Case series of 9 cases of intra-abdominal hemorrhage in mid- to late-term pregnancy.

From January 2019 to April 2025, a total of 27,324 pregnant women were admitted to Hangzhou First People’s Hospital, among which 9 cases of mid- to late-term intraperitoneal hemorrhage were identified, corresponding to an incidence rate of 0.033%. We retrospectively analyzed the causes of the intraperitoneal hemorrhage, as well as the patients’ symptoms, obstetric history, gestational age, previous surgical history, volume of blood loss, clinical management, and maternal and fetal outcomes.

Age of Patients with Mid- to Late-Term Intraperitoneal Hemorrhage. The ages ranged from 28 to 40 years old, with an average age of 33.1 years. Gestational ages were between 20 + 4 and 38 + 3 weeks, including 2 nulliparous patients (2/9), 7 multiparous patients (7/9), and 1 case of twin pregnancy (Tables  1 and 2 ). Table 1 General information, diagnosis and treatment process, and fetal outcomes of 9 cases Case Age Gravida/Para Gestational Age (weeks) Past Surgical History clinical sympto-ms Suspect-ed Cause of Laparoto-my Site of Ruptur-e Caus-es Blood Loss (mL) Clinical Management Fetal/Neonatal Outcome 1 38 G3P1 30 1 st trimester abortion Abdominal pain Intra-abdominal bleeding Posterior uterine wall surface vessels SHiP 1500 Uterine repair, hemostasis 6, 8 APGAR scores 2 40 G4P1 38 2nd trimester D&C, hysteroscopic adhesions lysis, Cesarean section Decelerating fetal heart rate Uterine rupture 3 cm scar dehiscence Uteri-ne ruptu-re 600 Uterine repair, hemostasis 4, 7 APGAR scores 3 30 G2P1 31 Cesarean section Abdominal pain Uterine rupture Branch of uterine artery SHiP 600 Uterine repair, hemostasis 9, 9 APGAR scores 4 28 G4P0 20 3rd trimester abortions, 6 hysteroscopic adhesiolysis Abdominal pain Appendicitis 10 cm transverse rupture of uterine fundus Uteri-ne ruptu-re 800 Uterine repair Stillbirth 5 29 G3P1 27 2nd trimester D&C, hysteroscopic adhesions lysis Abdominal pain Intra-abdominal bleeding 2 cm laceration on posterior uterine wall Uteri-ne ruptu-re 600 Uterine repair, hemostasis 2, 6 APGAR scores 6 40 G5P1 (twins) 25 Cesarean section, left salpingectomy, 2nd trimester abortions Abdominal pain Peritonitis 3 cm laceration on posterior uterine wall Uteri-ne ruptu-re 600 Uterine repair, hemostasis One fetus 5, 6 APGAR scores, one stillbirth 7 31 G1P0 32 None (prior history of splenic artery aneurysm) Abdominal pain Hemorrhagic shock Splenic artery aneurysm Sple-nic arter-y aneur-ysm ruptu-re 4500 Cesarean delivery + splenic artery aneurysm repair Stillbirth 8 35 G3P1 30 Hysteroscopic polyp removal Abdominal pain Intra-abdominal bleeding Posterior uterine wall surface vessels SHiP 800 Uterine repair, hemostasis 6.8 APGAR scores 9 34 G4P1 26 1 st trimester abortion, 2 weeks prior laparoscopic exploration for abdominal pain (no significant findings) Abdominal pain Intra-abdominal bleeding Posterior broad ligament tissue tear SHiP 1000 Uterine repair, hemostasis Stillbirth Table 2 General information, diagnosis and treatment process, and fetal outcomes of 9 cases (continued) Case Shock Index Hemoglobin (g/L) ICU Blood Transfusion Hospitalization Days 1 0.74 109 Y Y 6 2 0.73 105 N Y 4 3 0.75 111 N N 5 4 0.84 103 Y Y 6 5 0.86 119 Y Y 3 6 0.66 93 Y Y 8 7 death 109 Y Y 15 8 0.72 109 N Y 6 9 0.97 97 N Y 5 General information, diagnosis and treatment process, and fetal outcomes of 9 cases General information, diagnosis and treatment process, and fetal outcomes of 9 cases (continued) One case of uterine rupture during trial of labor after cesarean(case 2), one case of splenic artery aneurysm rupture(case 7), three cases of uterine rupture(case 4、5、6), and four cases of superficial uterine vessel rupture༈case 1、3、8、9 (Fig. 1 ). Fig. 1 Causes of intra-abdominal hemorrhage Causes of intra-abdominal hemorrhage Except for one case of induced abortion in a uterine scar from a previous cesarean section, all other patients presented with abdominal pain accompanied by