{"paper_id":"b9d2efb3-2c6c-446a-84ec-867e1f1a94bc","body_text":"Ital J Gynaecol Obstet 2025, 37, N.4\n412\nCASE REPORT\nGynæcology & Obstetrics\nItalian Journal of\nDecember 2025 - Vol. 37 - N. 4 - Quarterly - ISSN 2385 – 0868\nStefano Restaino 1, Ginevra Battello 2,*, Sara Olivola 1, Martina Arcieri 1, Lorenza Driul 2, Giuseppe \nVizzielli 2\n1 ASUFC – Udine, Department of Gynecology and Obstetrics, Udine, Italy.\n2 DMED Department of Medicine, University of Udine, Udine, Italy.\nA diagnostic challenge: spontaneous hemoperitoneum in pregnancy versus \nuterine rupture\n412\nARTICLE INFO\nHistory\nReceived: 07 January 2025\nReceived in revised form: 26 February 2025\nAccepted: 10 April 2025\nAvailable online: 30 December 2025\nDOI: 10.36129/jog.2025.222\nKey words \nEndometriosis; spontaneous hemoperitoneum \nin pregnancy; caesarean section; abdominal \npain in pregnancy.\n*Corresponding author: Ginevra Battello, \nM.D. DMED Department of Medicine, \nUniversity of Udine, via Colugna 50, 33100 \nUdine, Italy.  \nEmail: battello.ginevra@spes.uniud.it.  \nORCID: 0000-0001-8429-5317.\nCopyright 2025\nBACKGROUND\nThe differential diagnosis of pain and sonographic \nfindings of intra-abdominal effusion during pre -\ngnancy or in the hours immediately following \nbirth is complex and requires careful considera -\ntion of various potential causes. Uterine rupture \n[1], a life-threatening obstetric emergency, must \nABSTRACT\nBackground. Spontaneous hemoperitoneum in pregnancy (SHiP) is a rare \nbut life-threatening complication. SHiP typically presents with abdominal \npain, hypovolemia, and decreased haemoglobin in later pregnancy. \nCase presentation. A 38-year-old woman with a history of one prior caesare-\nan section, and otherwise in good health, presented at 29 weeks of gestation \nwith sudden onset of abdominal pain. Ultrasound revealed free fluid in her \nabdomen, raising concern for uterine rupture due to the previous caesarean \nsection. However, a dedicated ultrasound examination ruled this out. Lapa-\nroscopy confirmed the absence of uterine involvement. The lower uterine \nsegment was intact and was not the source of bleeding; indeed, the source of \nbleeding was identified as a 2-cm clot in the left fallopian tube resulting on \nhistology an endometriosis foci. \nConclusions. This case highlights the importance of considering SHiP in the \ndifferential diagnosis of acute abdomen during pregnancy, even in the absen-\nce of known risk factors because a high index of suspicion for SHiP is crucial \nfor prompt diagnosis and intervention, aiming for optimal maternal and feta \noutcomes.\nbe promptly excluded. However, other conditions \nsuch as spontaneous hemoperitoneum in pregnan-\ncy (SHIP), bladder rupture [2], and ascites [3] can \npresent with similar clinical features. A thorough \nevaluation, including imaging studies, laboratory \ntests, and clinical assessment, is essential to diffe -\nrentiate between these conditions and ensure ap -\npropriate management. \n\n413\nSHiP vs uterine rupture Stefano Restaino, Ginevra Battello, Sara Olivola, et al.\nIn particular, spontaneous hemoperitoneum in \npregnancy (SHiP) is defined as a sudden non-trau-\nmatic intraperitoneal bleeding in pregnancy and \nup to 42 days postpartum [4]. SHiP typically pre -\nsents during the latter stages of pregnancy, accom-\npanied by a combination of abdominal pain, signs \nof hypovolemia, a decrease in haemoglobin levels, \nand foetal distress. This condition carries a signifi-\ncant risk of maternal and perinatal mortality and \nmorbidity [5]. Due to the absence of comprehen -\nsive global surveillance, estimating the exact in -\ncidence of SHiP remains challenging. However, \na study conducted by the Italian Obstetric Sur -\nveillance System (ItOSS) between 2013 and 2017 \ndocumented seven maternal deaths attributed to \nSHiP and calculated a specific maternal mortality \nrate (MMR) of 0.2 cases per 100,000 live births [6]. \nWhile the precise aetiology of SHiP remains un -\nclear, advanced maternal age, endometriosis [7], \nmultiple pregnancies and assisted reproductive \ntechnologies (ART) have been suggested as po -\ntential risk factors [8, 9].