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Hemoperitoneum Caused by Spontaneous Uterine Varicose Vein Rupture in the
Third Trimester of Pregnancy-A Case Report
Fatnassi R1*, Mkhinini I1,Torki E1, Ragmoun H1,Kaabia O1, Hammami S1, Barhoumi H1 and Ben regaya L2
1Department of Gynecology-obstetrics, Ibn Jazzar hospital, Kairouan , Tunisia
2Department of Gynecology-obstetrics, Menzel Temim hospital, Nabeul, Tunisia
*Corresponding author: Fatnassi Ridha, Department of Gynecology and Obstetrics, Ibn El Jazzar Hospital , Kairouan, 3140 Kairouan ,Tunisia, Tel:+ 216 98 451 341;
E-mail: ridha.fatnassimohamed@rns.tn
Received date: March 09, 2015; Accepted date: April 21, 2015; Published date: April 28, 2015
Copyright: © 2015 Fatnassi R, et al., This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract
Spontaneous rupture of uterine varicose veins is a rare and poorly understood complication during pregnancy. Its
clinical presentation is misleading and non-specific. Due to the high maternal and fetal mortality, the diagnosis of a
hemoperitoneum must be done quickly.
We report a case of spontaneous rupture of uterine varicose veins revealed by an abundant hemoperitoneum that
occurred in a 35 year-old pregnant patient at 32 weeks of gestation. A laparotomy enabled the diagnosis and the
treatment of this complication in addition to the extraction through a cesarean section of a healthy newborn.
Keywords: Hemoperitoneum; Uterine varicose veins; Pregnancy;
Mortality
Introduction
The occurrence of a spontaneous hemoperitoneum during
pregnancy is a rare condition and often unknown but with potentially
serious maternal and fetal outcomes [1]. Its causes can be
gynecological, gastrointestinal or vascular such as the rupture of
uterine varicose veins. The diagnosis of a hemoperitoneum due to
ruptured uterine veins is difficult to establish because of its rarity and
the lack of specific clinical signs that may delay the therapeutic
management which should be quick and immediate to improve the
still reserved maternal and fetal prognoses [2].
Case Report
Mrs. H. aged 35, second a para with no specific medical history,
consulted at 32 weeks of gestation for an abdomino-pelvic pain of a
sudden onset that started initially in her low back. No pain trigger
especially no trauma was reported by the pregnant patient who
reported the notion of a prolonged walk the day before. The clinical
examination revealed mild skin pallor. The temperature of the patient
was normal of 37°C. Her pulse was steady at 79 bpm and her blood
pressure was 110/54 mm Hg. The abdominal palpation revealed a
sensitivity in both the iliac fossi without contracture. The vaginal
examination was painful without genital bleeding. The cervix was
posterior and closed, the fetal movements were present and irregular
uterine contractions were confirmed by external tocography. The fetal
heart rate was normal-responsive and varied. Laboratory tests revealed
the absence of leukocytosis, a low hemoglobin level of 10.7 g/dl and a
negative C Reactive Protein. Obstetric ultrasound showed an evolutive
singleton pregnancy in cephalic presentation with a 3 kg estimated
fetal weight and an anterior normally-inserted placenta without a
peeling image. An abdominal ultrasound was performed and revealed
a small peritoneal effusion interpreted initially as reaction ascites. The
patient was hospitalized in the high-risk pregnancy unit with strict
maternal and fetal monitoring and the decision was to await in a state
of uncertainty. Two days later, while the initial evolution of abdominal
syndrome was favorable, we witnessed an exacerbation of pelvic pain
associated with a fall in hemoglobin to 7 g/dl without any change in
the bishop score or in the uterine contractions rhythm. An emergency
abdomino-pelvic injected CT found an intrauterine fetus and an
abundant intra-peritoneal effusion predominant in the sub-mesocolic
region without any liver, kidney or spleen damage and with no visible
vascular malformation (Figures 1a and b). The patient was thus
transferred to the Intensive Care Unit with the transfusion of four red
blood cells packs and six pockets of fresh frozen plasma. The evolution
was marked by a 12-hour transient hemodynamic stability followed by
a gradual decrease in hemoglobin up to 6.3 g/dl hence the surgical
indication. The median under umbilical laparotomy revealed a
hemoperitoneum of about 1300 ml which was evacuated. We then
realized a cross segmental hysterotomy that allowed the extraction of a
healthy newborn of 3100g. The exploration of the abdomino-pelvic
cavity in search of the cause of the bleeding showed a large ruptured
varicose vein packet at the posterior face of the left large ligament
above the utero-sacred ligament with a venous bleeding responsible
for the hemoperitoneum (Figure 2). The hemostasis was achieved
through a number of suture points in X. The postoperative course was
uneventful and the patient was discharged on the 6th postoperative
day.