dizziness, nausea, vomiting, dyspnea, intrauterine fetal death, abnormal fetal heart rate, and vaginal bleeding. Imaging studies (ultrasound) in 5 cases (5/9) showed intra-abdominal fluid, and in 4 of those cases, abdominal paracentesis revealed non-coagulated blood. All patients underwent laparotomy, with concomitant cesarean section or intrauterine fetal extraction. No cases continued with pregnancy. One case of induced abortion through a cesarean scar resulted in uterine rupture, and repair of the uterine rupture site with hemostasis was performed in 3 cases of posterior uterine wall rupture bleeding, preserving the uterus. Hemostasis by ligation of surface vessel ruptures was performed in 4 cases of surface vessel bleeding, also preserving the uterus. One case of splenic artery aneurysm bleeding required hysterectomy. Outcomes Five patients (5/9) were transferred to the intensive care unit postoperatively. One patient (1/9) died. The deceased patient presented as a cardiac arrest/respiratory arrest emergency, and underwent emergency laparotomy upon admission. Intraoperative findings revealed a ruptured splenic artery aneurysm with active bleeding, and approximately 4500 ml of intra-abdominal blood. The patient died postoperatively due to multiple organ dysfunction syndrome. All other patients recovered and were discharged. Of the 5 pregnancies, 1 resulted in intrauterine fetal death, and 4 had favorable outcomes. The perinatal mortality rate was 20%(The term ‘perinatal’ here refers to the period from 28 weeks of pregnancy to 7 days postpartum).

Intraperitoneal hemorrhage in mid- to late-term pregnancy is a rare and serious complication, primarily referring to non-traumatic intraperitoneal bleeding occurring during the mid- to late stages of pregnancy. Clinically, this condition is extremely uncommon, and there are few case reports and studies available both domestically and internationally.Katti F et al.reported a complex instance of spontaneous uterine rupture in a pregnant patient during the second trimester with accompanying central placenta previa and placenta increta, Vuong ADB et al.reported two cases of spontaneous intra-abdominal bleeding during pregnancy, Chen H et al.reported a case of spontaneous rupture of liver capsule caused by preeclampsia [ 1 – 3 ]. Literature reports indicate that the maternal mortality rate in late-term pregnancy intraperitoneal hemorrhage is approximately 1.7%, while the perinatal mortality rate is about 26.9% [ 4 ]. Currently, it is believed that risk factors for intra-abdominal bleeding during mid to late pregnancy include uterine malformations, placental abruption during pregnancy, endometriosis, adenomyosis, placental implantation during pregnancy, history of uterine surgery, preeclampsia during pregnancy, history of aneurysms, and history of ovarian tumor resection [ 5 ,  6 ]. Because its onset often lacks obvious triggers and clinical symptoms are atypical—leading to frequent misdiagnosis—once it occurs, the condition can rapidly deteriorate and may result in sudden maternal death.Therefore, improving the diagnostic and treatment capabilities for this condition is critical to enhancing maternal and fetal outcomes. This article retrospectively analyzes the clinical data of 9 patients with mid-to late-term intraperitoneal hemorrhage during pregnancy, aiming to explore its etiology, clinical features, and prognosis, with a view to improving clinical management of the disease.

In summary, intra-abdominal bleeding is an extremely serious complication in obstetrics. When pregnant women in the middle and late stages experience persistent abdominal pain and ultrasound indicates abdominal fluid accumulation, especially those with a history of uterine surgery and arterial aneurysm, abdominal puncture should be actively performed. When non coagulation is detected through puncture, timely laparotomy exploration should be performed. Only rapid diagnosis and timely surgical intervention can help improve maternal and fetal outcomes.

