Endometriosis-related spontaneous hemoperitoneum in the early second trimester: A case report

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

Spontaneous haemoperitoneum in pregnancy is a rare but potentially life-threatening condition that requires prompt recognition and management to avert a catastrophic outcome for the mother and baby. The main aim of this review is to summarise the current knowledge on this topic, including its incidence and clinical presentation, highlight the diagnostic challenges, and suggest management strategies. To achieve our objective, we examine the existing literature to provide insights into this complex clinical presentation to enhance our understanding and, in so doing, contribute to the existing body of knowledge on the subject of spontaneous haemoperitoneum in pregnancy.

Spontaneous haemoperitoneum in the second trimester of pregnancy

This is a case of a spontaneous haemoperitoneum occurring in the second trimester of pregnancy which was managed with interventional radiology to avoid laparotomy and its potential consequences. We aim to raise awareness of this condition in pregnancy because the perinatal mortality rate is as high as 36%. Spontaneous haemoperitoneum in pregnancy (SHiP) has frequently been associated with vascular rupture from pre-existing endometriosis. Most cases of SHiP have been managed with laparotomy. However, transcatheter embolisation can impart lifesaving alternatives to more invasive interventions when caring for pregnant patients. More judicious use of imaging procedures may also help improve diagnostic and therapeutic pathways with SHiP. We recommend that high-risk pregnancies are managed in level IV regional perinatal healthcare centres, when possible, where subspecialists and alternative measures of management exist.

Spontaneous haemoperitoneum in pregnancy: Nationwide surveillance and Delphi audit system

OBJECTIVE

To evaluate the incidence, diagnostic management strategies and clinical outcomes of women with spontaneous haemoperitoneum in pregnancy (SHiP) and reassess the definition of SHiP.

DESIGN

A population-based cohort study using the Netherlands Obstetric Surveillance System (NethOSS).

SETTING

Nationwide, the Netherlands.

POPULATION

All pregnant women between April 2016 and April 2018.

METHODS

This is a case study of SHiP using the monthly registry reports of NethOSS. Complete anonymised case files were obtained. A newly introduced online Delphi audit system (DAS) was used to evaluate each case, to make recommendations on improving the management of SHiP and to propose a new definition of SHiP.

MAIN OUTCOME MEASURES

Incidence and outcomes, lessons learned about clinical management and the critical appraisal of the current definition of SHiP.

RESULTS

In total, 24 cases were reported. After a Delphi procedure, 14 cases were classified as SHiP. The nationwide incidence was 4.9 per 100 000 births. Endometriosis and conceiving after artificial reproductive techniques were identified as risk factors. No maternal and three perinatal deaths occurred. Based on the DAS, adequate imaging of free intra-abdominal fluid, and identifying and treating women with signs of hypovolemic shock could improve the early detection and management of SHiP. A revised definition of SHiP was proposed, excluding the need for surgical or radiological intervention.

CONCLUSIONS

SHiP is a rare and easily misdiagnosed condition that is associated with high perinatal mortality. To improve care, better awareness among healthcare workers is needed. The DAS is a sufficient tool to audit maternal morbidity and mortality.

Spontaneous Hemoperitoneum in Pregnancy: Masquerading as Acute Appendicitis

Spontaneous hemoperitoneum in pregnancy (SHiP) is a rare obstetric emergency that may have an adverse outcome for the mother and baby. This case report describes a unique SHiP case initially diagnosed as acute appendicitis in a patient with severe endometriosis before conception. A woman in her 30s, a primigravida, was admitted with abdominal pain at 32+5 weeks gestational age. Following a surgical review, she was initially diagnosed with acute appendicitis and commenced on intravenous antibiotics. She experienced a dramatic deterioration in her health in the form of clinical shock and fetal distress. She had an emergency laparotomy, a hysterectomy, and a left salpingo-oophorectomy for uncontrollable bleeding. The baby was born in good health, and the mother had an uneventful recovery.

