Hemoperitoneum as a precursor of deep pelvic endometriosis: a cohort study

OBJECTIVE: To determine whether significant hemoperitoneum could be a precursor of deep pelvic endometriosis METHODS: This was a prospective observational cohort study which was carried out in a dedicated gynecological diagnostic unit over a period of 18 months. We included consecutive pre-menopausal, non-pregnant women who attended with severe acute lower abdominal pain and underwent a pelvic ultrasound examination. Women were triaged for surgical or conservative management depending on the cause of pain and severity of their symptoms. Those who were selected for conservative management were invited for follow up ultrasound scans. The main outcome measure was evidence of newly developed deep endometriosis at follow up. RESULTS: One hundred and eighteen non-pregnant women attended with severe acute lower abdominal pain, 20 of whom had emergency surgery. Seventeen women with past history of endometriosis or evidence of endometriosis on the initial scan were excluded from the study. Conservative management was employed in 81 women, eight of whom had evidence of significant hemoperitoneum at presentation. A total of 35 women attended for all their follow up ultrasound scans. At the completion of follow up 4/6 (67%, 95% CI 22-96)] women who initially presented with significant intra-abdominal bleeding had developed new evidence of DE compared to 1/29 (3%, 95% CI 0-18) of those without hemoperitoneum. (RR 19.3 (95% CI 3-144) (p=<0.001). CONCLUSION: In some women, the presence of significant hemoperitoneum that is managed conservatively precedes the development of deep endometriosis (DE).