Massive obstetric hemorrhage caused by spontaneous rupture of uterine blood vessels

Spontaneous rupture of uterine veins and arteries is a rare and life-threatening cause of hemoperitoneum during pregnancy, labor, and the postpartum period. The differential diagnosis should exclude rupture of uterine, adrenal, splenic, renal, or hepatic veins, ruptured aneurysm or pseudoaneurysm, presence of arteriovenous malformation, as well as endometriosis or iatrogenic lesions.

Case report: A primigravida with a relevant surgical history (operated for retrocervical endometriosis and endometrioid cysts) at 35 weeks’ gestation (dichorionic, diamniotic twins) was admitted to the Krasnoyarsk Regional Clinical Center for Maternal and Child Health with complaints of intense pain in the abdomen and right subcostal area. An urgent cesarean section was performed due to suspected intra-abdominal hemorrhage. In order to identify the source of intra-abdominal bleeding, exploration of the abdominal cavity and pelvic organs was performed together with the abdominal surgeon involved in the operation. The abdominal exploration revealed that the source of intra-abdominal bleeding was a rupture of uterine superficial varicose veins which were localized in the right lower third of the posterior wall of the uterus. Reliable surgical hemostasis was achieved by suturing the bleeding superficial uterine veins. The total blood loss was 3000.0 ml. The patient’s hemodynamic parameters were restored during the operation. The patient spent three days in the intensive care unit. In the postoperative period, the woman received complex therapy including antibiotics, uterotonics, iron supplements, and anticoagulants. The postoperative period was without complications; the patient was discharged from the hospital on the 9th day after surgery in a satisfactory condition.

Conclusion: Hemoperitoneum due to the rupture of uterine vein or artery is a serious complication that requires rapid identification and urgent surgical intervention. In case when a pregnant patient has sudden abdominal pain accompanied by unstable hemodynamics, it is necessary to exclude the possibility of rupture of uterine blood vessels. Depending on the gestational age, patients may undergo laparotomy with or without cesarean section; reliable surgical hemostasis is obligatory.