Decidual Bleeding as a Cause of Spontaneous Hemoperitoneum in Pregnancy and Risk of Preterm Birth

Abstract

Background: Spontaneous hemoperitoneum in pregnancy (SHiP) is a rare, life-threatening event, particularly relevant to women with endometriosis or deciduosis. Methods: To determine the type of lesions leading to SHiP, a literature search was conducted among all published SHiP cases. From a total of 1,339 publications, information on pathological findings at the bleeding site with histological data was found in 24 case reports (16 pregnant, 8 postpartum). Results: Among pregnant women (81% primigravida), 75% had a diagnosis of endometriosis and 25% of deciduosis. Among postpartum women (38% primiparous), 63% had a diagnosis of deciduosis and 25% of endometriosis. In all cases except one, decidual cells, with or without glandular structures, were present at the bleeding site. Decidual vessels were described in 7 cases and all exhibited vascular changes, including distension of the lumen, medial disorganization, or loss of vascular integrity. These vessels were significantly different from arteries seen in the secretory endometrium, showing that structural modifications take place during the initial stage of the remodelling of placental bed spiral arteries. Conclusions: During pregnancy, a link seems to exist between ectopic decidualization, particularly that occurring in endometriotic foci, and occurrence of SHiP. In addition, subclinical decidual bleeding may be a potential risk factor for preterm labour.

Endometriosis and Risk of Adverse Pregnancy Outcome: A Systematic Review and Meta-Analysis

“…The rare outcome SHiP is a potentially life-threatening condition during pregnancy. Lier et al found that bleeding originated from endometriotic implants, ruptured uteroovarian vessels, hemorrhagic nodules of decidualized tissue, or a combination of these [91] Spontaneous bowel perforations during pregnancy are mostly located in deep infiltrating bowel endometriosis in the sigmoid and rectum [92], and decidualization of these lesions represents a possible, yet unproven pathogenetic mechanism [79,93].…”

Rupture of perivascular epithelioid cell neoplasm at 34 weeks’ gestation: A nonendometriosis case of spontaneous hemoperitoneum in pregnancy

“…In the process of pregnancy, estrogen and progesterone levels in the mother drastically increase until functional progesterone withdrawal at the end of pregnancy . Emerging evidence suggests that development of endometriosis‐associated SHiP is related to a drastic change in progesterone levels during pregnancy . This causes decidualization of endometriosis, leading to instability of parametrial arterioles and SHiP …”

Spontaneous Uterine Vessel Rupture During Pregnancy or in the Puerperium: A Review of the Literature

“…A common complicating factor among those women who experienced a ruptured uterine vein was endometriosis and chronic pelvic inflammatory disease. The question remains, was the bleeding due to the in vitro fertilization or due to the inflammation and scarring of tissue in close proximity to uterine vessels? 5,6 …”

“…Some authors speculate that uterine vessels may be compromised due to the increased blood flow secondary to the increased blood volume during pregnancy. These compromised vessel walls may rupture during pregnancy or in the postpartum period 4,6 …”

“…The question remains, was the bleeding due to the in vitro fertilization or due to the inflammation and scarring of tissue in close proximity to uterine vessels? 5,6 Some authors speculate that uterine vessels may be compromised due to the increased blood flow secondary to the increased blood volume during pregnancy. These compromised vessel walls may rupture during pregnancy or in the postpartum period.…”