{"paper_id":"4ddec738-7a85-4e4a-bd94-20ca05229a04","body_text":"CASE REPORT\nMassive haemoperitoneum due to uterine artery erosion\nby endometriosis and a review of the literature\nPaul Fiadjoe & Anne Thomas-Phillips & Kalpana Reddy\nReceived: 27 April 2007 / Accepted: 18 July 2007 / Published online: 16 August 2007\n# Springer-V erlag 2007\nAbstract The aim of the literature review was to compile\nand compare similar cases of massive haemoperitoneum in\nan asymptomatic woman where the bleeding was from the\nright uterine artery, which had been eroded by pelvic\nendometriosis. To our knowledge this is the second case\nreported in the literature. Case reports of other sources of\nbleeding leading to haemoperitoneum were studied, com-\nparisons were made, and the results compiled. Although\nseveral cases of massive haemoperitoneum have been\nreported, spontaneous bleeding from uterine artery erosion\nis a rare occurrence. The abdominal surgeon should be\nvigilant and alert to localise rare sites of bleeding. This\nliterature review emphasises that endometriosis can present\nin many ways and a high level of clinical suspicion is\nnecessary.\nKeywords Haemoperitoneum . Subfertility . Laparoscopy .\nLaparotomy\nEndometriosis is a gynaecologic condition affecting women\nof reproductive age, with an estimated prevalence of 3 –10%\nin the general population and of 25 –35% in infertile women\n[1]. It is rare that it presents as an acute abdomen, and when\nit does it is usually due to ruptured endometriotic cyst.\nThere are several cases of endometriosis causing hemoper-\nitoneum. Here, we report a case of massive intra-abdominal\nhaemorrhage from endometriosis eroding into the right\nbroad ligament and uterine artery.\nThe patient is a 39-year-old woman with a known\nhistory of primary subfertility of 2 years duration. She had\nslightly irregular menstrual cycle with no history of\ndysmenorrhoea and dyspareunia. Investigations revealed\nanovulation. She was hence commenced on clomifene\n50 mg tablets to be taken between days 2 and 6 of her\ncycle. Simultaneously a hysterosalpingogram was arranged\nwhich revealed unilateral blocked fallopian tube. Hence the\nclomifene treatment was stopped and she was awaiting a\ndiagnostic laparoscopy and dye test.\nA month later she presented to the Accident and\nEmergency Department with 6 days ’ history of lower\nabdominal, right lower back and flank pain. This was\nassociated with episodes of vomiting. She was then\ncurrently menstruating with no history of dysmenorrhoea.\nShe was seen by the general surgical team whose\nexamination revealed slight abdominal distension with\ngeneralised tenderness, but no acute signs of peritonism.\nShe declined vaginal examination as she was menstruating.\nShe was hemodynamically stable, but pyrexial of 38°C.\nInvestigations revealed haemoglobin of 7.6 g/dl and\nraised inflammatory markers. Abdominal and pelvic ultra-\nsound confirmed fluid in the abdominal cavity with areas of\nmixed echogenicity on both sides of the uterus. She hence\nwas transfused with 2 units of blood. She was reviewed by\nthe gynaecology team who made a provisional diagnosis of\na ruptured haemorrhagic ovarian cyst. Conservative man-\nagement was originally planned, but as her condition\ndeteriorated over 24 h she was subjected for a laparoscopy\nand laparotomy.\nGynecol Surg (2008) 5:133 –135\nDOI 10.1007/s10397-007-0331-4\nP . Fiadjoe (*)\nSt Michael ’s Hospital,\nSouthwell St,\nBristol BS2 8EG, United Kingdom\ne-mail: kgabla@yahoo.com\nA. Thomas-Phillips\nSouthmead Hospital,\nBristol, United Kingdom\nK. Reddy\nCheltenham General Hospital,\nCheltenham, United Kingdom\n\nLaparoscopy revealed hemoperitoneum of approximate-\nly 4.0 l. She hence had a laparotomy which confirmed a\nruptured right endometriotic cyst eroding into the broad\nligament, pelvic side wall and the uterine artery. There was\ncontinuous bleeding from the ruptured uterine artery. The\nright fallopian tube was stuck and damaged; the left tube\nand ovary revealed inflammatory reaction from endometri-\nosis and the rectum was stuck to the pouch of Douglas and\nback of the uterus with serosal damage.\nOnce haemostasis was achieved, help from the urologist\nand colorectal surgeon was solicited to ensure that the\nureter and rectum were intact. We proceeded to perform a\nright salpingo-ophorectomy.\nShe was managed in ITU and had 6 units of packed cells\nand 4 units of FFP . She made an uneventful postoperative\nrecovery and was discharged home on the 7th day with a\nfollow-up appointment at the fertility clinic to discuss her\nfertility options.\nEndometriosis has the unique ability to infiltrate the\nwalls of different structures like the bowel, bladder,\nuterosacral ligaments [ 4], broad ligaments [ 5], uterine\ncornua [ 3] and even ectopic endometrial tissue [ 5].\nThere have been several reports of endometriosis\ncausing massive hemoperitoneum. For a review of Litera-\nture, see Table 1.\nWe report a case of massive and acute hemoperitoneun\nwhere the site of bleeding was from the right uterine artery,\nwhich had been eroded by pelvic endometriosis. A similar\ncase has been reported [ 2], but our patient is different in\nthat she had been asymptomatic.