“Could It Be a Primary or Secondary Abdominal Ectopic Pregnancy?” – A Case Report and Reflection on Diagnostic Challenges in Resource-Limited Settings

Background: Abdominal pregnancy, a rare, life-threatening ectopic pregnancy, comprises 1–1.5% of ectopic gestations and occurs in 1 in 10,000 to 30,000 pregnancies. Its maternal mortality risk is 7–8 times higher than other ectopic pregnancies and up to 90 times higher than intrauterine pregnancies. Diagnosis is often delayed, particularly in low-resource settings with limited imaging and specialist services, exacerbating maternal morbidity. Case Presentation: A 29-year-old gravida 4 para 2 woman with two prior cesarean sections was referred to a tertiary facility in Lusaka, Zambia, initially managed as a missed abortion at 17 weeks. After three ineffective misoprostol doses, repeat imaging revealed a secondary abdominal pregnancy with a mummified fetus in the left adnexa and a partially retained placenta at the uterine cordual end. Laparotomy showed dense adhesions, a ruptured left cordual area, and a fetal capsule. The placenta was removed, the uterine defect repaired, and the patient recovered fully. Discussion: Abdominal pregnancies are diagnostically complex, often mimicking intrauterine pathologies. Transvaginal ultrasound, the primary tool, misses up to 50% of cases, necessitating a high index of suspicion. Advanced imaging (MRI, CT) or laparoscopy can aid diagnosis but is often unavailable in resource-limited settings, where laparotomy remains standard. Prior cesarean sections and contraceptive use may have contributed to uterine rupture and secondary implantation in this case. Conclusion: Enhanced clinician awareness, accessible diagnostics, and robust surgical planning are crucial for safe management of abdominal pregnancies. Strengthening diagnostic and surgical capacity in sub-Saharan African hospitals is essential to prevent maternal deaths from such rare obstetric complications.