Severe intraabdominal bleeding caused by endometriotic lesions during the third trimester of pregnancy

doi:10.1016/j.ajog.2007.04.030

American Journal of Obstetrics and Gynecology

Volume 197, Issue 5, November 2007, Pages 501.e1-501.e4

https://doi.org/10.1016/j.ajog.2007.04.030 Get rights and content

Objective

Endometriosis is known to be associated with an increased risk for early pregnancy complications, including ectopic pregnancy and miscarriage. However, little has so far been reported on complications linked to severe endometriosis occurring during the third trimester of pregnancy.

Study Design

A retrospective review of 800 women attending the endometriosis clinic of the Sheba Medical Center during the years 2002-2006 was performed. Cases with severe endometriosis and associated complications during late pregnancy were identified.

Results

Three women were found who experienced significant intraabdominal bleeding in the third trimester of pregnancy attributed to a lesion resulting from severe endometriosis. The intraabdominal bleeding occurred between 26-29 weeks of gestation. In all cases the major presenting prenatal symptom was severe lower abdominal pain. The pain was not relieved by the administration of tocolytics or mild analgesics. Explorative laparotomy, performed in all 3 cases, revealed the presence of significant intraabdominal bleeding requiring immediate transfusion of blood products stemming from endometriotic lesions. Fetal complications occurred in all 3 cases.

Conclusion

The symptoms of endometriosis are often relieved during pregnancy. Yet lesions caused by severe endometriosis can lead to significant intraabdominal bleeding during the third trimester of the pregnancy. Physicians must be aware that close antenatal follow-up and prompt intervention may be required in such cases.

Section snippets

Materials and methods

We undertook a retrospective review of 800 women attending the endometriosis clinic of the Sheba Medial Center during the years 2002-2006. Women with severe complications attributed to endometriosis during late pregnancy were identified.

Data were obtained from medical charts, delivery summaries, and surgical reports on the history of endometriosis and outcome of pregnancy.

The diagnosis of endometriosis was obtained in 2 cases during previous surgery before pregnancy.

The study protocol was

Results

We found 3 women with significant complications occurring during the third trimester that could be directly attributed to intraabdominal lesions of severe endometriosis.

Comment

Patients with endometriosis are increasing in number.1, 3 Although severe endometriosis is commonly associated with infertility, advanced treatment, such as IVF-ET, enables more patients with severe endometriosis to conceive.

Hemoperitoneum during pregnancy resulting from spontaneous rupture of uterine vessels is extremely rare, though almost always a dramatic life-threatening complication.18, 21 In the largest published series, reported maternal mortality ranged from 3.6%-49%.18, 19 The

Conclusions

The symptoms of endometriosis often disappear during pregnancy. Yet patients with severe endometriosis undergoing IVF treatment may be at increased risk for intraabdominal bleeding in third trimester of pregnancy. The bleeding can occur from spontaneous rupture of utero-ovarian vessels, or from endometrial lesions. Physicians must be aware that close antenatal follow-up and early diagnosis is crucial. Prompt intervention may be required in such cases. Because of the complex situation to the

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Cited by (40)

