A diagnostic challenge: spontaneous hemoperitoneum in pregnancy versus uterine rupture

This paper reports a 38-year-old pregnant woman at 29 weeks with sudden acute abdominal pain and a prior full-term caesarean section, initially evaluated for uterine rupture after ultrasound showed free intraperitoneal fluid and her hemoglobin fell from 9.2 to 8.3 g/dL. Serial imaging suggested hemorrhagic fluid, and urgent diagnostic laparoscopy found about 1,300 mL hemoperitoneum; because the bleeding source could not be identified and hemodynamic instability persisted, the team converted to laparotomy, ruling out uterine rupture and identifying active bleeding from a 2-cm clot in the left fallopian tube plus a secondary omental site. Emergency caesarean delivery was performed, followed by salpingectomy and partial omentectomy, and histology unexpectedly demonstrated endometriosis foci in the fallopian tube; the authors do not provide a broader cohort, limiting generalizability beyond this single case report. This paper is centrally about endometriosis—unexpected tubal endometriosis was identified as the bleeding source causing spontaneous hemoperitoneum in pregnancy, providing a detailed differential diagnosis from uterine rupture in a case shaped by an endometriosis mechanism.

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