Spontaneous hemoperitoneum in pregnancy: Italian prospective population‐based cohort study

Abstract

Introduction: Spontaneous hemoperitoneum in pregnancy is defined as a sudden non-traumatic intraperitoneal bleeding in pregnancy and up to 42 days postpartum.In the present study we aim to estimate the incidence and investigate the risk factors, the management and the outcomes of spontaneous hemoperitoneum in pregnancy in order to improve its clinical identification and reduce avoidable maternal deaths. Material and methods: This is a prospective population-based cohort study, set in maternity units from nine Italian regions covering 75% of the national births. The study population comprises all women admitted for spontaneous intraperitoneal hemorrhage during pregnancy and up to 42 days postpartum between November 2017 and March 2020. Incident cases were reported by trained clinicians through electronic data collection forms. Descriptive statistics were performed. The main outcome measures included incidence rate of spontaneous hemoperitoneum in pregnancy, association with potential risk factors, clinical management and maternal and perinatal outcomes.Results: Twenty-nine cases met the adopted definition of spontaneous hemoperitoneum in pregnancy with an estimated incidence rate of 0.04 per 1000 births. An increased risk ratio (RR) of this condition was observed in pregnancies conceived by assisted reproductive technology (RR = 6.60, 95% CI 2.52-17.29), in the case of multiple pregnancies (RR = 6.57, 95% CI 1.99-21.69) and maternal age ≥35 years (RR 2.10, 95% CI 1.01-4.35). In 17/29 cases the bleeding site was intra-pelvic (23.5% in the posterior uterine wall and 35.2% in the left hemipelvis). Laparotomy represented the surgical treatment in 27 cases (93%), and most women underwent a cesarean delivery (92.6%). Median blood loss was 1900 mL, one hysterectomy was necessary, and two women died. Twenty-two preterm births were recorded.Conclusions: Spontaneous hemoperitoneum in pregnancy is a rare, life-threatening condition associated with high perinatal morbidity and mortality. Maternal age ≥35 years, multiple pregnancies and assisted reproductive technology were associated to a higher risk of the condition. Two women of 29 died and 70% of births occurred preterm.

Endometriosis‐related spontaneous hemoperitoneum in pregnancy: A case series

“…During the study period, three additional cases of SHiP without any association with endometriosis were identified, with a prevalence of 8.6 per 100,000 maternities. Although uncommon, the higher rate of endometriosis‐related SHiP compared with SHiP without endometriotic lesions among cases at our Institution, confirms that endometriosis may be a potential risk factor for the occurrence of SHiP 10 …”

“…Although uncommon, the higher rate of endometriosis-related SHiP compared with SHiP without endometriotic lesions among cases at our Institution, confirms that endometriosis may be a potential risk factor for the occurrence of SHiP. 10 The rarity of the endometriosis-related SHiP and its association with non-specific presenting symptoms also constitute the challenges in correctly suspecting the condition and formulating a definitive diagnosis 7 .…”

Maternal Sepsis in Italy: A Prospective, Population-Based Cohort and Nested Case-Control Study

“…A maternal “near-miss” case is defined as “a woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within the 42 days of termination of pregnancy” [ 11 ]. ItOSS collected data on women with any of the following events: sepsis, eclampsia [ 16 ], amniotic fluid embolism, and spontaneous hemoperitoneum in pregnancy [ 15 ]. This manuscript focuses on sepsis.…”

“…As previously described [ 15 , 16 ], a reference clinician from each maternity unit was identified to attend a single-day training course at regional level to share the study’s objectives and methodology and learn how to use the web platform for data entry.…”

“…Given the substantial relevance of maternal sepsis in maternal morbidity and mortality in Italy [ 12 ], where there is a paucity of high-quality studies on this condition, ItOSS implemented a prospective population-based study on maternal “near-miss” events, including maternal sepsis [ 15 , 16 ].…”