Ignoring The Odds: Interprofessional Planning For Positive Outcomes In Abdominal Pregnancy

Background:

Abdominal pregnancy is rare and risky. Interdisciplinary collaboration, comprehensive clinical management, emotional support, and family inclusion in planning have a positive impact on outcomes as was demonstrated in this case. 

Case:

A 33 year old G2P1 presented at 19 weeks/3 days gestation with an abdominal pregnancy during routine prenatal anatomy scan. Early transvaginal ultrasound obtained in the ED due to bleeding confirmed pregnancy, but did not confirm fetal location.  Due to this finding, the patient was transferred to the High Risk OB service at a large academic medical center.

The patient’s health history included a history of smoking, anxiety, and a cesarean section due to non-reassuring fetal heart tones.  An MRI indicated a placenta that enveloped and adhered to the left pelvic sidewall, sigmoid colon, bladder, right ovary, left iliac, and left ureter. Medical recommendation to remove the fetus was counter to the patient’s religious beliefs. The medical team and her spouse disagreed with her decision, but accepted it and developed a comprehensive plan of action to preserve the life of both the mother and neonate.

Upon admission to the hospital, a special team developed a patient centered plan of care. This team included a core set of RNs and respresentatives from Obstetrics, Interventional Radiology, Vascular Surgery, Gynecologic Oncology, Neonatalogy, Blood Bank, Pastoral Care, and OB Social Work. Multiple family meetings were held and limited options were discussed.  Obstetrics coordinated the care team during delivery.  The delivery process was discussed with the patient early in her hospitalization and she verbalized awareness of the steps needed to ensure maternal/fetal safety. Despite a poor prognosis the pregnancy continued and the neonate was delivered at 24 weeks due to perigestational hemorrhage.  At delivery, the patient lost 5500ml of blood and received 37 units of blood products.  She was transferred intubated to the ICU.  Mother was discharged home on postoperative day 8 and the infant was discharged home on room air after six months.

Conclusion:

The focus of evidence based nursing care is both patient centered and holistic.  While nursing staff agreed termination of the pregnancy was the healthiest option for mom, they respected and advocated for her choices.  Facilitating lengthy bed rest, maintaining DVT prophylaxis, and providing emotional support were priorities for the nursing team. Once nursing staff detected maternal status changes, clear interdisciplinary communication and rapid mobilization for delivery changed the odds for this patient. Both mother and baby are home today. 

Keywords: abdominal pregnancy, interdisciplinary, interprofessional communication, patient and family centered care (PFCC)