Intra-abdominal hemorrhage in the mid-to late-term of pregnancy is complex, with diverse etiologies including uterine rupture, placental abruption, spontaneous hepatic rupture due to hypertensive disorders of pregnancy, implantation site placental vascular rupture, and spontaneous intra-abdominal hemorrhage [ 7 – 9 ]. In this study, there were mainly 4 cases of spontaneous intra-abdominal bleeding, 3 cases of spontaneous uterine rupture bleeding, 1 case of uterine rupture during trial of labor after cesarean, and 1 case of splenic artery aneurysm rupture bleeding. The main manifestations of intra-abdominal bleeding in the middle and late stages of pregnancy are acute abdominal pain and hemodynamic abnormalities. In this study, 8 patients presented with abdominal pain as the main clinical manifestation.And hemodynamics can exhibit different states as the disease progresses. In the early stages of the disease, if there is less intra-abdominal bleeding, the patient’s vital signs remain stable. However, as the bleeding increases, the patient’s hemodynamics become unstable, which can manifest as shock symptoms such as pale skin, wet and cold limbs, low blood pressure, and tachycardia [ 10 ].In this study, 8 patients did not show significant shock state upon admission, and the shock index was below 1, indicating that they were in the early stage of onset at the time of admission. But among these 8 patients, 4 were admitted to the ICU and 7 received intraoperative blood transfusion treatment, indicating that the condition was still in a progressive state before bleeding was controlled. When there is a large amount of bleeding in the abdominal cavity, patients may experience respiratory and cardiac arrest. In case 7 of this study, a splenic artery aneurysm ruptured and there was a large amount of bleeding in the abdominal cavity. On the way to the hospital, respiratory and cardiac arrest had already occurred.Special attention should be paid to the differential diagnosis of sudden abdominal pain accompanied by hemodynamic abnormalities and no obvious traumatic bleeding. The following pregnancy complications should be considered: uterine rupture, sepsis, aortic dissection, and venous thromboembolism [ 11 ]. Meanwhile, B-ultrasound examination also plays an important role and can provide imaging support for abdominal puncture. In this study, 7 cases underwent ultrasound examination, of which 5 cases indicated the presence of fluid accumulation in the abdominal cavity. Among these 5 patients, except for case 7, which did not undergo abdominal puncture, the other 4 cases all showed non coagulation after puncture. From this, it can be seen that B-ultrasound plays an important role in diagnosing whether there is intra-abdominal bleeding, and abdominal puncture can help us further clarify the diagnosis and provide favorable evidence for the next step of laparotomy exploration. In addition, except for Case 7, the other 8 patients had a history of uterine related surgeries, including cesarean section, hysteroscopy, and curettage. We can list patients with a history of uterine surgery as high-risk factors for intra-abdominal bleeding, but we should also pay attention to excluding the possibility of bleeding from other organs such as the spleen and liver. Uterine rupture is a severe complication directly threatening both maternal and fetal life, with an incidence of approximately 5.6/10,000 [ 12 ]. China has seen a high cesarean section rate in recent years, reaching 71.59% in some regions [ 13 ]. Consequently, a history of cesarean section is a major risk factor for uterine rupture. Other common risk factors include a history of myomectomy, ectopic pregnancy surgery, inappropriate forceps delivery, inappropriate use of oxytocin, uterine malformations, and multiple uterine cavity procedures [ 14 ]. Cesarean section, myomectomy, endometrial ablation, or even induced abortion can potentially lead to disruption of the uterine muscle layer, scar tissue defects, decreased compressive strength, and subsequent rupture under the increased pressure of pregnancy or labor [ 15 ].In most European countries, if there are no absolute contraindications for a cesarean section, women with a history of previous cesarean section generally first attempt vaginal delivery after cesarean section (TOLAC). TOLAC rates range from 47% to 72% [ 16 ]. In Norway, among 247 cases of complete uterine rupture, 66.8% involved a cesarean scar, while 33.2% did not [ 17 ]. In Belgium, 73 out of 90 (81.0%) uterine rupture cases involved a cesarean scar, and 57 of these TOLAC cases resulted in uterine rupture [ 18 ]. Because TOLAC can lead to serious