Spontaneous haemoperitoneum in pregnancy (SHiP) due to endometriosis is a very rare condition and this is a case of a 41-year-old primigravida, who presented at 32 weeks with sudden onset of severe lower abdominal pain without any uterine activity. This was a dichorionic-diamniotic twin pregnancy, following in vitro fertilisation for subfertility secondary to severe endometriosis. On admission, pain score was eight, with ten being the maximum of the scale. The vital signs were stable. Abdominal palpation revealed generalised tenderness with no guarding or palpable contraction. There was no evidence of bleeding and the cervical os was closed on speculum examination. The cardiotocograph (CTG) was pathological and a plan was made to deliver the babies with emergency caesarean section. Intraoperatively, there was massive haemoperitoneum which was managed successfully with the involvement of multidisciplinary input from general surgeons and urologists with optimum maternal and fetal outcome.

Aim: To find out the timeline for diagnosis and outcome of pregnancy of unknown location PUL cases. To find out the approach for accuracy of diagnosis and to prevent doing unnecessary scan follow ups and βHCG tests. Method:Prospective observational study over one year period between January 2015 and January 2016. Result:In this study 50 patients were included and six patients were excluded as they didn't meet the criteria. The Intra-uterine Pregnancy (IUP) was diagnosed in 28% (n=14). The suboptimal βHCG was seen in 11% (n=5) patients, who later were diagnosed with ectopic pregnancy. The remaining 56% (n=25/44) patients unfortunately had failing IUP, and none of them were labelled as persistent PUL. The number of βHCG tests undertaken in Ectopic group ranged from 3-8, compared to 2-6 times in failing IUP group whereas in IUP cohort it remained one to two tests. Similarly, we found that number of pelvic scan required for making diagnosis in three above-mentioned groups varied. Our study data revealed that each patient had 2-4 scans in Ectopic group, and 1-3 scans needed in Failing IUP. Conclusion:To reach the final definite diagnosis / outcome in PUL cases in set time limit may not be possible in some atypical presentation of early pregnancy problems especially when the aim is to avoid un-necessary scans, follow ups and blood test without compromising the safety. Therefore we suggested a new local protocol for diagnosing and managing atypical presentations aiming to achieve outcome in 5 to 9 days durations.