Spontaneous hemoperitoneum with intrahepatic cholestasis during the third trimester of pregnancy

Spontaneous hemoperitoneum in pregnancy is a rare but potentially life-threatening condition for the mother and fetus. A case of spontaneous hemoperitoneum with intrahepatic cholestasis of pregnancy during the third trimester is presented. The bleeding site remained undiscovered after two exploratory laparotomies. A 33-year-old woman (G5, P1) at 32 weeks of pregnancy presented at the affiliated hospital of North Szechwan Medical College in January 2012 with acute pain in the right middle abdomen that had been ongoing for 6 hours. The patient reported no history of trauma or previous cesarean delivery, had no vaginal bleeding, no fever or vomiting, and had not received regular prenatal check-ups. Her vital signs were stable and there was severe abdominal tenderness on physical examination. Fundal height was 32 cm and the patient's cervix was not effaced. A nonstress test was reactive and uterine contractions were not detected. The laboratory results indicated infection and mild anemia (Table 1). Sonographic examination showed a singleton fetus in vertex presentation and the patient's liver, spleen, and gallbladder were normal; appendicitis was suspected. An exploratory laparotomy was performed under epidural anesthesia. The incision was made over the right lower quadrant and a profuse amount of blood and a blood clot were observed. The appendix was intact. A right paramedian incision was then performed under general anesthetic. After removing 1.5 liters of intraperitoneal clotted blood, the peritoneal cavity was palpated carefully to find the source of the bleeding. The exploration was suboptimal owing to the enlarged uterus, and no obvious active bleeding was found. The patient's condition was stable and preterm delivery was avoided. Surgical drains were left in place postoperatively to monitor the output. The daily output was 30–50 mL of exudative sanguineous fluid and there was no evidence of new active bleeding. The patient received dexamethasone, formula supplements including vitamin B complex, aminofusin, and potassium and magnesium aspartate, and a red blood cell suspension transfusion of 7 units. Laboratory results on the seventh day after the first laparotomy raised suspicion for intrahepatic cholestasis of pregnancy with associated hypoproteinemia (Table 1). A viable male neonate weighing 2390 g was delivered by emergency cesarean and treated in the intensive care unit. APGAR scores were 9 and 10 at 1 and 5 minutes, respectively. Following closure of the uterine incision, a second laparotomy was performed to check the abdominal and pelvic organs, but the origin of the hemorrhage could still not be located. The postoperative period was uneventful. The patient and neonate were discharged on the ninth day after delivery. No further hemoperitoneum or adverse outcomes occurred during the next six months of follow-up. Spontaneous hemoperitoneum during the second or third trimester of pregnancy is rare. The pathogenesis of spontaneous hemoperitoneum is unclear because it may develop from the rupture of various abdominal or pelvic structures, including the liver, spleen, uterus, and blood vessels [1]. A review of the literature and 25 cases reported that endometriosis might be another risk factor for the condition [2]. Only one case, described by Koifman et al. [3], reported a similar unknown source of bleeding. Diagnosis is difficult owing to nonspecific clinical symptoms and physical examination. Ultrasonographic imaging may also be insufficient. In the present case, preterm delivery after the first laparotomy posed a risk to the fetus as dexamethasone had not been given at that time. In addition, the patient's condition was stable and therefore expectant management was implemented. Based on the authors’ experience it was important to place a drainage tube into the abdominal cavity to observe any recurrent bleeding and to distinguish anemia caused by a nutritional disorder from that caused by blood loss. One week postoperatively the patient suffered intrahepatic cholestasis of pregnancy. This condition is characterized by pruritus and has an increased risk of intrapartum fetal distress and intrauterine death in the second half of pregnancy [4]. Owing to the increased risk of recurrent bleeding, a cesarean delivery and a second exploratory laparotomy were performed. However, the origin of the hemorrhage remained obscure. Both mother and baby survived and were healthy, which implies that key management should be a prompt laparotomy with an individual flexible strategy. The authors have no conflicts of interest.