Intra-abdominal hemorrhage in a pregnant woman as a manifestation of endometrioid disease

Background: The effect of pregnancy on the course of endometrioid disease is ambiguous and can be implemented in both curbing the progression of the disease and activating the pathological process with the development of life-threatening conditions, particularly spontaneous intra-abdominal hemorrhage, which requires complex differential diagnosis and timely surgical tactics.

Case report: A female patient at 32 weeks of gestation was admitted to the perinatal center with complaints of lower abdomen pain. Her medical history showed that she had undergone laparoscopic enucleation of right ovarian endometrioid cyst, cauterization of single endometriotic foci, and adhesiolysis two years before this pregnancy. Threatened preterm birth was diagnosed; a thorough examination was performed. A differential diagnosis was made between acute appendicitis, pelvic vascular thrombosis, ileus, pyelonephritis, renal colic, uterine rupture, preterm placental abruption, and threatened preterm birth. Following an examination by a surgeon, a council of physicians made a decision for surgical treatment due to suspected intra-abdominal hemorrhage. Intraoperatively, there is blood in the abdominal cavity; the source of bleeding was varicose vein wall perforation in the region of the right broad ligament of the uterus; a biopsy was done. A histological examination revealed that there were foci of external genital endometriosis. A hemostatic sponge was applied to control bleeding. A caesarean section was performed. The mechanism of tissue perforation is related to rejection of highly vascularized endometrioid tissue foci with hemorrhages and necrosis in the presence of an impaired estrogen/progesterone ratio in the third trimester of pregnancy, with the development of spontaneous hemoperitoneum. To overcome diagnostic difficulties, interdisciplinary interaction was needed to achieve a favorable gestational and perinatal outcome in a pregnant woman with a life-threatening condition.

Conclusion: The accumulation of knowledge and experience in managing pregnant women with endometrioid disease will be able to optimize medical tactics and to avoid critical obstetric conditions and deaths. Each confirmed clinical observation of the course of endometrioid disease in pregnant women, which is complicated by spontaneous hemoperitoneum, is undoubtedly of scientific and practical value.