If cervical curettage is planned, intraoperative bleeding may be lessened by preoperative UAE, by intracervical vasopressin injection, or by a cerclage placed at the internal cervical os to compress feeding vessels (Chen, 2015; Fylstra, 2014; Wang, 2011). Also, cervical branches of the uterine artery can efectively be ligated with vaginal placement of hemostatic cervical sutures on the lateral aspects of the cervix at 3 and 9 o'clock (Bianchi, 2011). Following curettage, a Foley balloon can be placed to tamponade bleeding and is managed as described earlier. Suction curettage may be especially favored in rare cases of a heterotopic pregnancy composed of a cervical and a desired uterine pregnancy (Tsakos, 2015).
hese rare ectopic pregnancies are defined as an implantation in the peritoneal cavity exclusive of tubal, ovarian, or intraligamentous implantations. Although a zygote can traverse the tube and implant primarily in the peritoneal cavity, most abdominal pregnancies are thought to follow early tubal rupture or abortion with reimplantation. In cases of advanced extrauterine pregnancy, it is not unusual for the placenta to be still at least partially attached to the uterus or adnexa.
Diagnosis may be diicult. First, symptoms may be absent or vague. Laboratory tests are typically uninformative, although maternal serum alpha-fetoprotein levels can be elevated. Clinically, abnormal fetal positions may be palpated, or the cervix is displaced (Zeck, 2007). Sonographically, the diagnosis is often missed (Costa, 1991). Oligohydramnios is common but nonspecific. Other clues include a fetus seen separate from the uterus or eccentrically positioned within the pelvis; lack of myometrium beween the fetus and the maternal anterior abdominal wall or bladder; extrauterine placental tissue; or bowel loops surrounding the gestational sac (Allibone, 1981; Chukus, 2015). If additional anatomical information is needed, MR imaging can help confirm the diagnosis and provide maximal information concerning placental implantation (Bertrand, 2009; Mittal, 2012).
Treatment of an abdominal pregnancy depends on the ges tational age at diagnosis. Conservative management carries a maternal risk for sudden and dangerous hemorrhage. Moreover, in 20 percent. Thus, we believe that termination generally is indicated when the diagnosis is made. Certainly, before 24 weeks, conservative treatment rarely is justified. Despite this, some have described waiting until fetal viability with close sur veillance (Kim, 2013; Marcellin, 2014).
Once placental implantation has been assessed, several options to control intraoperative hemorrhage mimic those used for placenta accrete syndrome (Chap. 41, p. 792). he principal surgical objectives involve delivery of the fetus and careful assessment of placental implantation without provoking hemorrhage. Unnecessary exploration is avoided because the anatomy is commonly distorted and surrounding areas are extremely vascular. Importantly, placental removal may precipitate torrential hemorrhage because the normal hemostatic mechanism of myometrial contraction to constrict hypertrophied blood vessels is lacking. If it is obvious that the placenta can be safely removed or if there is already hemorrhage from its implantation site, then removal begins immediately. When possible, blood vessels supplying the placenta should be ligated irst.