\nEndometriosis has a distinct, cancer-like, invasive charac-\nter that leads to fibrosis, scarring and occasional erosion\nthrough different structures, resulting in rectal bleeding,\nhaemoptysis and haematuria [6]. It is well known that there\nis no correlation between the extent of pelvic endometriosis\nand symptomatology as patients with mild and minimal\ndisease may be severely incapacitated, whereas patients with\nextensive disease may report a paucity of symptoms [ 1].\nEven pregnant patients have not been spared, and several\ncases have been reported that presented with hemoperito-\nneum secondary to pelvic endometriosis [ 9, 10]. This is\ncontrary to common belief that pregnancy improves and may\neven cure endometriosis. Massive hemoperitoneum leading\nto preshock has also been reported as the first presenting\nsymptom in two patients in whom there was no previous\nhistory suggestive of endometriosis [ 6].\nInfertility is frequently associated with endometriosis.\nAnother aspect to be kept in mind is that when these\npatients become pregnant by artificial reproductive treat-\nments, spontaneous rupture of vessels can occur in\npregnancy [ 10] All this goes to emphasise that endometri-\nosis can present in different ways and a high level of\nclinical suspicion is necessary.\nWhen a patient presents with hemoperitoneum leading to\npreshock, it may be difficult to localise the original site of\nbleeding. During laparotomy trauma due to manual explo-\nration, blunt dissection, retraction and packing of the bowel\nwill obscure the original bleeding source by producing many\nother bleeding areas [2]. However, we were able to pinpoint\nthe origin of bleeding. The entire pelvis was unhealthy\nlooking with clear endometriotic areas. Where did the\ndisease actually originate and did it then erode into the right\nuterine artery? Or was there a rupture of an endometrioma\nthat was impinging on the uterine artery? We do not know\nif there was endometriosis in the pelvic side wall and broad\nligament which could have infiltrated the ovary leading to\nan endometrioma or if it was an endometrioma which\ninfiltrated into the broad ligament. However, histological\nexamination confirmed endometriosis in the ovarian tissue\nwith no evidence of malignant change.\nTable 1 On compiling reports of hemoperitoneum\nAuthor, year, reference Source of bleeding Unusual salient points\nThomas et al, 2002, [ 2] Rupture of uterine artery Stage 3 endometriosis, primary infertility\nUri et al, 1979, [ 3] Cornual rupture Lap. sterilisation by diathermy 6 years\npreviously\nRanney, 1970, [ 4] Pelvic endometriotic implants, ruptured endometriotic cyst,\novarian implants\nSeveral different sites, 6 patients\nCarmichael & Williams,\n1972, [ 5]\nErosion of ectopic endometrial tissue Ulcerated area on broad ligament\nHarmanli et al, 1998, [ 6] Fallopian tube No previous endometriosis\nKumar, 1996, [ 7] Endometriotic peritoneal deposits Earlier normal laparoscopy, on COCs\nFujino et al, 1992, [ 8] Uterine serosal surface Uterine adenomyosis\nIsmail et al, 1999, [ 9] Raw area on posterior aspect of uterus Pelvic endometriosis in pregnancy: 2\npatients\nMizumoto et al, 1996, [ 10] Spontaneous rupture of uterine vessels Pregnancy complicated by endometriosisa: 5\npatients\n134 Gynecol Surg (2008) 5:133 –135\n\nIn any instance this and similar cases emphasise that the\nabdominal surgeon must be vigilant and alert always so as\nnot to overlook rare sources of bleeding.\nReferences\n1. Speroff L, Glass RH, Kase NG (1994) Endometriosis. In: Mitchell\nC (ed) Clinical gynaecologic endocrinology and infertility.\nWilliams and Wilkins, Baltimore, pp 853 –872\n2. Thomas I, Janicki MD, Laura J, David MD, Rana S (2002) Massive\nand acute hemoperitoneum due to rupture of the uterine artery by\nerosion from an endometriotic lesion. Fertil Steril 78(4):879 –881\n3. Uri FI, Opaneye A (1979) Hemoperitoneum due to corneal\nendometriosis after laparoscopic sterilization. British J of Obstet\n& Gynecol 86:664 –665\n4. Ranney B (1970) Endometriosis, Emergency operations due to\nhemoperitoneum. Obstet Gynecol 36:437 –442\n5. Carmichael JL, Williams DB (1972) Hemoperitoneum from\nerosion of ectopic endometrial tissue. South Med J 65:371 –372\n6. Harman OH, Chastain A, Cay JG (1993) Massive hemoperito-\nneum from endometriosis of the fallopian tube. J Reprod Med\n43:716–718\n7. Kumar S (1996) Acute massive hemoperitoneum due to mild\npelvic endometriosis. Aust NZ J Obstet Gynecol 36(4):490 –491\n8. Fujino T, Wantanabe T, Shinmura R, Hahn L, Nagata Y , Hasui K\n(1992) Acute abdomen due to adenomyosis of the uterus. Asia-\nOceania J Obstet Gynecol 18:333 –337\n9. Ismail KMK, Shervington J (1999) Hemoperitoneum secondary to\npelvic endometriosis in pregnancy. Int J Obstet Gynecol 67:107–108\n10. Mizumoto Y , Furuya K, Kikuchi Y , Aida S, Hyakutake K, Tamai\nS, Nagata I (1996) Spontaneous rupture of the uterine vessels in a\npregnancy complicated by endometriosis. Acta Obstet Gynecol\nScand 75:860 –862\nGynecol Surg (2008) 5:133 –135 135","source_license":"CC0","license_restricted":false}