Spontaneous hemoperitoneum in the second and third trimester of pregnancy: two uncommon case reports at Tu Du Hospital, in Vietnam and a literature review

BACKGROUND

Spontaneous hemoperitoneum in pregnancy (SHiP) refers to fluid collection in the abdominal cavity with a vague presentation of clinical symptoms. Particularly, SHiP causes a life-threatening condition with the coexistence of intrauterine pregnancy, since this dangerous complication significantly increases the maternal and fetal mortality. Herein, we present two cases of nontraumatic SHiP in the second and third trimester of pregnancy, respectively.

CASE PRESENTATION

The pregnant woman in case 1 was admitted to our hospital owing to severe paroxysmal shoulder pain along with abdominal pain. Her medical history was remarkably recorded with endometriosis and adenomyosis. At the emergency room, an ultrasound scan revealed a live fetus corresponding to 21 weeks and 3 days and free fluid in the abdominal cavity. She was subsequently diagnosed with SHiP and underwent immediate laparotomy for hemostatic procedures. During the postpartum course, the patient was uneventfully monitored. Unfortunately, the patient delivered on the 4th postoperative day in spite of the initial administration of tocolytic agents and close monitoring. The primigravid woman in case 2 complained of lower abdominal pain and vaginal bleeding. The patient's history was noted with ovarian tumor removal. At admission, the sonography scan revealed free fluid in the abdominal cavity, a fetus at 34 weeks and 3 days gestational age with bradycardia of 70 bpm, and a laboratory test showed a low hemoglobin level. Thus, exploratory laparotomy and hysterotomy were performed at the same time due to fetal distress. The postpartum course was uneventful. The patient was discharged 5 days later.

CONCLUSIONS

In pregnant women with a history of endometriosis, adenomyosis, or ovarian tumor removal, acute abdominal pain combined with the presence of free fluid collection in the intraperitoneal cavity, and a decreased hemoglobin levels should be first assessed as SHiP originating from the spontaneous rupture of abnormal vascular proliferation. Proper management is strongly indicated for an emergent laparotomy to control the active bleeding point, thus increasing the survival rate for both mother and neonate.

Endometriosis-related spontaneous hemoperitoneum in pregnancy: A case series

Endometriosis can be associated with adverse pregnancy outcomes. We report six cases of endometriosis-related spontaneous hemoperitoneum diagnosed in pregnant and postpartum women over 13 years. Spontaneous hemoperitoneum in pregnancy mainly occurred in the second half of gestation. All women presented with acute abdominal pain; four of them needed an emergent surgery, two were managed expectantly. The median estimated blood loss was 4250 ml, four women required massive transfusion. Three out of six women had a known history of endometriosis, all of them had histologically confirmed endometriosis after surgery. No maternal or perinatal deaths occurred. In one case, reticence to perform a computed tomography scan led to delayed diagnosis. Since delay can lead to lethal consequences, high levels of suspicion for spontaneous hemoperitoneum should be maintained in cases of severe abdominal pain, even with a woman's negative history of endometriosis. Improved knowledge and regular interdisciplinary meetings are pivotal to ameliorate outcomes.

Stage IV endometriosis: to treat or not to treat before in-vitro fertilization? Further considerations besides the pregnancy rate: a case of near-miss for spontaneous hemoperitoneum

Endometriosis represents a well-known cause of infertility. Recently, its association with spontaneous hemoperitoneum in pregnancy (SHIP) was reported. Its occurrence seems to be increased in patients with endometriosis who underwent IVF techniques. We present a case of near miss at 15 weeks of pregnancy associated with SHIP in a nulliparous patient of 39 years old with chronic endometriosis. Previously, she underwent several IVF cycles and controlled ovarian hyperstimulation plus embryo transfer (COH-ET). An explorative laparoscopy was performed, then converted in laparotomy. The bleeding endometriotic tissue was removed and an ureteral stent was placed. The patient lost a total of 4 liters of blood and fully recovered. Unfortunately, miscarriage occurred. The potential link between COH-ET, the number of cycles of ovarian stimulation and SHIP in severe endometriosis must take a part in the balanced decision between preventive surgery of direct hormonal stimulation.