Abdominal apoplexy during pregnancy

Background

Idiopathic spontaneous intraperitoneal haemorrhage (ISIH) also known as abdominal apoplexy in pregnancy is a rare clinical entity for majority of obstetricians across the globe. It is characterised by spontaneous non-traumatic haemorrhage in peritoneal cavity from unidentified source. The pathophysiology of ISIH during pregnancy is uncertain. Emerging evidence suggests that factors such as endometriosis and nulliparity, can predispose to this condition but the aetiology is still obscured in majority of reported cases.1

Chronic inflammation secondary to endometriosis is responsible for fragility of utero-ovarian vessels and the resultant adhesions may give further tension to these vessels during pregnancy. These changes with endometriosis are culprit for spontaneous haemoperitoneum in vast majority.2 3

In vitro fertilisation in patients with severe endometriosis may be a risk factor for ISIH.4

Clinical presentation of ISIH in pregnancy can vary from mild abdominal pain of uncertain nature to acute circulatory collapse compromising fetal and maternal life. High maternal and fetal mortality is observed in severe cases. Any culprit lesion is unidentified in majority of cases. High index of clinical suspicion in selected case with multidisciplinary team approach is the integral part of patient management.

We describe a rare case of ISIH in pregnancy that lead to acute circulatory collapse during caesarean section. With few case reports available to date to the best of our knowledge, we highlight the importance of its possibility in pregnancy.

Case presentation

This is a case report of a 31-year-old, gravida 2 para 1, Caucasian white woman who was diagnosed with abdominal apoplexy during lower segment caesarean section (LSCS).

The patient presented to labour ward at 37 weeks with regular painful contractions which had quickly followed on from an initial sharp, twitching pain in the left iliac fossa associated with nausea and three episodes of vomiting. She denied any history of trauma or physical or sexual activity before the onset of pain. This was her second pregnancy with spontaneous conception. She had a previous uncomplicated vaginal birth at term. She had no history of subfertility or dysmenorrhoea. The patient was booked in this pregnancy at 12 weeks under midwifery care with no significant medical, surgical or gynaecological history. She attended all of her routine antenatal visits without any event.

On general physical examination, she appeared pale and distressed with pains. Her vital signs confirmed blood pressure of 121/78 mm Hg, pulse rate of 110 beats/min, temperature of 36.5°C, SaO₂ (arterial oxygen saturation) of 98% on ambient air and respiratory rate of 16 breaths per min.

Contractions were regular about 3 in 10 min, moderate in intensity. Vaginal examination confirmed her to be in early labour. A transabdominal ultrasound confirmed footling breech presentation. After written informed consent, urgent LSCS was performed in view of fetal positioning.

A massive haemoperitoneum was identified during caesarean section, with intact uterus. A total of ~3 L of fresh blood and clots were drained from the abdominal cavity.

The liquor was clear. The baby was delivered as a breech presentation with Apgar scores of 6 and 10 at 0 and 5 min. Arterial pH was 7.01 and venous pH was 7.04. The baby did not require resuscitation and was transferred to the ward with mother. The time between presentation and delivery was 50 min. Spinal anaesthesia failed, requiring general anaesthesia.

Treatment/management

Expert obstetrical and surgical opinion was obtained with an urgent laparotomy, secondary to massive haemoperitoneum. During laparotomy, patient became haemodynamically unstable with a blood pressure of 40/20 mm Hg and a heart rate of 125 bpm. Arterial line was secured by the senior anaesthetist and massive transfusion protocol was activated as per local transfusion guidelines. She received 6 units of red cell concentrate, 4 units of fresh frozen plasma, 4 gm of fibrinogen and 2 gm of tranexamic acid.

Inspection of her ovaries, fallopian tubes, broad ligament, omentum, large and small intestine, spleen and liver did not identify any source of bleeding. After resuscitation, patient became haemodynamically stable with no further active bleeding. As bleeding had stopped spontaneously, vascular surgical input was not required. Peritoneal washout was performed. A drain was left in situ and the abdomen closed routinely. The patient was monitored in high dependency unit for next 24 hours. A CT scan including thorax, abdomen and pelvis was performed 12 hours post caesarean section to determine any potential source of active bleeding. The scan did not reveal any source of bleeding or haematomas.

Outcome and follow-up

The patient was debriefed about the events and was transferred to postnatal ward after 24 hours of monitoring in high dependency unit. She was discharged home on day 5 in well condition with haemoglobin of 10 gm/dL. A postnatal follow-up appointment was arranged to review the patient and to address her concerns. She was fortunate to survive as early identification of the problem resulted from the coincidental footling breech presentation. Urgent caesarean section was performed because of the footling breech presentation in early labour due to the risk of cord prolapse.