Hemoperitoneum during Pregnancy: A Rare Case of Spontaneous
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A 32-year-old woman, gravida 1, para 0, presented at 22 weeks of gestation with severe abdominal pain with a sudden onset after a bowel movement followed by lipothymia. At admission, the patient complained of general malaise and worsening abdominal pain. At the examination, she was pale and sweaty, blood pressure (BP) was 77/43mmHg, heart rate (HR) 90-110bpm. After immediate fluid resuscitation, the patient remained hypotensive (BP 98/65 mmHg) and tachycardic (HR 110 bpm). The abdomen was distended; there is general tenderness at palpation with abdominal guarding and lack of bowel sounds.
Abdominal Ultrasonography (US) in the emergency department revealed a normal intrauterine pregnancy with a single alive fetus. On the pouch of Douglas, there was an echogenic image with suggestive of a blood clot. There was a small amount of free fluid in the perihepatic and perisplenic space.

An abdominal-pelvic computerized tomography (CT) was performed to aid the differential diagnosis. Immediate evaluation of the CT scan images revealed hemoperitoneum but without an identifiable origin. At this point, the tachycardia was severe (150-160bpm), and the abdominal pain was worsening. Assuming hemorrhagic shock with hemoperitoneum, the team decided to perform an emergency laparotomy. Under general anesthesia, an exploratory laparotomy was performed. During the procedure, a laceration of the left posterior leaf of the broad ligament was detected. An active site of bleeding from the left uterine artery branch with blood pulsating from the laceration was identified and sutured. There were no signs of obvious underlying condition such as endometriosis observed. The estimated blood loss was 2000 mL. Intraoperatively, the patient was resuscitated with 1600 mL of crystalloids, 4 units of erythrocyte concentrate, 3 units of fresh frozen plasma, 2g of fibrinogen, and 1g of tranexamic acid. The patient was admitted to the intensive care unit under vasopressor support. The abdominal US performed immediately after surgery revealed intrauterine fetal death.

The recovery was favorable, and psychological support was offered. The delivery of the fetus occurred spontaneously on day 4. The patient was discharged on day 6 after admission under lactation suppression. Fifteen days after admission, the patient became dyspneic and complained of pleuritic chest pain—pulmonary thromboembolism was diagnosed. Anticoagulation (apixaban) was instituted. Three months after, the patient was stable with no other hemorrhagic/thrombotic events. In the interim, the patient withholds her reproductive life plan, and her main concern is the recurrence of the spontaneous uterine artery laceration. Regarding the possibility of recurrence, a pelvic angio-MRI was performed revealing no further vascular malformations.

Source: https://www.hindawi.com/journals/criog/2020/8882016/