Introduction About 2% of all pregnancies are ectopic, accounting for 10% of all pregnancy related deaths (1). More than 95% of ectopic pregnancies occur within the fallopian tubes (2). Abdominal pregnancy, a rare variety of ectopic pregnancy, is defined as an intra-peritoneal implantation that is exclusive of tubal, ovarian or intra-ligamentous implantation. The world-wide incidence ranges from 1:3300 to 1:10200 births and accounts for 1 to 4% of all ectopic pregnancies (3-7). Even more uncommonly does it reach an advanced stage of gestation, and a viable abdominal pregnancy with a successful outcome is a rare event (8-10). The condition is associated with very high maternal mortality, with reported rates of 0.5 to 18% (1). The major cause for this is massive hemorrhage which may occur during pregnancy, during surgery or in the post operative period. Similarly, the condition is associated with very high perinatal mortality rate of about 95% (1, 11). This is attributed to preterm deliveries resulting from active intervention, done in the majority of the cases as soon as the diagnosis is made. Diagnosis of abdominal pregnancy is difficult and often missed (1, 4). Symptoms and signs such as abdominal pain, gastro-intestinal symptoms, painful fetal movements, abnormal presentations, uneffaced and displaced cervix, vaginal bleeding, palpation of pelvic mass distinct from the uterus, inability to stimulate uterine contraction with oxytocin, are considered suggestive evidences of an abdominal pregnancy (3, 4). This paper reports a 35 years old gravida two para one mother who was 7 months pregnant and presented with sign and symptoms of intestinal obstruction and later diagnosed to have an advanced abdominal pregnancy which was managed at Ambo hospital. Case Report The patient was 35 years old gravida two para one mother from Gindeberet, West Shoa, who was amenorrhic for seven months with abdominal pain and failure to pass feces for one week with subsequent failure to pass flatus and vomiting of ingested material since one day prior to her presentation to Ambo Hospital, West Shoa, Ethiopia. Initially she was seen at the surgical department and was admitted as a case of intestinal obstruction in the third trimester of pregnancy. After further work up she was transferred to the obstetric department with the diagnosis of advanced abdominal pregnancy. She had no antenatal follow-up. She said that pregnancy was uneventful before the onset of the above symptoms. She used to feel fetal movements. She is married and a farmer. During examination, she was acutely sick looking. Vital signs were stable with blood pressure of 120/60 mmHg, pulse rate of 88/ min, and a temperature of 36.6 degrees Celsius. On abdominal examination, it was grossly distended and difficult to appreciate fetal parts and presentation. Abdomen was diffusely tender with hyperactive bowel sounds. Fetal heart sounds were heard. On pelvic assessment, cervix was closed uneffaced, and it was pushed anteriorly. There was a soft bulge at posterior cul-de-sac. Hematocrit was 30% and on abdominal ultrasound examination there was an alive fetus and it was difficult to measure BPD because of irregular contour of the skull bones. There was scanty amount of amniotic fluid. There was small sized uterus posterior to urinary bladder. Just posterior to the uterus, there was a homogenous echogenic mass occupying the posterior cul-de-sac and which looked like the placenta (Fig.1). With the assessment of an abdominal pregnancy and intestinal obstruction laparotomy was performed, and the intra-operative finding was that there were grossly distended small bowel loops. When the small intestine was exposed, there was an intact gestational sac free in the peritoneal cavity extending to the posterior cul-de-sac and there was a viable fetus inside the sac. The urinary bladder was edematous and non pregnant size uterus was found just posterior to bladder. The fallopian tubes and both ovaries were intact but edematous. What we did was that we opened the gestational sac and clear liquor came out. A female fetus weighing 900g was extracted. The placenta was found in the cul-de-sac and it had attachments to the posterior wall of uterus, pelvic peritoneum of posterior cul-de-sac and part of anterior wall of rectum. It was removed completely with the gestational sac. Peritoneal cavity was lavaged with copious amount of saline. Post operative hematocrit was 20% and the patient was put on IV triple antibiotics and she was supplemented with iron tablets for 3 months. She was discharged on the sixth post operative day with improvement and was appointed to regular Gynecologic OPD but she was lost to follow up. On examination of the fetus there were deformities over the head and both lower extremities. She was put under radiant warmer, oxygen through nasal catheter was given, and NG tube was inserted for feeding. Umbilical catheterization was attempted by the pediatrician but failed. The fetus was able to survive for 36 hours then expired (Fig.2). Fig.1: Abdominal ultrasound showing an empty uterus separate from the gestational sac and the deformed fetal skull. Fig.2: The fetus from abdominal pregnancy with multiple compression deformities Discussion The incidence of abdominal pregnancy appears to be increasing in both developed and developing countries (11). In the former, increasing use of assisted reproductive technology with embryo transfer has been associated with increasing numbers of heterotopic pregnancies (12-15). In developing countries, particularly in the rural areas, a high incidence of abdominal pregnancies is reported, presumably due to restriction of human resources and diagnostic facilities, and poor utilization of medical care by pregnant women (16-18). Under both circumstances, some undiagnosed tubal pregnancies may abort into the peritoneal cavity, implant and continue into advanced abdominal pregnancies. The clinical presentation depends on the gestational age: in the first trimester, symptoms are similar to those of tubal ectopic pregnancies. In the second or third trimesters, the diagnosis may be suspected because of an abnormal fetal presentation, signs and symptoms of intestinal obstruction, displaced uterine cervix or easily palpable fetal parts (6). In our case, the patient presented with signs and symptoms of intestinal obstruction in the third trimester of pregnancy. To diagnose an abdominal pregnancy on ultrasound, one should try to delineate the uterus as a separate structure from the fetus and placenta. Sometimes even under best circumstances, and using sonography, the diagnosis is often missed (6, 19-21). On ultrasound examination of our case, it was possible to demonstrate intra-abdominal pregnancy with placental implantation outside a non pregnant size uterus. CT scan and MRI have been used successfully to complement sonography in making an accurate diagnosis of abdominal pregnancy (1, 22-25). Once the diagnosis is made, optimal management requires careful evaluation and planning. If it is diagnosed in the first trimester or in early second trimester, the management is surgical intervention without delay. However, due to late presentation of cases, the condition may remain undiagnosed until viable stage of gestation, i.e. after 24 weeks of gestation. The major questions raised in such cases are related to the timing and mode of delivery. Although no consensus exists on the issue, a conservative approach is proposed in the absence of fetal gross malformation, placental implantation remote from the upper abdomen, good maternal condition, and close management in a tertiary care hospital (7). In our case, conservative approach had no place because she presented with signs and symptoms of intestinal obstruction. Similarly, no consensus exists on the management of the placenta and each case is managed on an individual bases according to intra-operative findings. Regardless of gestational age, removal of placenta can result in hemorrhage. Unless the entire blood supply of placenta can be ligated, it is best to leave the placenta in situ and then follow the patient with serial B-hCG levels and sonography [6, 24, 28]. In the present case, the implantation site was in the lower part of abdomen at cul-de-sac. The major arterial supply of the placenta was identified and was ligated. 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