\nThe case we are about to present is unique in its \nkind, as it is a case of spontaneous hemoperito -\nneum in pregnancy in a patient with previous cae-\nsarean section. This case underlines the importance \nof making a correct differential diagnosis, because \nin a pregnant patient with previous uterine sur -\ngery, the onset of abdominal pain and the presence \nof intra-abdominal fluid do not necessarily mean \nuterine rupture.\nCASE PRESENTATION\nWe present the case of a 38-year-old woman, G3P1, \nwith a previous obstetric history of a full-term ca-\nesarean section for arrested labour, pregnant at 29 \nweeks of gestation with a sudden onset of acute \nabdominal pain.\nUltrasound performed upon admission showed a \nmoderate amount of free fluid collection in both \nthe hepatic and splenic recesses, extending into the \npelvis. At the level of the lower uterine segment, in \nthe site of a previous caesarean section scar, there \nare no apparent signs of dehiscence or rupture of \nthe uterine wall. Blood tests revealed a haemoglo-\nbin level of 9.2 g/dL.\nTwelve hours after the previous tests, a blood sam-\nple was repeated and attested a sudden drop of \nthe haemoglobin level at 8.3 g/dL.  A repeated \nultrasound revealed diffuse abdominal free fluid \ncollection, increased in volume compared to the \nprevious imaging documentation, with echogeni -\ncity compatible with a haemorrhagic type of fluid \ncollection.\nIt was decided to administer antenatal corticoste -\nroid prophylaxis and foetal neuroprotection with \nmagnesium sulphate. Due to persistent acute abdo-\nminal pain, anaemia with signs of initial hemody-\nnamic instability in a suspected case of hemoperito-\nneum, an urgent surgical intervention was decided. \nA diagnostic laparoscopy was performed to inve -\nstigate intra-abdominal bleeding. Blood clots were \nfound in the parietocolic gutters, hepatic lodge, and \nsplenic lodge and about 1,300 mL of blood in the \nabdominal cavity was evacuated. No active blee -\nding from the upper abdomen seemed to be pre -\nsent. However, the gravid uterus impeded adequa-\nte visualization of the lower abdomen, preventing \nidentification of the bleeding source.\nTherefore, a decision was made to convert to la -\nparotomy based on the haemodynamic instability \nof the patient and the confirmed significant he -\nmoperitoneum (> 1,000 cc) found on laparoscopic \napproach. Upon open exploration, no active up -\nper abdominal bleeding was confirmed. While the \npelvic cavity was thoroughly examined, no signs \nof uterine rupture or bleeding from previous scar \nsites were detected. The laparotomic surgical ap -\nproach allowed for a complete visualization of the \npelvis, leading to the identification of the active \nbleeding focus: a 2-cm firm clot with surrounding \ninflammation and active bleeding in the middle \nthird of the left fallopian tube. Additionally, a se -\ncondary bleeding site was found on the omentum.\nDue to the patient’s deteriorating hemodynamic \nstatus, an emergency caesarean section was de -\ncided.