placental
involution [5].
An interesting observation by Dubinsky et al. [6] states
that placental attachment to the uterus appears to be a factor
for better foetal survival, although in our case the foetus
survived despite mesenteric and colonic attachment of the
placenta.
Intraoperative decision regarding removal or non-manip-
ulation of the placenta is an important management issue. If
the blood supply to the placenta can be ligated safely,
removal in toto results in a smooth postoperative recovery
[7], but leaving the placenta behind increases the morbidity
and mortality of the patient. The risks include peritonitis,
abscess formation, wound breakdown, sepsis, dessiminated
intravascular coagulation and persistent trophoblastic dis-
ease. If the placenta is left in situ, every effort should be
made to avoid leaving a drainage tube in place to prevent risk
of abscess formation and septicaemia. In cases of intractable
bleeding from the placenta, one has to consider placental
107
compression using surgical packing, which was life saving
in our case. The procedure of surgical packing has been
mentioned before by Myerscough [8]. However, he is of the
opinion that the procedure is most unsatisfactory in con-
trolling placental haemorrhage associated with advanced
abdominal pregnancy. To our knowledge, this is the first
reported case where surgical packing proved to be successful
in controlling such a catastrophic haemorrhage.
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