Dr. Shikha Sharma passed her MBBS from Lady Hardinge Medical College, Delhi, and MS (Obs & Gynae) from UCMS & GTB Hospital, Delhi. She is currently working as Graded Specialist in Department of Obstetrics and Gynaecology at Military Hospital, Agra. Her field of interest is high-risk pregnancy and minimally invasive surgery.
Haemoperitoneum anytime during pregnancy is a rare but catastrophic event. With advancement in antenatal and intrapartum care, the maternal survival has improved manyfold. Management involves immediate resuscitation with volume correction followed by surgery, mostly laparotomy. This case is of a booked primigravida, with otherwise uneventful pregnancy, who suffered a massive haemoperitoneum. On laparotomy, the only cause found was a small uterine varix on the posterior uterine surface. The patient survived after multiple transfusions, but it led to a fresh stillborn baby. Immediate action is the only answer to improving maternal and foetal survival.
Keywords : Haemoperitoneum, Varix, Uterine varices
Spontaneous haemoperitoneum during pregnancy is of rare occurrence but with significant maternal and foetal outcomes [1]. The wide array of aetiologies vary from gynaecological to gastrointestinal to vascular. Haemoperitoneum with spontaneous rupture of uterine varices is a rarity [2, 3].
A 25-year-old booked, low-risk primigravida, case, presented to the gynaecological emergency at 1600 h in labour at term. Systemic and general physical examinations were normal. On per abdomen examination, there were mild contractions with a single live foetus in cephalic presentation. On per vaginal examination, cervix was soft, posterior, admitting tip of finger and vertex was at -3 station. The patient was left for spontaneous progress of labour which was partographically charted. At around 01:00 h, she complained of sudden acute pain abdomen and became agitated, the foetal heart sound could not be localized, and the patient collapsed. Examination revealed free fluid in the abdomen with the uterine contour maintained. At laparotomy, about 3.5 l of haemoperitoneum was drained and a fresh stillborn baby was delivered by caesarean section. No major bleeding vessel was seen except a small profusely bleeding vessel on the posterior surface of the uterus which was secured. Further exploration of the abdominal cavity revealed no abnormality. The post-operative period was uneventful, and she was discharged in good condition.
Spontaneous haemoperitoneum during pregnancy is a rare event but if not diagnosed can be life-threatening to both the mother and foetus. A series in 1950 reported that the maternal mortality may reach up to 49 % [4] but with improving maternal care the current rate is 3.6 % [5]. Perinatal mortality still remains high at 30 % [6]. Majority of these cases occur in the last trimester.
Spontaneous rupture of uterine varices causative of haemoperitoneum is even rarer with an incidence of 1/10,000 births. Till date, about 150 cases have been reported. The sites listed are the broad ligament (78.3 %), the posterior surface of the uterus (18.3 %) and the anterior surface (3.3 %) [7]. The rupture of uterine varices can occur anytime from 10th week to up to 3 weeks post-partum. Varied reasons cited are expulsive efforts during labour, coughing, defecation or even sexual intercourse. The condition mandates a high index of suspicion and should be suspected whenever there is sudden acute abdominal pain, signs of shock and foetal distress disproportionate to the degree of bleeding. The pre-operative diagnosis of haemoperitoneum is made in only 37 % of the cases, and this falls to 4 % in cases of ruptured uterine vessels or varices [8]. Differential diagnosis is placental abruption, rupture uterus, rupture of an aneurysm of the renal artery, hepatic or splenic vessels.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflicts of interest related to this manuscript.
Ethical approval The study was approved from institutional ethical committee, and an informed written consent was taken from the patient.
