Spontaneous hemoperitoneum in pregnancy

Spontaneous hemoperitoneum in pregnancy (SHP) is an uncommon, but very critical complication when present in pregnancy, leading to important morbidity and mortality for both mother and fetus. The etiology includes a large spectrum of causes, not taking into consideration trauma or other pathologies not pregnancy related. One of the most frequent triggers is the rupture of the varicose veins around the uterus that can occur either spontaneously or during labor, that can be associated with the unfortunate event of delivery of a stillborn baby. Endometriosis has been suspected to be also implicated in the apparition of spontaneous hemoperitoneum in pregnant women due to the fragility of the tissues associated with endometriosis chronic inflammation (ruptured endometrioma, intraabdominal adhesions, decidualization at the site of endometriotic implants). Even the operative vaginal delivery can conduct to this complication, but the cases described in the literature were also associated with lesion of endometriosis at the bleeding site. Moreover, assisted reproductive procedures (IVF-ET) is incriminated as one of the possible etiologies. The improvements in the resuscitation, operative and anesthetic management of these cases have lowered the maternal mortality, but perinatal mortality still has a high value (31%). Symptoms as acute or subacute abdominal pain, that can be associated or not with hypovolemic shock and signs of fetal affliction, identified as heart decelerations, should raise a question mark regarding the possibility of a hemoperitoneum. Electronic research for subject related reviews and articles has been made, using PubMed, Medline, Cochrane Data Base and also the current international guidelines regarding the management of hemoperitoneum in pregnancy, recommended by Obstetrics and Gynecology Societies in United States and United Kingdom. Adequate case management as hematologic analysis, abdominal ultrasound, CT scan or MRI should reveal free intrabdominal fluid and estimate the blood loss, which can then be confirmed by paracentesis or by direct urgent laparotomy or laparoscopy. The aim of the current review is to raise awareness of this rare, but potentially fatal, complication in pregnancy and its most appropriate management, according to the current information presented in the medical literature.