Spontaneous hemoperitoneum in pregnancy: A life-threatening maternal and fetal complication of endometriosis

BACKGROUND: Spontaneous hemoperitoneum in pregnancy (SHiP) is a complication of endometriosis. We describe the clinical characteristics and outcomes of mother and fetus in 11 new cases of SHiP with endometriosis and 43 cases reported in the literature since 1995. MATERIAL AND METHODS: The 60 maternity hospitals in the Auvergne-Rhône-Alpes region in France were contacted to identify cases of SHiP associated with endometriosis. In parallel, a systematic review of the literature used the PRISMA chart to report published cases. RESULTS: Fifty-four cases of SHIP associated with endometriosis are presented. Twenty-four patients (44%) conceived with assisted reproductive techniques. Hemoperitoneum occurred before delivery in 47/54 cases (87%).The average gestational age of occurrence was 27 weeks (13 weeks to 40+6 weeks). An hypovolemic shock was present in 24/51 (47%) of patients. Forty-six women (85%) were treated by laparotomy, 5 (9%) by laparoscopy, 2 (2%) by interventional radiology. The hemorrhage site was in the mediolateral compartment of the pelvis in 29 cases (54%), corresponding to bleeding from vessels in the broad ligament in 24/29 (83%) of these cases. The mean estimated blood loss was 1957 mL (150-7500 mL). Emergency peripartum hysterectomy was required in 3/54 cases (6%). There were no maternal deaths. The average gestational age at birth was 30 weeks (13+2 weeks to 42 weeks). The fetus died in 19/64 cases (30%). CONCLUSION: SHiP is an underestimated potentially fatal complication of endometriosis. Maternal salvage by emergency laparotomy is usually required to identify and treat the bleeding site. Fetal prognosis remains poor.