Gynecology & Obstetrics
Fatnassi, et al., Gynecol Obstet (Sunnyvale) 2015,
5:4
http://dx.doi.org/10.4172/ 2161-0932.1000291
Case Report Open Access
Gynecol Obstet (Sunnyvale)
ISSN:2161-0932 Gynecology, an open access journal Volume 5 • Issue 4 • 1000291
Figure 1a: Fluid effusion in the parieto-colic groove.
Figure 1b: b- Peri-hepatic hemoperitoneum.
Figure 2:Per-operating view of venous rupture in the posterior face
of the uterus.
Discussion
The hemoperitoneum during pregnancy due to a vascular rupture
was first described in 1950 by Hodgkinson and Christensen [1]. It was
an intraperitoneal bleeding in connection with a rupture of the utero-
ovarian veins. The rupture of uterine varicose veins during pregnancy
is a rare vascular complication and a little known one despite its very
serious maternal and fetal prognosis [1].
The physiopathology of the rupture of uterine of varicose veins is
still poorly understood. It seems to get into the general framework of
the physiological changes in the vascularization of the pregnant uterus.
These changes are related to hormonal factors and also to a
mechanical factor due to the compression of both the inferior vena
cava and the iliac vessels by the gravid uterus. This results in an
increase in the venous pressure and elasticity associated with a slowing
of the blood flow promoting the appearance of aneurysms that may
rupture particularly during late pregnancy [1,3]. This rupture can also
result of the physiological vascular changes during pregnancy,
including the delicacy and fragility of the vessel walls by the atrophy of
their muscular layer.
The rupture of the uterine veins most often occurs without any
triggering factor such as in our case. However, it can be promoted by
any increase in the venous pressure, frequently observed during the
expulsive efforts during childbirth, during coughing, defecating, lifting
heavy objects or even sexual intercourses [1,4] .
The diagnosis of hemoperitoneum from ruptured uterine veins
during pregnancy is difficult to determine preoperatively due to the
few and often delayed specific symptoms [5,6]. This diagnosis should
be considered when dealing with any brutal abdominal pain despite its
location and its nature that may be associated with signs of peritoneal
irritation and hypovolemic shock including acute fetal distress
proportional to the importance of the bleeding. In some cases, an
unexplained hemorrhagic shock with no external bleeding may be the
only warning signal. The signs of hemodynamic instability may be
delayed or even absent in the minor hemorrhagic forms or during any
compression of the ruptured vessel by the gravid uterus [2,7]. In our
case, the diagnosis was delayed three days due to the poor non-specific
initial symptoms reduced to an isolated abdomino-pelvic pain.
The rupture of the uterine veins can occur from the tenth week of
gestation and up to three weeks postpartum but the majority of cases
have been reported in the third trimester of pregnancy [1, 3,6].