adverse maternal and fetal outcomes, clinical practice guidelines for TOLAC emphasize the importance of shared decision-making between the obstetrician and the pregnant woman regarding the mode of delivery for subsequent pregnancies in women with a history of cesarean Sect [ 19 ].In this study of four uterine rupture cases, one involved a scarred uterus undergoing a trial of labor after cesarean (TOLAC) with fetal heart rate deceleration suggestive of rupture. Emergency cesarean delivery was performed, but the newborn still experienced asphyxia, highlighting the need for enhanced monitoring. Besides cesarean scars, other procedures such as myomectomy, hysteroscopic septum resection, ectopic pregnancy treatment, and incomplete abortions can also cause uterine scarring. Subtle scarring from the latter procedures may be overlooked by clinicians, potentially leading to more severe outcomes [ 20 ]. Accurate pre-partum prediction is often difficult due to incomplete surgical history information. Therefore, all patients with a history of uterine surgery should be closely monitored for the possibility of uterine rupture during pregnancy and delivery.The four cases in this study exhibited the following histories: two cesarean deliveries (Fig. 2 ), three hysteroscopic procedures, one tubal surgery, and four induced abortions. This suggests that women with a history of pelvic surgery should be considered high-risk for uterine rupture, necessitating enhanced prenatal education and management. Three of the four ruptures occurred in the mid-trimester, all with a history of induced abortions and pelvic surgery, and intra-abdominal hemorrhage ranging from 600 to 800 ml. Two cases presented with abdominal fluid detected on ultrasound, one of which contained non-clotting blood. Mid-trimester uterine rupture is not uncommon but often difficult to diagnose accurately, primarily due to the potential involvement of intra-abdominal organs, leading to misdiagnosis. In fact, in three of the cases, the initial suspicion for uterine rupture was not considered before laparotomy; rather, the diagnosis was made intraoperatively. Prompt cesarean section is essential once uterine rupture is diagnosed prepartum or intrapartum; postpartum diagnosis necessitates immediate laparotomy to improve maternal and neonatal outcomes. Uterine repair is the primary surgical approach for uterine rupture. If the rupture site edges are intact, there is no significant infection, and the patient desires future fertility, uterine repair may be a viable option [ 21 ]. All four cases in this study underwent successful uterine repair with favorable outcomes.Meanwhile, for pregnant women complicated with placenta percreta, uterine myometrial resection combined with transverse B-Lynch suture or rectangular hemostatic suture technique can be adopted to reduce the probability of hysterectomy and preserve the patient’s fertility potential as much as possible [ 22 – 24 ]. Fig. 2 Intraoperative findings in case4. (At 20 weeks of gestation, with a history of three induced abortions and six hysteroscopic adhesiolysis procedures, laparoscopic exploration revealed an impending rupture at the right uterine cornu (as shown in the photo) and a concurrent 10-cm transverse rupture at the uterine fundus (which was not photographed).) Intraoperative findings in case4. (At 20 weeks of gestation, with a history of three induced abortions and six hysteroscopic adhesiolysis procedures, laparoscopic exploration revealed an impending rupture at the right uterine cornu (as shown in the photo) and a concurrent 10-cm transverse rupture at the uterine fundus (which was not photographed).) Additionally, this study included four cases of spontaneous hemoperitoneum in pregnancy (SHiP). SHiP is a type of non-traumatic intra-abdominal bleeding and is a serious pregnancy complication associated with adverse pregnancy outcomes. Currently, the exact causes of spontaneous hemoperitoneum during pregnancy are not well understood, and its occurrence and severity may be related to endometriosis [ 25 ].Current theories suggest that the decidualization, chronic inflammation, and pre-existing adhesions associated with endometriosis play a role in the development of SHiP. Endogenous progesterone during pregnancy can enhance the decidualization and vascular penetration of endometriotic implants. The chronic inflammation associated with endometriosis leads to the formation of adhesions, while pregnancy-related hormonal changes cause surrounding tissues and blood vessels to become fragile. As the uterus enlarges, the formed adhesions exert traction on surrounding tissues, making the affected tissues