{"paper_id":"198d3e19-51da-4897-ad20-a7c2681f5edf","body_text":"Case Report\nObstetrics and Gynecology Reports\nObstet Gynecol Rep, 2020          doi: 10.15761/OGR.1000150\n Volume 4: 1-2\nISSN: 2515-2955\nSpontaneous hemoperitoneum in pregnancy (SHiP) \ncomplicated by endometriosis: A case report\nYukyoung Sim1*, Jonghyun Kim1,2, Youngju Jeong1,2, Chulhee Rheu1,2 and Heesuk Chae1,2\n1Department of Obstetrics and Gynecology, Chonbuk National University Hospital, Jeonju, South Korea\n2Research Institutue of Clinical Medicine, Chonbuk National University Hospital, Jeonju, South Korea\nAbstract\nBackground: Spontaneous hemoperitoneum in pregnancy (SHiP) is a rare but life-threatening condition associated with maternal and perinatal mortality. Herein, \nwe report a case of intra-abdominal hemorrhage caused by spontaneous utero-ovarian vessel rupture at 27 gestational weeks following surgery two years earlier for \nsevere endometriosis. \nCase: A 31-year-old woman primigravida presented to the hospital at 27 weeks’ gestation with acute abdominal pain. She had a history of laparoscopy for severe \nendometriosis and bilateral ovarian endometriomas. Although the initial ultrasound done was normal, there was a clinical suspicion of hemoperitoneum in pregnancy, \nwhich was confirmed by MRI. An emergency laparotomy was performed. \nResults: About 2000 mL of blood in the abdominal cavity was evacuated. Cesarean section was performed at the same time due to difficulty in hemostasis and \ndifficulty in securing the field of vision. Extensive adhesions including both adnexa tightly adhered to the posterior surface of the uterus and completely obliterated \npouch of Douglas behind the uterus were noted. Active bleeding from the left-posterior uterine-ovarian vessels was found and hemostasis was achieved. \nConclusions: If pregnant women with a history of previous endometriosis treatment present with acute abdominal pain, a fall in hemoglobin, and the absence of \nvaginal bleeding, intraabdominal hemorrhage should be considered. \n*Correspondence to: Heesuk Chae, Department of Obstetrics and Gynecology, \nChonbuk National University Hospital, Jeonju, South Korea, Tel: 821062644762; \nE-mail: jb0429@hanmail.net \nKey words: endometriosis, pregnancy, spontaneous hemoperitoneum\nReceived: October 10, 2020; Accepted: October 16, 2020; Published: October \n20, 2020\nIntroduction  \nSpontaneous hemoperitoneum in pregnancy (SHiP) is a rare but \nalmost always life-threatening condition associated with high maternal \nand perinatal mortality [1,2]. This situation occurs mainly in the second \nand third trimester of pregnancy [3]. The etiology of this condition is \nunknown, but recently, it is believed to be related to endometriosis \n[1,3,4]. We report a case of SHiP complicated by endometriosis. \nCase \nA 31-year-old woman primigravida presented to the hospital \nat 27 weeks’ gestation with acute abdominal pain. Besides previous \npelvic surgery which she had received laparoscopy because of severe \nendometriosis and bilateral ovarian endometriomas two years \npreviously, she was otherwise healthy. Her antenatal course had been \nuneventful. The patient’s main symptom started during a defecation \nattempt. \nOn admission, her blood pressure and heart rate were 120/70 \nmmHg and 77 beats/min, respectively. Her circulating hemoglobin \nlevel was 8.6 g/dL. On examination, she had a soft abdomen with \nslight tenderness on gentle palpation. There were no signs of vaginal \nbleeding or vaginal discharge. The cervix was closed. Cardiotocogram \ndemonstrated no uterine contractions and showed fetal heart rate with \nnormal variability.  Ultrasound imaging showed normal amniotic fluid \nvolume and a placenta without any signs of abruption. \nThe following day the patient’s clinical condition abruptly worsened \nwhen she tried to stool again.  Blood pressure was 80/50 mmHg and \nthe hemoglobin level decreased to 6.0 g/dL. Magnetic resonance image \n(MRI) revealed massive intra-abdominal fluid collection (Figure 1A \nand 1B).\nAn emergency laparotomy was performed. Intraoperatively, almost \n2,000 mL of blood and clots were noted. However, because of the gravid \nuterus, it was difficult to find the bleeding site, so caesarean section \nwas decided. A female baby weighing 905 g was extracted. The Apgar \nscores were 1 and 3 at 1 and 5 minutes, respectively. Both adnexa were \ntightly adhered to the posterior surface of the uterus and completely \nFigure 1(A). Transverse MR image shows perihepatic hemoperitoneum. (B) Coronal MR \nimage shows fluid collection in the abdomen\n\nSim Y (2020) Spontaneous hemoperitoneum in pregnancy (SHiP) complicated by endometriosis: A case report\n Volume 4: 2-2\nObstet Gynecol Rep, 2020          doi: 10.15761/OGR.1000150\nConclusion \nIn conclusion, as shown in our case, the presence of endometriosis \nmay be a risk factor for SHiP. If pregnant women with a history of \nendometriosis had development of conditions of sudden abdominal \npain, a reduction of hemoglobin, and the absence of vaginal bleeding, \neven if rare, obstetricians should bear in mind the possibility of SHiP. \nAcknowledgment \nThank numerous individuals participated in this study. \nAuthors disclosure statement\nThe authors have no conflicts of interest to declare. \nReferences\n1. Brosens IA, Fusi L, Brosens JJ (2009) Endometriosis is a risk factor for spontaneous \nhemoperitoneum during pregnancy. Fertil Steril 92: 1243-1245.