A few years ago, we sat through a very fascinating session in an annual scientific congress for the Kenya Society of Obstetricians and Gynaecologists. It was the last session of the afternoon and while you would have expected most people to have slipped away, the room was full and everyone was animatedly following the presentation.
This was a case presentation of a mother who had had an otherwise normal pregnancy, attending her local clinic with no inkling anything could be amiss. She was expecting her fourth baby and was not particularly anxious. When she went into labour, she went to the local health centre, but after 24 hours of mild contractions and no progress in labour, the midwives referred her to the referral hospital for review by an obstetrician/gynaecologist.
She spent a further 48 hours in the referral hospital without progress despite the gynaecologist trying to aid her labour using induction medication. When the doctor suggested caesarean section delivery, she opted to wait a little longer and was discharged home with instructions to go back immediately if labour progressed or within one week if nothing happened. Throughout this period, she had an ultrasound scan done that reported the baby was fine.
The mother went home and never came back. It was assumed she had a normal delivery elsewhere and no one gave it a thought. Three years later, this mother got pregnant again and had another uneventful pregnancy. She had a normal delivery at her local health centre and mother and baby were fine.
RECURRENT ABDOMINAL DISCOMFORT
Following this birth, she started experiencing recurrent abdominal discomfort that was vague in nature, but since it would resolve spontaneously, she did not pay much ttention. With time, this got worse as she developed on and off constipation, bloating and colicky pain. She would get medication from the local dispensary and symptoms would ease up.
It took a further two years to seek help at the referral hospital and by this point, she was quite unwell. She was constipated and had started vomiting, classic features of intestinal obstruction. This is a surgical emergency requiring admission and immediate treatment. She was put on intravenous fluids to prevent dehydration and had a nasogastric tube to drain stomach contents and prevent vomiting.
Upon examining the patient, the doctors found a mass in the abdomen that was poorly defined. It was impossible to tell what it was. She was scheduled for an abdominal ultrasound scan to visualise the mass and help them decipher its origin. The radiologist was completely perplexed and further ordered for an abdominal X-ray. His report left the entire team dazed.
This took them back to the patient for a further review of her medical history. It was then that she mentioned that she had a ghost pregnancy at some point. She narrated the ordeal she went through five years before, when she carried a term pregnancy, but never gave birth. Upon being discharged home, the pains persisted for two days then progressively subsided. She figured she had experienced false labour and waited for it to set in properly. This never happened and with time, she even began to lose the pregnancy symptoms and her abdomen reduced in size gradually. She assumed she was never really pregnant and she moved on with her life. She went on to conceive again and bear a child without complications and she stopped thinking about the previous experience.
AN ABDOMINAL PREGNANCY
Her story made complete sense to the surgical team. She was prepared for surgery by a multidisciplinary team and wheeled into theatre with a lot of trepidation. Upon opening of her abdomen, the doctors found that their suspicion was right all along. The patient had a mummified abdominal pregnancy! Yes, she was truly pregnant for nine months. However, her baby grew in her abdominal cavity instead of inside her uterus, an abdominal pregnancy. At term, as there was no logical physiologic way out, and since there was no surrounding uterine muscle to contract, there was no progress of labour. The cervix could not open since the uterus was empty. Failing to come out, the natural ageing of the placenta happened until it could no longer support the baby and the little one died. As the baby was in a sterile environment with no access to micro-organisms, there was no decomposition, but over time, it calcified into a hard chalky mass.
The baby was delivered whole during surgery, with pictures to boot. However, the presence of the baby in the abdomen was perceived as a foreign body by the mother’s immune status and a lot of scar tissue formed around it. This led to the distortion of the intestines, liver and other organs, resulting in the intestinal obstruction that had brought her to the hospital.
It was a difficult surgery, fraught with the risk of bleeding or causing injury to the intestines, but the patient hung in there. She made amazing recovery in the ward and was able to go home with a tale never to be forgotten. I could only imagine the explanations that her people came up with.
Abdominal pregnancy is an extremely rare occurrence, happening in one in 10,000 to 30,000 pregnancies. It 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 supplied with blood. The placenta forms and digs into the organ to find blood vessels from which the pregnancy draws nutrition and oxygen that enables it to survive.
Very few of these pregnancies get to term and even rarer to extract a live baby, but a few have been documented. This mother may have had an undesirable outcome, but it is not always the case. Next week we shall talk about the miracles that have come to us in the same space.
It may sound morbidly crazy, but it is still science, not witchcraft!