In our daily practice, abdominal pregnancy remains a rare disease of ectopic pregnancy [3]. Its frequency is not the same in the regions. High in countries with low medical density where her diagnosis is also later [9] - [15], the frequency of abdominal pregnancy is low in countries with high medical density such as pointed out Sfar and al. in Tunis with the lowest rate: 1 in 21,439 births [2]. This difference is explained by the socio-economic level of the country and by the quality of the surveillance of pregnancy and childbirth [16] [17] [18] but also by the high prevalence of sexually transmitted diseases as well as abortions in septic conditions, causing tubal lesions, frequently observed in Africa [19].

Reported in some publications, the incidence in the black race is up to 10 to 25 times that of the white race [10] [20] [21]. A few cases have been reported on assisted reproduction [22] [23].

Women over 30 with few deliveries are much more eligible according to the literature [24].

There are several classifications of abdominal pregnancies. Among these classifications, the oldest distinguishes the primitives from the secondaries [11].

The primary form is the least frequent [25]. By delay in oocyte uptake, the ovum can remain in the free peritoneum until the 6th day after ovulation and can be fertilized and nest on any structure of the cavity [26]. Confirmation of this form must meet the four conditions of Studdiford [2] [11] namely both tubes and ovaries must be free from any lesion; absence of utero-peritoneal fistula; the relations of the ovular sac concern exclusively the peritoneal surface; the pregnancy must be young enough.

More frequent, the secondary form can result from a ruptured tubal pregnancy or from a tubo-abdominal abortion and can be consecutive to a secondarily abdominal intrauterine pregnancy on the occasion of a ruptured hysterotomy scar, a breach of uterine perforation, or a rupture of a rudimentary horn [2].

A new classification based on gestational age or location of implantation has been proposed by certain Anglo-Saxon authors [27]. It distinguishes early abdominal pregnancy whose gestational age is less than 20 weeks with a trophoblastic implantation which takes place mainly on the uterus, the broad ligament, the parietal peritoneum and the dead end of Douglas, from pregnancy late abdominal pain after 20 weeks [11].

We will discuss the diagnosis both clinically and paraclinically.

Clinically, the diagnosis is guided by several symptoms [28] [33]:

- digestive disorders: nausea, vomiting, constipation, subocclusion;

- abdomino-pelvic pain concomitant with fetal movements with or without metrorrhagia;

- anemia with deterioration of the general condition;

- a very superficial fetus often in an atypical, high transverse position;

- sometimes palpation of the uterus increased in size but empty corresponding to a second mass;

- on vaginal examination, the cervix is often fixed under the pubic symphysis, it is hard and long;

- it is not uncommon for a progressive complication to dominate the picture (internal or externalized hemorrhage, anemia, jaundice, oliguria, toxi-infectious syndrome).

Our patient presented many of these signs supporting the diagnosis.

Paraclinically, our diagnosis was confirmed by abdominal ultrasound. But in case of occlusive syndrome or an atypical position of the fetus, the X-ray of the abdomen without preparation is indicated. However, the key examination remains laparoscopy [29], inaccessible in all hospital structures in the country.

The only therapeutic sanction used to manage an abdominal pregnancy is surgery, the operational urgency of which is theoretically qualified according to fetal viability [2].

A preventive laparotomy was performed at 34 WA + 2 days in our case in order to avoid the risk of maternal-fetal mortality. Despite this, the newborn baby died a few days after prematurity and neonatal infection.

Because of the risk of cataclysmic hemorrhage, all attempts at placental extirpation are strictly prohibited, especially if the placenta is inserted into a noble organ or a vessel [30]. The placenta is left in place but by cutting the cord as close as possible and by strictly monitoring the patient postoperatively in order to detect complications (fistula, peritonitis, abscess, secondary hemorrhage, occlusion). Ultrasound coupled with the dosage of placental hormones [4] makes it possible to control spontaneous placental resorption which takes place in two phases, namely very slow until the 10th week and faster which could last up to 3 years [31].

In order to accelerate this absorption, we used an antimitotic (Methotrexate). But this attitude is still discussed in the literature not only because of its toxicity but also of its inability to avoid the complications caused [28]. In the meantime, whole blood bags were donated and drains put in place. Thromboprophylaxis under platelet control was started for 10 days as well as iron supplementation for one month. It should be noted that during the operation, antibiotic prophylaxis was also administered.

The fetal prognosis of abdominal pregnancy is poor with mortality ranging between 75% and 95% due to poor placental vascularity, hypotrophy and fetal malformations [32].

On the other hand, the prognosis of the mother depends for its part on the delay in diagnosis and the attitude towards the placenta; maternal mortality is of the order of 0% to 18% according to Hainaut [11].