\nA transplacental transverse corporal incision was \nperformed, and a female newborn was extracted. \nThe neonate weighed 1,237 grams and had an AP-\nGAR score of 1/4/7, umbilical cord pH was 7.30 \nwith a BE of -2.3 mMol/L. The newborn required \nintubation and ventilation, and surfactant was ad-\nministered. The newborn was subsequently extuba-\nted at 6 hours of life with a good neonatal outcome. \nAfter the caesarean section, a salpingectomy and a \npartial omentectomy were therefore performed. No \nother sources of bleeding were evident. The histo-\nlogical results were unexpected, demonstrating foci \nof endometriosis in the fallopian tube, even though \nthere was no previous medical history suggestive \nof endometriosis.\n\nItal J Gynaecol Obstet 2025, 37, N.4\n414\nSHiP vs uterine rupture\nly from SHiP to uterine rupture. While with uterine \nrupture always necessitates a caesarean section, in \ncases of SHiP , in the presence of maternal hemody-\nnamic stability and after identifying and control -\nling the bleeding site, it is possible, in some cases, \nto continue the pregnancy [12].\nCOMPLIANCE WITH ETHICAL STANDARDS\nAuthors’ contribution\nS.R.: Conceptualization. S.O.: Data curation. L.D., \nG.V .: Supervision. G.B.: Writing – original draft. \nM.A.: Writing – review & editing.\nFunding\nNone.\nStudy registration\nN/A.\nDisclosure of interests\nThe authors declare that they have no conflict of \ninterests.\nEthical approval\nIRB approval was obtained (RIF. Prot IRB: 42/2024).\nInformed consent\nPatient’s consent to publication was obtained.\nData sharing\nN/A.\nREFERENCES\n1. Guiliano M, Closset E, Therby D, LeGoueff F, \nDeruelle P , Subtil D. Signs, symptoms and com-\nplications of complete and partial uterine rup-\ntures during pregnancy and delivery. Eur J Ob-\nstet Gynecol Reprod Biol. 2014;179:130-4. doi: \n10.1016/j.ejogrb.2014.05.004.\n2. Stabile G, Cracco F, De Santo D, Zinicola G, \nRomano F, De Manzini N, et al. Spontaneous \nBladder Rupture after Normal Vaginal Deliv-\nery: Description of a Rare Complication and \nSystematic Review of the Literature. Diagnos-\ntics (Basel). 2021;11(10):1885. doi: 10.3390/diag-\nnostics11101885.\n3. Epelde C, Saravia F, Aguinaga M, Toledo A, Le-\nkuona A, Gorostidi M. Acute Abdomen in Preg-\nDISCUSSION\nHormonal changes during pregnancy can exert a \nsubstantial impact on the endometriotic tissue, in \na process termed “decidualization” of ectopic en -\ndometrium, ultimately increasing the likelihood of \nbleeding from endometriotic lesions [10].\nThis phenomenon of decidualization explains why \nendometriosis is a major risk factor for SHiP . Un-\nfortunately, endometriosis is still an underdiagno-\nsed and underestimated condition, as evidenced \nby the case presented of an incidental diagnosis \nof endometriosis following a case of spontaneous \nhemoperitoneum of pregnancy.\nIn our case, the most obvious differential diagnosis \nwas the previous caesarean section scar rupture but \nthat was ruled out by a sonographic evaluation of \nthe lower uterine segment. In our Clinic we routi -\nnely perform an ultrasound evaluation of the lower \nuterine segment (LUS) in pregnant women with a \nhistory of caesarean delivery. We use state-of-the-\nart ultrasound equipment and highly trained sono-\ngraphers to perform LUS evaluations. Acquiring a \nhigh level of expertise in ultrasound evaluation of \nthe lower uterine segment is essential for optimal \nmaternal and foetal care in pregnant women with \na previous caesarean section. Our team has exten-\nsive experience in interpreting ultrasound images \nand can identify even subtle abnormalities [11]. The \nexpertise in sonographic LUS evaluation allows to \naccurately assess the thickness and integrity of the \nLUS and identify or rule out potential complica -\ntions such as uterine rupture and dehiscence of a \nprevious caesarean scar.