#372 : Spontaneous Hemoperitoneum in an Advanced Intracytoplasmic Sperm Injection In-Vitro Fertilization Conceived Pregnancy

A 38-year-old primigravid, six years infertile, conceived a dichorionic-diamnionic twin gestation by intracytoplasmic sperm injection and in vitro fertilization.

At 33 weeks gestation, she was admitted, due to a sudden excruciating abdominal pain with profuse vaginal bleeding. Abruptio placenta was suspected and emergency cesarean section was done revealing massive hemoperitoneum. The babies were delivered first. On further inspection, actively bleeding, coalesced, friable pinkish blebs with a pulsating, bleeding vessel were seen at the left posteromidlateral corpus. Pinkish blebs were also seen occupying the right posterior area. Bilateral uterine artery ligation and repair of the bleeding site were done. Postoperative course was stable and she was discharged after 6 days.

Sudden, severe abdominal pain in late pregnancy has numerous causes. Intraoperative findings seen in this case, is a condition known as Spontaneous Hemoperitoneum in Pregnancy (SHiP).

SHiP is a rare disorder associated with unprovoked peritoneal bleeding reported to occur during the second half of pregnancy, in labor, or early postpartum. Its diagnosis is rarely made before laparotomy and surgery is often due to a preoperative diagnosis of abruptio placenta. Etiology of SHiP remains unknown but is particularly relevant in women with endometriosis and deciduosis.

Deciduosis is believed to be a physiologic phenomenon of pregnancy that would spontaneously involute after delivery. It generally has no clinical symptoms but may present pathologic conditions such hemoperitoneum. In this patient, hemoperitoneum was caused by rupture of utero-ovarian vessels or bleeding endometriotic implants believed to be related to progesterone resistance manifested by selective molecular abnormalities causing aberrant decidualization of stromal cells of the ectopic endometrium leading to bleeding of unpredictable severity.

This case illustrates the surgical challenge of controlling bleeding from multiple decidualized lesions and eroded blood vessels. Fortunately, both the mother and the babies were saved by early detection and immediate intervention.