Spontaneous hemoperitoneum in pregnancy

Spontaneous hemoperitoneum in pregnancy (SHiP), although rare, is strongly associated with maternal and fetal morbidity and mortality. Pregnant women with endometriosis should be routinely screened for the presence of this condition.

A 28-year-old primigravida was hospitalized at 34 weeks of gestation due to a sudden onset of right lower abdominal pain after a meal. The pain was described as intense. 

Her, physical examination depicted abdominal guarding along with rebound tenderness at the right lower quadrant of the abdomen. The uterus was mildly sensitive. 

On admission, the abdominal pain seemed to be slightly relieved; ultrasonography confirmed the absence of free peritoneal fluid or pelvic mass. Her prenatal care was unremarkable. Acute appendicitis during pregnancy was suspected. 

Explorative laparotomy showed intermittent bleeding from a ruptured uterine varicose vessel in the right uterine cornua. A lower segment cesarean section was immediately performed, delivering a male infant with Apgar scores of 10 and a birth weight of 2300 g. 

Hemostasis was successfully achieved after ligation of the vessel and no other source of bleeding could be identified. The posterior uterine wall adhesion was obvious. The postoperative course was uneventful and the patient was discharged 4 days post-surgery.

The physiological demands during pregnancy cause a tremendous increase in uterine blood flow that leads to passive congestion of the uterine vessels and weakness of the vessel wall. These damage the vascular wall due to sudden increases in the venous pressure during – uterine contractions, coughing, defecation, coitus, and lifting. 

Endometriosis and chronic pelvic inflammatory disease render chronic inflammation making uterine vessels more friable and prone to rupture. Pregnancy causes additional stress and may overstretch the vessel, causing it to tear. 

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