or blood vessels prone to bleeding during rapid growth in mid-pregnancy [ 26 ]. Brosens [ 27 ] summarized 25 cases of spontaneous hemoperitoneum during pregnancy, finding that 20 cases (80%) of the bleeding sites originated from veins, 4 cases (16%) from arteries, and 1 case (4%) had no obvious bleeding point identified, with 90% of the bleeding sites located in the posterior uterine wall or broad ligament. In this study, 2 cases were on the uterine surface (Fig. 3 ), and 2 cases were in the broad ligament, consistent with the literature. In one case, when abdominal pain symptoms appeared, the local hospital suspected intra-abdominal bleeding and performed a laparoscopic exploration, but no bleeding point was found, and the patient continued to experience abdominal pain postoperatively. It was not until two weeks later that our hospital performed another laparotomy, discovering a bleeding point from a tear in the tissue of the posterior leaf of the left broad ligament (Fig. 4 ). This illustrates that intra-abdominal bleeding can sometimes be very subtle, posing significant challenges for clinical diagnosis. Since spontaneous hemoperitoneum during pregnancy mostly originates from veins and involves substantial blood loss (averaging 1600 ml), surgical exploration is the preferred treatment. In studies by Mci et al., 94.9% of cases underwent surgical intervention, with 91.1% of cases showing active bleeding during surgery, and suturing was the most commonly used method for hemostasis. Notably, 8.5% of cases experienced recurrence, almost all occurring during the current pregnancy or postpartum period [ 28 ]. Given that 33% of endometriosis cases are not diagnosed prior to spontaneous hemoperitoneum during pregnancy, it is recommended to perform histological confirmation [ 29 ].In this study, only Case 4 underwent intraoperative pathological examination and was confirmed to have endometriosis. Therefore, it is recommended to perform histopathological examination on cases of uterine vascular bleeding and cases described as exudation of uterine surface inflammation to confirm whether it is related to endometriosis. Fig. 3 Intraoperative findings in case 3. (During surgery at 31 weeks gestation, a ruptured branch of the ascending uterine artery was identified, with active bleeding.) Intraoperative findings in case 3. (During surgery at 31 weeks gestation, a ruptured branch of the ascending uterine artery was identified, with active bleeding.) In this study, there was also a case of intra-abdominal bleeding caused by a ruptured splenic artery aneurysm. Due to the sudden onset of the disease, respiratory and cardiac arrest occurred on the way to the hospital, and continuous cardiopulmonary resuscitation kept the fetus in a weak heartbeat. The patient’s family insisted on rescuing the newborn, so a cesarean section was immediately performed. After investigation, it was found that the splenic artery aneurysm had ruptured and 4500 ml of intra-abdominal blood had accumulated. Subsequently, due to DIC and repeated bleeding, hysterectomy was performed, but the condition was still critical. The family gave up rescue, resulting in the tragic outcome of the death of both the pregnant woman and the fetus. From this, it can be seen that bleeding at the surgical level often has a sudden onset and severe condition. Therefore, for patients with a history of splenic artery aneurysm, it is necessary to conduct a careful evaluation with obstetricians and surgeons before pregnancy, and solve the “time bomb” of splenic artery aneurysm through surgery or embolization, in order to avoid the terrible outcome of splenic artery aneurysm rupture during pregnancy [ 30 ]. Fig. 4 Intraoperative findings in case 9. (At 26 weeks of gestation, the patient underwent laparoscopic exploration at another hospital two weeks prior to the onset of symptoms due to “abdominal pain,” but no significant abnormalities were detected. Subsequently, an exploratory laparotomy at our hospital revealed a localized tear in the posterior leaf of the broad ligament. Tissue samples from the bleeding site were collected for pathological examination, which confirmed endometriosis.) Intraoperative findings in case 9. (At 26 weeks of gestation, the patient underwent laparoscopic exploration at another hospital two weeks prior to the onset of symptoms due to “abdominal pain,” but no significant abnormalities were detected. Subsequently, an exploratory laparotomy at our hospital revealed a localized tear in the posterior leaf of the broad ligament. Tissue samples from the bleeding site were collected for pathological examination, which confirmed endometriosis.)