A 30-year-old gravida VI para-V, all delivered at home vaginally and alive. The last delivery was three years back. The women does not remember her last normal menstrual period for the current pregnancy, but stated to be amenorrheic for 9 months, visited Hiwot Fana Specialized University Hospital (HFSUH) with the chief complaint of abdominal pain of two weeks duration. She never had antenatal care or an ultrasound examination for the index pregnancy. She came to the health facility for the first time since the conception of the current pregnancy.
She stated that she started to feel a dull aching abdominal pain all over the abdomen which later worsened and she started to feel shortness of breath. She also experienced increased nausea and vomiting and increased fetal movement compared to the previous five pregnancies. She reported to have had no vaginal bleeding.
On physical examination, she looks malnourished with prominent zygomatic bones. Her vital sign were blood pressure 120/80 mmhg, pulse rate 90 beats per minutes, temperature 36.9  C and respiratory rate 20 per minutes. All these records showed that the vital signs were within normal limits. She has pink conjunctiva and non-icteric sclera. Her respiratory and cardiovascular examination is unremarkable. On abdominal examination, the pregnancy was a term sized, with easily palpable fetal parts, transverse lie, and positive fetal heartbeat of 152 beats per minute. There is no clear border of the uterus nor was there felt any signs of uterine contraction. On pelvic examination the cervix is closed, posterior and uneffaced.
After admission, the laboratory results showed that her hematocrit level was 33% and blood group was O positive. Ultrasound findings indicated intra-abdominal viable pregnancy with gestational age of 37 weeks and 5 days, transverse fetal lie, empty uterus, fluid inside the cul-de-sac and Doppler evaluation showed vascularization of uterine fundus (Figure 1).
Based on the above findings, she was diagnosed to have a term intra-abdominal pregnancy and emergency laparotomy was decided. Three units of blood was prepared as an emergency in case excessive bleeding happened. The women was counselled on her condition and the possible options of intraoperative management and complications. Then, after written consent was taken, prophylactic antibiotics were given and the patient taken to the operation theater. Under general anesthesia she underwent a laparotomy. The findings were an intra-abdominal pregnancy with intact gestational sac. The placenta was attached to the uterine fundus and the omentum. The uterus looked normal grossly except the fundal part where the placenta covered it. Both tubes and ovaries also looked healthy.