The diagnosis of a hemoperitoneum from ruptured uterine veins
during pregnancy is a maternal and fetal emergency. Indeed, any delay
in the diagnosis and/or the therapy is associated with a considerable
risk of maternal and fetal mortality. This diagnosis, often made intra-
operatively, may be suspected in case of some biological and/or
radiological abnormalities associated with this illness. Indeed, the
blood count often shows an unexplained drop in hemoglobin [8].
Radiological investigations are based on ultrasound which is a first-
line examination to visualize and quantify the intra-peritoneal effusion
without specifying its nature. It also assesses the fetal vitality [7]. The
magnetic resonance imaging (MRI) and computed tomography
confirm, when performed, the hemorrhagic nature of effusion and
exclude many digestive, urinary and gynecological differential
diagnoses. These investigations should in no way delay the surgical
exploration in a shocked pregnant woman presenting with an intra-
peritoneal effusion [9]. In our case, the abdominal ultrasound revealed
a small intra-peritoneal effusion and when facing the rapid and
massive blood loss, a CT scan was performed because of the
unavailability of the MRI and confirmed the diagnosis of a
hemoperitoneum and eliminated any digestive, urinary or
gynecological causes for this effusion.
The differential diagnoses of a non-traumatic hemoperitoneum
during pregnancy are numerous and essentially represented by:
- The placental abruption which is the main differential diagnosis
but it is often associated with uterine contractions and vaginal
bleeding.
Citation: Fatnassi R, Mkhinini I, Torki E, Ragmoun H, Kaabia O, Hammami S, Barhoumi H, Ben regaya L (2015) Hemoperitoneum Caused by
Spontaneous Uterine Varicose Vein Rupture in the Third Trimester of Pregnancy-A Case Report. Gynecol Obstet (Sunnyvale) 5: 291.
doi:10.4172/ 2161-0932.1000291
Page 2 of 3
Gynecol Obstet (Sunnyvale)
ISSN:2161-0932 Gynecology, an open access journal Volume 5 • Issue 4 • 1000291
- The uterine rupture should be suspected especially in a parturient
with a history of scarred uterus.
Other differential diagnoses should be discussed and are
represented mainly by the placenta percreta, the hepatic or splenic
rupture in a context of severe preeclampsia, the rupture of an
aneurysm of the renal artery or the rupture of hepatic or splenic
vessels [6].
Any hemoperitoneum from ruptured uterine veins during
pregnancy is a surgical emergency. This surgery must be preceded by
an adequate maternal intensive care adapted to her hemodynamic
status. The surgery often involves a laparotomy to evacuate the
hemoperitoneum and ligate the bleeding vessels thus achieving
hemostasis. A caesarean section for the fetal extraction is discussed in
ante partum according to the maternal hemodynamic status. The
vaginal delivery is possible in case of an early diagnosis and surgical
treatment in a stabled patient with no hemodynamic shock and no
severe signs of fetal distress [10].
Conclusion
The rupture of uterine varicose veins during pregnancy is a rarely
mentioned but an extremely serious cause of hemoperitoneum. The
diagnosis is always difficult to establish because of the very few and
sometimes delayed specific clinical symptoms. Early diagnosis and
treatment are the cornerstone of the maternal and fetal prognosis. The
diagnosis is often facilitated by ultrasound which is a first-line
examination. The management is surgical which is preceded by an
adequate resuscitation. Fetal extraction is debatable depending on the
maternal and fetal state and on the gestational age.
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Citation: Fatnassi R, Mkhinini I, Torki E, Ragmoun H, Kaabia O, Hammami S, Barhoumi H, Ben regaya L (2015) Hemoperitoneum Caused by
Spontaneous Uterine Varicose Vein Rupture in the Third Trimester of Pregnancy-A Case Report. Gynecol Obstet (Sunnyvale) 5: 291.
doi:10.4172/ 2161-0932.1000291
Page 3 of 3
Gynecol Obstet (Sunnyvale)
ISSN:2161-0932 Gynecology, an open access journal Volume 5 • Issue 4 • 1000291
