Spontaneous Hemoperitoneum in Pregnancy and Endometriosis: A New Challenge in a Known Disease

Abstract

Importance: Spontaneous hemoperitoneum in pregnancy (SHiP) is a rare life-threatening event previously associated with endometriosis. Although pregnancy is thought to improve the symptoms of endometriosis, abrupt intraperitoneal bleeding can occur, jeopardizing both maternal and fetal outcomes.Objective: The aim of this study was to review the published information regarding SHiP pathophysiology, presentation, diagnosis, and management in a flowchart approach.Evidence Acquisition: A descriptive review of published articles in the English-language was carried out.Results: SHiP most commonly presents in the second half of pregnancy with a combination of abdominal pain, hypovolemia, a decline in hemoglobin level, and fetal distress. Nonspecific gastrointestinal symptoms are not uncommon. Surgical management is suitable in most scenarios and avoids complications such as recurrent bleeding and infected hematoma. Maternal outcome has improved greatly, whereas perinatal mortality remained unchanged. In addition to physical strain, SHiP was reported to have a psychosocial sequela.Conclusions and Relevance: A high index of suspicion is required when patients present with acute abdominal pain and signs of hypovolemia. Early use of sonography contributes to narrowing down the diagnosis. Health care providers should be familiar with the SHiP diagnosis because early identification is crucial when attempting to safeguard maternal and fetal outcomes. Maternal and fetal requirements are often contradictory, creating a greater challenge in decision-making and treatment. A multidisciplinary team approach should coordinate the treatment, whenever a SHiP diagnosis is suspected.Target Audience: Obstetricians and gynecologists, family physicians.Learning Objectives: After completing this activity, the learner should be better able to identify SHiP symptoms and contributing factors; propose recommendations for diagnosis and differential diagnosis; and describe the treatment options, emphasizing multidisciplinary approach.All authors, faculty, and staff have no relevant financial relationships with any ineligible organizations regarding this educational activity.

Endometriosis-associated spontaneous major haemoperitoneum in pregnancy

“…In conclusion, our case highlights a rare but potentially catastrophic clinical presentation in pregnancy 1 7–9. SHiP has been associated with a number of causes including endometriosis 5.…”

“…Ultrasound sonography will confirm the presence of peritoneal haemorrhagic fluid, its amount and possibly its origin. MRI or CT may conclude the diagnosis 2 7. Interestingly, our case presented with vaginal bleeding from a rectovaginal endometriotic nodule fully infiltrating the wall of the posterior vaginal fornix in addition to the signs and symptoms of internal haemorrhage.…”

“…Recurrence may occur if the foetus remains undelivered. Delivery, or even hysterectomy in the first trimester with the foetus in utero, may be necessary occasionally to stop the bleeding and save the mother’s life 7 8. In our case, the combination of extreme prematurity and our patient being haemodynamically stable prompted us to avoid delivery of the foetus at first presentation.…”

“…Advanced laparoscopic skills will be required in such cases. In most cases, an exploratory laparotomy will be appropriate 7. Delivering the foetus may be necessary in some cases to gain access to the pelvis.…”

Spontaneous haemoperitoneum in pregnancy in women with endometriosis: Diagnostic challenges and management strategies

“… 2 , 3 SHiP has been described in the setting of ruptured uterine arteries, varicose veins or aneurysms of the splenic artery, but causes due to endometriosis are increasingly reported in the literature. 3 – 10 Other reported causes of SHiP include spontaneous rupture of the liver, the right renal hamartoma, rupture of the external iliac vessel branch and unscarred uterine rupture due to placenta accreta spectrum. 11 The exact pathogenesis of SHiP in women with endometriosis remains an area of ongoing scientific research.…”