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

Abstract

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.

Keywords: Emergency; Fetal death; Hemoglobin; Maternal mortality; Pregnancy; Spontaneous hemoperitoneum; Ultrasound.

Fig. 1

Ultrasound scan shows as follows: A free fluid in the pelvic cavity. B Single alive fetus at 21 weeks and 3 days of gestation and maternal hydronephrosis at the third grade. C Adenomyosis image. D Endometriotic cyst. E Hypervascularity on the lateral wall of the uterus. F Abnormal appearance with laceration on the serosal surface of the uterus and vessel ligations (white arrow) were performed during exploratory laparotomy

Fig. 2

Ultrasonography shows A a single a live fetus and proliferative vasculature at the cervix. B Free fluid collection in the abdominal cavity. C Extravasation in the right adnexa, suspected to arise from the right utero-ovarian plexus (yellow arrow). D Uterine closure accompanied with a multiple hemostatic sutures were performed (blue arrow). One of the adherent bandages existed between the lateral posterior of the uterus and the abdominal anterior wall of the abdomen (white arrow). The bleeding stopped after releasing a part of the adhesion, excision of fragile tissue, and suturing