A California medical team recently delivered a healthy baby born at term from an abdominal pregnancy during which the mother didn’t even know she was pregnant, due to a known massive ovarian cyst.
Medpage Todayreports that John Ozimek, DO, medical director of Labour and Delivery at Cedars-Sinai Medical Centre in Los Angeles, said the case was exceptionally complex.
Suze Lopez (41), a nurse, had found out she was pregnant just days before arriving at the Cedars-Sinai emergency department. When she was in her early 20s, she’d had bilateral benign ovarian masses, one of which was large enough that it had to be removed. Lopez opted to keep the other mass to maintain her fertility and not enter early menopause.
The mass grew over many years, protruding from her abdomen. When growth seemed to accelerate, her doctor ordered a CT scan to check on it. However, the urine pregnancy test before the scan came back positive.
Three days later, Lopez experienced some abdominal pain and sought care at Cedars-Sinai. Her blood pressure was dangerously high at 190/110 mm Hg.
During an ultrasound, Ozimek needed to reposition Lopez several times to look for her potential pregnancy, due to her massive mass.
“Finally, I moved the probe almost posteriorly towards her back, and then really high up near her ribs, and I was able to see what I thought was a femur,” Ozimek said, noting that this is a good way to quickly gauge gestational age.
The femur measured 37 weeks – full term. He also managed to get a view of the baby’s head, which also measured full term.
“I thought, ‘oh my gosh’,” he said. “They just thought the mass was growing, but really it was a full-term baby growing behind that and pushing the mass out.”
Fuller picture
An MRI confirmed a complete abdominal ectopic pregnancy and that Lopez’s uterus was empty. The baby was sitting in the posterior left portion of her abdomen with its head under the spleen and bottom resting on the uterus. Lopez’s abdominal mass was 30cm across and a whopping 9.9kg.
Ozimek’s team then did a CT angiogram to see where the placenta was getting most of its blood.
“When a placenta is trying to implant outside the uterus, it doesn’t know that it’s outside, and it’s just looking for vascular supply,” Ozimek explained. “So what we worry about in a very rare case like this is that it implants on something like the liver or the spleen or even the aorta, which, as you might imagine, would cause a massive, massive haemorrhage at the time of delivery.”
The scan revealed the placenta was primarily implanted in the right pelvic sidewall. In no way was this pregnancy ideal, but this was not the worst-case scenario, Ozimek noted.
“On the spectrum of horrifying to absolutely terrifying, this is probably on the horrifying end.”
With the mass in the way, they could not determine the baby’s chances for survival, or if there had ever been amniotic fluid, which is necessary for the lungs to develop.
Even though Lopez’s blood pressure was extremely high, they decided the safest way to proceed was to wait until morning so they could assemble an expert team and formulate a plan. Ozimek connected with several specialists, including gynaecologic oncologic surgeons with expertise in complex pelvic surgeries and managing haemorrhage, trauma surgery, the neonatal intensive care unit (NICU), and obstetric anaesthesiology.
The next morning, the team started by removing the mass. It was large, well circumscribed, and very mobile, and they were able to rapidly move it out of the way.
“The baby was just lying in her abdomen like nothing you’ve ever seen before,” Ozimek said.
The amniotic sac was around the baby and a robust umbilical cord was visible. Interestingly, the abdominal contents were meconium stained, meaning the baby had already had a bowel movement. It’s common to see meconium staining on the placenta, but not the maternal abdominal and pelvic organs as the team saw here.
The team then removed the baby from the abdomen and handed him off to the waiting NICU team. Baby Ryu Lopez was more than 4kg and had a full head of hair.
Caesarean deliveries usually involve epidural or spinal anaesthesia in which the mother remains awake. But this was an exploratory abdominal laparotomy and given the expected haemorrhage risk, it would have been physiologically too risky for her to be awake, so Lopez was put under general anaesthesia.
Next, the team readdressed Lopez’s abdomen and found a large, mature placenta primarily implanted in the pelvic sidewall, just as the imaging had shown. Part of it was also adherent to the right cornua of the uterus and to the large bowel, though it did not invade these structures.
Lopez started haemorrhaging as anticipated. She lost 4.7 litres of blood – almost her entire blood volume. Ozimek said the anaesthesiology team “was resuscitating her and transfusing her throughout and keeping her very, very stable”.
Under normal circumstances, the uterus is decompressed, contracts down, and shears off the wall. But for Lopez, a surgeon had to carefully isolate the pedicle, clamp it, cut it, and tie off the bleeding.
Last, Lopez had to have a hysterectomy to control the bleeding. The whole endeavour took about 3.5 hours.
Defying the odds
After the surgery, Lopez’s blood pressure was still high, but she was extubated within 12 hours and out of the intensive care unit and back on labour and delivery within 24 hours. Baby Ryu was healthy and normal.
While some may wonder how Lopez didn’t know she was pregnant until her baby was full term, Ozimek emphasised that all of her pregnancy symptoms blended in with what she was already living with: having a huge mass inside her. She was used to looking pregnant and had missing or irregular periods for the past 17 years.
“So it all makes sense that any pain or discomfort or nausea she was feeling from the pregnancy, she was attributing to normal discomfort and pain associated with that mass,” he said, adding that a case like this is far rarer than one in a million.
“Miracle” is a loaded term in the maternal-foetal medicine space, but Ozimek added that he can’t help but think this case was pretty close to that.
See more from MedicalBrief archives:
Under-diagnosis of ectopic pregnancies is killing women – UK expert
‘Miracle’ Cape baby grew outside mother’s womb