Table 1 Summary of spontaneous intraperitoneal hemorrhage related to the uterus and adnexa
Reports | GA, timing detection | Etiology, lesion position | Risk factors | Clinical symptoms and imaging modalities | Management | Outcomes |
|---|---|---|---|---|---|---|
Sigurd et al. (1988) [7] | 39 weeks | Blood oozing from a rupture of a uterine vein on the back side of the uterus | Not found | An intensive burning pain in the lower part of the abdomen and in the shoulders Deep hypotensive shock | Laparotomy for CS and hemostasis | Fetal death Maternal survival EBL at 3000 ml |
Choobun et al. (2006) [17] | 31 weeks | Spontaneous rupture of the utero-ovarian plexus | Not found | Acute lower abdominal pain, distended abdominal wall | Laparotomy for CS and sutured ligation | Maternal survival and alive newborn EBL at 750 ml |
24 weeks, then, recurrence at 31 weeks | Spontaneous rupture of the uterine varices | Not found | Acute abdominal pain, the right lower quadrant tenderness with guarding, and vomiting A moderate amount of free fluid in the peritoneal cavity on US | Twice laparotomy for hemostatic procedures | Vaginal delivery with alive newborn of 33 weeks GA EBL at 1500 ml and 2000 ml, respectively | |
Hamadeh et al. (2017) [15] | Third trimester | Ruptured vessels in the uterine–ovarian plexus | Not mentioned | Severe generalized abdominal pain | Laparotomy for immediate CS and hemostasis | Survival |
Hardin et al. (2017) [16] | 20 weeks | Spontaneous rupture of a uterine artery | Unknown | Suprapubic abdominal pain, emesis and vaginal spotting Decreased Hb of 9.7 g/dl and Hct of 28.9% Hb/Hct was 8.7 g/dl and 25.7% on follow-up | Emergent laparotomy surgery with ligation of active bleeding artery | The patient discharged at 22 weeks of GA and IOL at 36 weeks and delivered a 2346 g infant with Apgar scores of 8 and 9 via CS |
Xu et al. (2019) [3] | 40 weeks 6 days 3 h After vaginal birth | An area of 4 × 2 cm existed in the lower left posterior wall of uterus | Endometriosis | Paroxysmal pain, abdominal distention The Hb was from 10.31 to 7.48 g/dL. Abdominal CT and abdominal ultrasonography indicated presence of free fluid in the abdominal cavity | Open exploration and hemostasis | Survival EBL and blood transfusion were about 3600 ml and 1600 ml |
40 weeks 2 days | Multiple inflammatory adhesions and multiple active bleeding related to the rupture of endometriosis cyst. A local hematoma of 4 × 4 × 11 cm was found | Left ovarian cyst about 3 × 4 × 5 in size | Not reported SHiP was coincidentally found during CS due to fetal distress | CS and hemostasis | Survival EBL and blood transfusion were about 2000 ml and 800 ml, respectively | |
25 weeks 5 days | The active bleeding was seen near the posterior lobe of broad ligament on the left posterior wall of uterus. Extensive hyperemia, edema, and inflammatory exudation were found in the surrounding tissues | History of laparoscopic surgery | Paroxysmal pain in lower abdomen Hb 7.3 g/dl Emergency abdominal ultrasonography and abdominal CT indicated large amounts of effusion in abdominal cavity. Noncoagulant blood was drawn out from the abdominal cavity | Open exploration and hemostasis | Fetal death EBL and blood transfusion were about 2400 ml and 2200 ml, respectively | |
Yang et al. (2020) [1] | 29 weeks 1 day | Ruptured subserosal vein on the posterior uterine wall | Uterine malformation with didelphic uterus | Lower abdominal pain, nausea, dizziness, palpitations, and anal bloating Hb was 88 g/L, and Hct was 26% A large amount of fluid was seen in the pelvis and abdominal cavity on US Posterior culdocentesis yielded non-coagulable blood | Exploratory laparotomy, CS, and control of bleeding | Fetal death EBL at 1900 ml six units of packed RBC intraoperatively |
Kim et al. (2020) [13] | First trimester | Continuous active bleeding was observed from the peritoneal wall of the pouch of Douglas | Endometriosis | Acute abdominal pain, vaginal bleeding, peritoneal irritation signs along with hemodynamic instability Decreased Hb to 7.0 g/dl Ultrasonographic evidence of pelvic fluid collection | Emergency exploratory laparoscopy and laparoscopic electrocoagulation | Survival EBL was 1800 ml Received 3 units of RBC transfusion Spontaneous abortion |
Silva et al. (2020) [14] | 22 weeks | A laceration of the left posterior leaf of the broad ligament. An active site of bleeding from the left uterine artery branch with blood pulsating | Not found | General malaise, worsening abdominal pain, and hemorrhagic shock Drop in Hb levels US revealed an echogenic image with 95 × 88 × 53 mm suggestive of a blood clot on the pouch of Douglas Immediate evaluation of the CT scan images revealed haemoperitoneum | Exploratory laparotomy and hemostasis | Survival EBL was 2000 mL. Intraoperatively, the patient was resuscitated with 1600 mL of crystalloids, 4 units of erythrocyte concentrate, 3 units of FFP, 2 g of fibrinogen, and 1 g of tranexamic acid Pulmonary thromboembolism on the 15th day of postoperation |
Huang et al. (2021) [12] | 18 weeks | Bleeding from decidualized endometriotic tissue over posterior uterine surface | Endometriosis | Diffuse lower abdominal pain, signs of peritoneal irritation, and abrupt deterioration with maternal shock | Emergent laparotomy and multiple hemostatic sutures | EBL at 1500 ml The patient recovered smoothly Stillbirth |
The present case 1 | 21–22 weeks | Ruptured vessels and laceration on the serosal surface of the uterus | Abnormal vascular proliferation of adenomyosis and endometriosis | Abdominal tenderness, shoulder pain, hypovolemic shock Dropped Hb level US revealed a large amount of free fluid in abdominal cavity | Exploratory laparotomy and hemostasis | EBL at 2000 ml 4 units of packed RBC Maternal survival with uterine conservation Very preterm birth on the 4th postoperative day |
The present case 2 | 34 weeks 3 days | Spontaneous rupture of vessels eroding into utero-ovarian plexus | Abnormal proliferation of utero-ovarian plexus and adhesions from previously ovarian tumor resection | Abdominal pain Low Hb levels US showed free fluid collection in abdominal cavity extended to hepatic and renal space | Exploratory laparotomy, CS, releasing adhesion, vessel ligation and hemostasis | EBL at 1200 ml 2 units of packed RBC The patient was alive and the uterus was preserved Preterm delivery with a live newborn |