Spontaneous hemoperitoneum in pregnancy: A life-threatening maternal and fetal complication of endometriosis
2022, Journal of Gynecology Obstetrics and Human Reproduction
Citation Excerpt :
SHiP is thought to be associated with endometriosis in about 55% of cases [4]. Between 1995 and 2020, 31 articles [5–36] described 43 cases of SHiP associated with endometriosis. The true incidence of this complication is probably underestimated because of poor reporting.
Spontaneous hemoperitoneum in pregnancy (SHiP) is a complication of endometriosis. We describe the clinical characteristics and outcomes of mother and fetus in 11 new cases of SHiP with endometriosis and 43 cases reported in the literature since 1995.
The 60 maternity hospitals in the Auvergne-Rhône-Alpes region in France were contacted to identify cases of SHiP associated with endometriosis. In parallel, a systematic review of the literature used the PRISMA chart to report published cases.
Fifty-four cases of SHIP associated with endometriosis are presented. Twenty-four patients (44%) conceived with assisted reproductive techniques. Hemoperitoneum occurred before delivery in 47/54 cases (87%).The average gestational age of occurrence was 27 weeks (13 weeks to 40+6 weeks). An hypovolemic shock was present in 24/51 (47%) of patients. Forty-six women (85%) were treated by laparotomy, 5 (9%) by laparoscopy, 2 (2%) by interventional radiology. The hemorrhage site was in the mediolateral compartment of the pelvis in 29 cases (54%), corresponding to bleeding from vessels in the broad ligament in 24/29 (83%) of these cases. The mean estimated blood loss was 1957 mL (150–7500 mL). Emergency peripartum hysterectomy was required in 3/54 cases (6%). There were no maternal deaths. The average gestational age at birth was 30 weeks (13+2 weeks to 42 weeks). The fetus died in 19/64 cases (30%).
SHiP is an underestimated potentially fatal complication of endometriosis. Maternal salvage by emergency laparotomy is usually required to identify and treat the bleeding site. Fetal prognosis remains poor.
Endometriosis and spontaneous hemoperitoneum in pregnancy: evaluation of the magnitude of the risk in women becoming pregnant via in vitro fertilization
2021, Fertility and Sterility
Citation Excerpt :
We aimed to provide an estimate shrinking the amplitude of this interval below 1.5%. Hypothesizing that the rate of SHIP would be below 0.5% (5, 6, 8), we calculated that the number of pregnancies needed to be included in the study was approximately 340 (OpenEpi, http://www.openepi.com/SampleSize/SSPropor.htm). Because women could be included more than once, the denominator used to describe our population was the number of pregnancies, not the number of patients.
To estimate the frequency of spontaneous hemoperitoneum in pregnancy (SHiP) in women with endometriosis achieving pregnancy with in vitro fertilization (IVF).
Retrospective case series.
Referral academic assisted reproductive technology (ART) center.
Three hundred and forty-eight women with a history of surgery for endometriosis and women with ovarian endometriomas or deep endometriotic nodules detected at basal transvaginal ultrasound performed before IVF cycle.
Information obtained from patients’ charts on basal characteristics, IVF cycle, and pregnancy outcomes, and binomial distribution model created to determine the 95% confidence interval (CI) of the proportion of SHiP.
Rate of SHiP.
Overall, 362 pregnancies were included, among which 238 (66%) had a history of previous surgery for endometriosis and 231 (64%) had endometriosis detected at ultrasound (107 women, 30%, had both). Pregnancies were achieved after fresh and frozen cycles in 244 (67%) and 118 (33%) women, respectively. One case of SHiP was recorded, corresponding to a rate of 0.3%.
In the general population of women with endometriosis undergoing IVF, SHiP is uncommon. Future studies should better identify the risk factors for SHiP to disentangle the subgroups of women at higher risk.
Endometriosis y hemoperitoneo espontáneo en el embarazo: evaluación de la magnitud del riesgo en mujeres embarazadas mediante fertilización in vitro.
Estimar la frecuencia de hemoperitoneo espontáneo en el embarazo (SHiP) de mujeres con endometriosis que lograron embarazo con fertilización in vitro (FIV).
Serie retrospectiva de casos.
Centro académico de referencia de tecnología de reproducción asistida (ART).
Trescientas cuarenta y ocho mujeres con antecedentes de cirugía por endometriosis y mujeres con endometriomas ováricos o nódulos endometriósicos profundos detectados en una ecografía transvaginal basal realizada antes del ciclo de FIV.
información obtenida de los gráficos de los pacientes sobre las características basales, el ciclo de FIV y los resultados del embarazo, y el modelo de distribución binomial creado para determinar el intervalo de confianza (IC) del 95% de la proporción de SHiP.
Tasa de SHiP.
En total, se incluyeron 362 embarazos, de los cuales 238 (66%) tenían antecedentes de cirugía previa por endometriosis y 231 (64%) tenían endometriosis detectada en la ecografía (107 mujeres, 30%, tenían ambos). Los embarazos se lograron después de ciclos frescos y congelados en 244 (67%) y 118 (33%) mujeres, respectivamente. Se registró un caso de SHiP, correspondiente a una tasa del 0,3%.
En la población general de mujeres con endometriosis sometidas a FIV, la SHiP es poco común. Los estudios futuros deberían identificar mejor los factores de riesgo de SHiP para determinar los subgrupos de mujeres con mayor riesgo.
Obstetrical outcome in women with endometriosis including spontaneous hemoperitoneum and bowel perforation: a systematic review
2018, Best Practice and Research: Clinical Obstetrics and Gynaecology
Increasing evidence suggests that pregnant women with endometriosis have a higher risk of adverse obstetrical complications. The aim of this study was to systematically review the existing literature on this aspect. A PubMed/MEDLINE search was performed from its inception until September 2017 for studies on adverse obstetrical complications in pregnant women with endometriosis, including: preeclampsia, preterm birth, small for gestational age (SGA), antepartum hemorrhage, spontaneous hemoperitoneum, spontaneous bowel perforation, preterm birth, cesarean delivery, stillbirth and postpartum hemorrhage. Overall, the results showed an increased risk of preterm delivery, antepartum hemorrhage, delivery by cesarian section, and the rare complications of spontaneous hemorrhage in pregnancy and spontaneous bowel perforation. There is no firm evidence for any increased risk of preeclampsia, having a child born small for gestational age, stillbirth, or postpartum hemorrhage. In conclusion, pregnant patients with endometriosis should be offered special clinical attention.
