A Rare Case of a Third Trimester Intra-abdominal Pregnancy En Caul Delivered via Cesarean Section

Uterine rupture is among the most dangerous complications that can occur in pregnancy. The risk of this complication increases with multiparity, prior rupture, and prior cesarean sections. In combination, these pose a serious risk to both patient and fetus and should be properly evaluated in the setting of refractory abdominal pain in pregnancy. We present a case of a 30-year-old pregnant woman at approximately 30 weeks of gestation with a past medical history (PMH) of prior ectopic pregnancies, prior pelvic surgeries, and limited prenatal care who arrived at our institution following reports of an intra-abdominal pregnancy with no fetal heart tones detected on an ultrasound performed at an outside institution. She arrived hemodynamically stable; however, it was notable that she had a critically low hemoglobin of 6.5 and leukocytosis. She received a CT abdomen and pelvis, which demonstrated an intra-abdominal pregnancy with an adjacent fundal defect and prominent hemoperitoneum. The patient was subsequently transported to the operating room and underwent an exploratory laparotomy, with visualization and delivery of a nonviable female infant within the amniotic sac. The intraoperative evaluation of the uterus demonstrated a prominent cornual defect with active bleeding. The decision was made to perform a hysterectomy, and the patient recovered well postoperatively without complications. This case illustrates how a comprehensive evaluation of a pregnant patient, with both lab work and appropriate cross-sectional imaging, can provide critical information regarding obstetrical emergencies such as uterine rupture and highlights a rare finding in the delivery of an intra-abdominal fetus en caul.