\nCONCLUSIONS\nSpontaneous hemoperitoneum of pregnancy (SHiP) \nis a critical differential diagnosis in cases of acute \nabdominal pain during pregnancy. It should be \nconsidered especially in women with risk factors \nlike endometriosis or those who have undergone \nassisted reproductive technologies (ART). Howe -\nver, as this case demonstrates, SHiP can occur even \nin the absence of known risk factors, and therefore, \nit should always be considered as a possible cause \nof acute abdominal pain in pregnant women, re -\ngardless of their medical history, and even if other \nconditions, like a ruptured caesarean scar, seemed \nmore likely.\nEarly and accurate differential diagnosis is essen -\ntial, as the therapeutic approach differs significant-\n\n415\nSHiP vs uterine rupture Stefano Restaino, Ginevra Battello, Sara Olivola, et al.\nnancy due to Idiopathic Chylous Ascites. Case \nRep Obstet Gynecol. 2024;2024:8898451. doi: \n10.1155/2024/8898451.\n4. Say L, Souza JP , Pattinson RC; WHO working \ngroup on Maternal Mortality and Morbidity classi-\nfications. Maternal near miss--towards a standard \ntool for monitoring quality of maternal health care. \nBest Pract Res Clin Obstet Gynaecol. 2009;23(3):287-\n96. doi: 10.1016/j.bpobgyn.2009.01.007. \n5. Lier MCI, Malik RF, Ket JCF, Lambalk CB, Bros-\nens IA, Mijatovic V . Spontaneous hemoperitone-\num in pregnancy (SHiP) and endometriosis - A \nsystematic review of the recent literature. Eur J \nObstet Gynecol Reprod Biol. 2017;219:57-65. doi: \n10.1016/j.ejogrb.2017.10.012.\n6. Donati S, Maraschini A, Dell’Oro S, Lega I, \nD’Aloja P; Regional Maternal Mortality Work-\ning Group. The way to move beyond the num-\nbers: the lesson learnt from the Italian Obstet-\nric Surveillance System. Ann Ist Super Sanita. \n2019;55(4):363-70. doi: 10.4415/ANN_19_04_10.\n7. Maiorana A, Zaccaria G, Parisi G, Mercurio A, For-\nlani F. Spontaneous hemoperitoneum in pregnan-\ncy due to rupture of uterine vessels in woman with \nendometriosis: a case report. Ital J Gynaecol Ob-\nstet. 2024;36(2):191-5 doi: 10.36129/jog.2023.124.\n8. Brosens IA, Lier MC, Mijatovic V , Habiba M, \nBenagiano G. Severe spontaneous hemoperito-\nneum in pregnancy may be linked to in vitro \nfertilization in patients with endometriosis: a \nsystematic review. Fertil Steril. 2016;106(3):692-\n703. doi: 10.1016/j.fertnstert.2016.05.025.\n9. Mazzocco MI, Donati S, Maraschini A, Corsi \nE, Colciago E, Guelfi F, et al. Spontaneous he-\nmoperitoneum in pregnancy: Italian prospec-\ntive population-based cohort study. Acta Ob-\nstet Gynecol Scand. 2022;101(11):1220-6. doi: \n10.1111/aogs.14431. \n10. Leeners B, Damaso F, Ochsenbein-Kölble N, \nFarquhar C. The effect of pregnancy on endo-\nmetriosis-facts or fiction? Hum Reprod Up-\ndate. 2018;24(3):290-9. doi: 10.1093/humupd/\ndmy004.\n11. Zermano S, Seminara G, Parisi N, Serantoni V , \nArcieri M, Biasioli A, et al. Prenatal Detection \nand Conservative Management of Uterine Scar \nDehiscence in Patient with Previous Uterine \nRupture and Multiple Surgeries-A Case Re-\nport. Healthcare (Basel). 2024;12(10):988. doi: \n10.3390/healthcare12100988.\n12. Lier MCI, Malik RF, Ket JCF, Lambalk CB, Bro-\nsens IA, Mijatovic V . Spontaneous hemoperito-\nneum in pregnancy (SHiP) and endometriosis \n- A systematic review of the recent literature. \nEur J Obstet Gynecol Reprod Biol. 2017;219:57-\n65. doi: 10.1016/j.ejogrb.2017.10.012.","source_license":"CC0","license_restricted":false}