Obstetrical complications of endometriosis, particularly deep endometriosis
2017, Fertility and Sterility
Over the past few years, a new topic in the field of endometriosis has emerged: the potential impact of the disease on pregnancy outcomes. This review aims to summarize in detail the available evidence on the relationship between endometriosis, particularly deep endometriosis (DE), and obstetrical outcomes. Acute complications of DE, such as spontaneous hemoperitoneum, bowel perforation, and uterine rupture, may occur during pregnancy. Although these events represent life-threatening conditions, they are rare and unpredictable. Therefore, the current literature does not support any kind of prophylactic surgery before pregnancy to prevent such complications. Results on the impact of DE on obstetrical outcomes are debatable and characterized by several limitations, including small sample size, lack of adjustment for confounders, lack of adequate control subjects, and other methodologic flaws. For these reasons, it is not possible to draw conclusions on this topic. The strongest evidence shows that DE is associated with higher rates of placenta previa; for other obstetrical outcomes, such as miscarriage, intrauterine growth restriction, preterm birth and hypertensive disorders, results are controversial. Although it is unlikely that surgery of DE may modify the impact of the disease on the course of pregnancy, no study has yet investigated this issue.
Complications during pregnancy and delivery in women with untreated rectovaginal deep infiltrating endometriosis
2016, Fertility and Sterility
Citation Excerpt :
Among the 101 women with posterior DIE included in this study, only 51.4% achieved pregnancy, confirming the very high infertility rate of women with endometriosis. Endometriosis may also negatively affect pregnancy in terms of an increased risk of preterm birth, preeclampsia, antepartum bleeding, and cesarean delivery (21–23). In our study population, we also observed complications such as preterm delivery and placenta praevia, with a high incidence compared with the general population (24, 25).
To study outcomes and complications during pregnancy and at delivery in women with a posterior deep infiltrating endometriosis (DIE) nodule persisting after surgery and diagnosed at transvaginal sonography (TVS) in comparison with a control group of women without endometriosis.
Multicenter observational and cohort study.
University hospital.
Women (n = 200) with a posterior DIE nodule equal or more than 2 cm centimeters in size who desired a pregnancy and a control group of women (n = 300) with no previous recorded diagnosis of endometriosis who delivered in our clinic during the same time period.
Patient data collected from medical charts and by phone interviews.
Evaluation of complications during pregnancy and delivery.
Of the 101 women with a posterior DIE nodule, 52 become pregnant among whom 25 used assisted reproductive technology. Of these 52 pregnancies, 11 ended in an early abortion, and 41 delivered a baby; 13 (31.7%) had a premature delivery, 7 (17.8%) a placenta praevia, and 28 (68.2%) had a cesarean delivery. When compared with the control group, the women with endometriosis had a higher risk of pregnancy complicated by preterm birth, placenta previa, placental abruption, and hypertension. Cesarean delivery and complications during surgery (hysterectomy, hemoperitoneum, and bladder injuries) were statistically significantly more frequent in women with endometriosis than in controls.
Women with an incomplete removal of posterior DIE have a high complications rate during pregnancy and delivery.
Severe spontaneous hemoperitoneum in pregnancy may be linked to in vitro fertilization in patients with endometriosis: a systematic review
2016, Fertility and Sterility
To evaluate existing evidence of a possible association in women with endometriosis between controlled ovarian hyperstimulation plus embryo transfer (COH-ET) and the occurrence of spontaneous hemoperitoneum in pregnancy (SHiP).
Comprehensive review.
Not applicable.
None.
An electronic literature search up to February 2016 was conducted using Scopus and PubMed.
The role of COH-ET in SHiP.
Controlled ovarian hyperstimulation plus embryo transfer may increase the severity or incidence of the rare condition known as SHiP. An analysis of published cases shows that bleeding often occurs from multiple or diffuse sites, mainly situated in the posterior pelvic cavity, making it difficult to control without interfering with the pregnancy itself. Spontaneous hemoperitoneum in pregnancy is linked to adverse perinatal outcomes, including stillbirth, neonatal mortality, and very low or low birth weight. In 14 cases a biopsy of the bleeding site was obtained, and in all cases, even in the absence of visible endometriosis, decidualization was documented. At present, the relatively small number of cases published prevents firm conclusions, although they are highly suggestive of a link between COH-ET in women with endometriosis and the occurrence and seriousness of SHiP.
Spontaneous hemoperitoneum in pregnancy is a rare but potentially fatal complication for the pregnant woman and her unborn child. In vitro fertilization in women with severe endometriosis may be a risk factor for SHiP.

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: Cite this article as: Katorza E, Soriano D, Stockheim D, et al. Severe intraabdominal bleeding caused by endometriotic lesions during the third trimester of pregnancy. Am J Obstet Gynecol 2007;197:501.e1-501.e4.

: Reprints not available from the authors.

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ResearchObstetricsSevere intraabdominal bleeding caused by endometriotic lesions during the third trimester of pregnancy

Objective

Study Design

Results

Conclusion

Section snippets

Materials and methods

Results

Comment

Conclusions

Fertil Steril

Fertil Steril

Fertil Steril

Lancet

Int J Gynaecol Obstet

Am J Obstet Gynecol

Prevalence and anatomical distribution of endometriosis in women with selected gynaecological conditions: results from a multicentric Italian study

Hum Reprod

Prevalence and genesis of endometriosis

Hum Reprod

Spontaneous rupture of the uterine vessels in pregnancy

Obstet Gynecol

Deciduosis of the appendix

Am J Gastroenterol

Research
Obstetrics
Severe intraabdominal bleeding caused by endometriotic lesions during the third trimester of pregnancy