Spontaneous Hemoperitoneum in Pregnancy Due to Endometriosis in the Second Trimester

Abstract

Spontaneous hemoperitoneum in pregnancy (SHiP) is defined as unprovoked intraperitoneal bleeding during pregnancy or up to 42 days postpartum. A 31-year-old primigravid woman presented to our hospital at 19 weeks of gestation with acute left lower abdominal pain. Upon several examinations, she was found to have intraabdominal bleeding. However, pelvic magnetic resonance imaging (MRI) failed to yield specific findings. The following day, owing to increased pain and progressive anemia, she underwent an exploratory laparotomy. Preoperative ultrasound imaging revealed intrauterine fetal death. Laparotomy revealed oozing-type active bleeding from three delicate tissues related to endometriosis: the myometrium at the uterine anterior and posterior surfaces and a portion of the peritoneum in the vesicouterine excavation. A cesarean section was performed, successfully halting the bleeding and obviating the need for a hysterectomy. She was ultimately diagnosed with SHiP. SHiP in the second trimester is relatively uncommon, and the subacute progression of symptoms made early diagnosis challenging. For a correct diagnosis and appropriate treatments, full consideration of the clinical circumstance is needed without excessive reliance on imaging findings, including MRI, and an early exploratory laparotomy may be the best approach in cases of an unclear source of bleeding.