Spontaneous haemoperitoneum during the 3rd trimester of pregnancy resulting from tear or rupture of a uterine or ovarian vessel is a rare yet catastrophic event. Hodgkinson and Christensen in 1950 reported an overall mortality rate of 49%.[3] These figures reflect the difficulties faced by the obstetricians prior to the modern resuscitative, anaesthetic and operative technique. Ever since there has been a fall in the maternal mortality rate to 3.6%.[4]
Aetiology of the condition is unknown though at times arteriovenous malformation or uterine artery aneurysm may be present. The congenital malformation, arterial degeneration and inflammatory process are causes of aneurysm, which can be aggravated by haemodynamic stress of pregnancy and labour.
Presenting symptoms seen are of sudden onset of abdominal pain without vaginal bleeding associated with signs of acute abdomen and hypovolaemia. Foetal distress is a rare finding.[1]
An accurate diagnosis is rarely made prior to laparotomy because of a host of other surgical and obstetrical conditions that can present with a similar clinical picture.
Differential diagnosis includes
-Abruptio placentae
-Rupture uterus
-Abdominal pregnancy
-Perforated appendicitis
-Rupture of splenic/hepatic artery aneurysms.
Placental abruption is the most common differential diagnosis for rupture of the utero-ovarian vessels. The diagnosis of which is aided by establishing the presence of haemoperitoneum in case of a vessel rupture.
Active preoperative resuscitation is crucial. Exploratory laparotomy and control of haemorrhage is the only option. Caesarean is often needed in order to locate the site of the haemorrhage. If the source of bleeding is not identified then other causes of haemoperitoneum should be ruled out and managed accordingly.
Obstetricians should be aware of this rare aetiology of shock, which can present either antenatal or in labour.
REFERENCES
1.Steinberg LH, Goodfellow C, Rankin L. Spontaneous rupture of uterine artery in pregnancy. British Journal of Obstetrics and Gynecology Feb. 1993; 100 : 184.
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