\n2. Katorza E, Soriano D, Stockheim D, Mashiach R, Zolti M, et al. (2007) Severe intra-\nabdominal bleeding caused by endometriotic lesions during the third trimester of \npregnancy. Am J Obstet Gynecol 197: 501.e1-e4.\n3. Lier M, Malik RF, van Waesberghe J, Maas JW, van Rmpt-van de Geest DA, et al. \n(2017) Spontaneous haemoperitoneum in pregnancy and endometriosis: a case series. \nBJOG 124: 306-312.\n4. Inoue T, Moriwaki T, Niki I (1992) Endometriosis and spontaneous rupture of utero-\novarian vessels during pregnancy. Lancet 340: 240-241.\n5. Maggiore ULR, Ferrero S, Mangili G, Bergamini A, Giorgione V, et al. (2016) A \nsystematic review on endometriosis during pregnancy: diagnosis, misdiagnosis, \ncomplications and outcomes. Hum Reprod Update 22: 70-103.\n6. Passos F, Calhaz-Jorge C, Graca LM (2008) Endometriosis is a possible risk factor \nfor spontaneous hemoperitoneum in the third trimester of pregnancy. Fertil Steril 89: \n251-252.\n7. Loi ES, Darwish B, Abo C, Millischer-Bellaiche AE, Angioni S, et al. (2016) Recurrent \nhemoperitoneum during pregnancy in large deep endometriosis infiltrating the \nparametrium. J Min Invasive Gynecol 23: 643-646.\n8. Wada S, Yoshiyuki F, Fujino T, Sato C (2007) Uterine vein rupture at delivery as a \ndelayed consequence of laparoscopic surgery for endometriosis: a case report. J Minim \nInvasive Gynecol 14: 463-469.\n9. Cozzolino M, Corioni S, Maggio L, Sorbl F, Guaschino S, et al. (2015) Endometriosis-\nrelated hemoperitoneum in pregnancy: a diagnosis to keep in mind. The Ochsner J 15: \n262-264.\n10. Wu CY, Hwang JL, Lin YH, Hsieh BC, Seow KM, et al. (2007) Spontaneous \nhemoperitoneum in pregnancy from a ruptured superficial uterine vessel. Taiwan J \nObstet Gynecol 46: 77-80.\n11. Kapila P (2011) Fatal non-traumatic spontaneous hemoperitoneum in second trimester \nof pregnancy-autopsy findings. J Forensic Leg Med 18: 139-140.\n12. O’Leary SM (2006) Ectopic decidualization causing massive postpartum intraperitoneal \nhemorrhage. Obstet Gynecol 108: 776-779.\nobliterated pouch of Douglas were observed. Active bleeding was found \nin the fragile veins at the left-posterior uterine-ovarian vessels, which \nwas then sutured for hemostasis. During surgery, the patient received 3 \nunits of red blood cells and 2 units of cryoprecipitate. The patient had \nan uneventful course and was discharged 6 days after the operation. \nThe infant was transferred to an intensive care unit and was discharged \n10 weeks after birth. \nDiscussion \nSpontaneous hemoperitoneum in pregnancy (SHiP) is a relatively \nrare condition associated with maternal and perinatal mortality [1,5]. \nFurthermore, as in the first case, hemoperitoneum in pregnancy \nresulting from spontaneous rupture of uterine-ovarian vessels is \nextremely rare. During the past 20 years over 25 cases of SHiP have \nbeen reported, occurring during the antepartum (61%), labor (18%), \nand early postpartum periods (21%) [6,7].\nThe cause of the condition remains poorly understood. However, \nseveral etiologic factors have been proposed: increase in venous \npressure in the uteroovarian circulation, resulting from the physiologic \ndemands of pregnancy and during muscular activity and straining, such \nas coughing, defecation, coitus, or during the pushing phase of second \nstage labor [2]. However, a series of recent reports have been suggested \nthat endometriosis may cause SHiP. Hemoperitoneum in pregnant \nwomen with endometriosis can be caused by spontaneous rupture of \nutero-ovarian vessels or direct bleeding of endometriosis implants. \nInoue, et al. suggested first that endometriosis might be a possible \nrisk factor for SHiP [4]. Friable uterine vessels resulting from chronic \ninflammation accompanied by endometriosis or vessel tension resulting \nfrom adhesion presumably contributes to vessel rupture [4,8].  Brosens, \net al. noticed that SHiP was associated with endometriosis in >50% of \ncases [1]. The pathologic examination of the site of bleeding during \npregnancy confirmed endometriosis, characterized by prominent \nvascularization and decidualization of the lesion [1,9].   We agree with \nInoue’s hypothesis based on the facts that severe endometriosis was \nobserved at the time of surgery and hemoperitoneum due to spontaneous \nrupture of the uterine vessels rather than endometriosis lesions occurred. \nThe uterine vessels weakened by endometriosis cause rupture when \nintraabdominal pressure during physical activity such as defecation.\nThe diagnosis of SHiP is rarely made before laparotomy due to their \nextreme rarity and it is frequently misdiagnosed as placental abruption. \nOther differential diagnoses include uterine rupture, ruptured \nappendix, abdominal pregnancy, ruptured vasculature of the liver or \nspleen, and HELLP syndrome [10]. In addition, a correct preoperative \ndiagnosis based on a clinical entity is difficult because SHiP is usually \nrelated to non-specific symptoms of acute abdominal pain, vomiting \nand maternal anemia [3]. This explains a higher rate of maternal and \nperinatal mortalities of SHiP [11,12].\nCopyright: ©2020 Sim Y. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, \ndistribution, and reproduction in any medium, provided the original author and source are credited.","source_license":"CC0","license_restricted":false}