Introduction

The most frequent cause of gynaecological haemoperitoneum is ruptured ectopic pregnancy. Haemoperitoneum resulting after normal vaginal delivery is very rare but is associated with high maternal mortality. Only limited cases have been reported in literature with undefined etiologies. Although rare, a high index of suspicion of this condition is imperative to avoid delay in diagnosis and management.

Case Summary

A 23 years old primipara woman underwent normal vaginal delivery without any instrumentation in our hospital. After one hour of postpartum, she had acute abdominal pain and hypovolumic shock. With ongoing resuscitation, urgent sonographic profile was done which revealed free fluid with internal echoes in pelvis and left paracolic gutter extending up to the lower pole of spleen. Keeping splenic injury into strong suspicion, immediate laparotomy was done. Spleen was found to be normal on exploration. The cause of shock was a profusely bleeding left superficial uterine vessel located on the posterior uterine wall. The internal bleeding was up to 2 litres with blood clots present in left paracolic gutter and reaching up to spleen. The uterine wall was intact and not damaged. Bleeder was secured and peritoneal cavity was cleaned. Postoperatively, patient remained well and was discharged after one week of surgery in healthy condition.

Discussion

The most frequent cause of gynaecological haemoperitoneum is ruptured ectopic pregnancy. Intraperitoneal bleeding after normal vaginal delivery is very rare with undefined etiology. There is a paucity of literature in this regard. Similar case of intraperitoneal haemorrhage due to rupture of ovarian artery was reported on second day of puerperium.₁ Another case reported had delivered a healthy baby at 36 weeks and developed a syncopal episode due to hypovolumic shock. At laparotomy, a fibrous band between right fallopian tube and uterus was found to be avulsed and actively bleeding.₂ Some other causes of intraperitoneal haemorrhage after labour mentioned in literature are bleeding from a ruptured angiomyolipoma and bleeding following rupture of hepatic metastasis from unsuspected choriocarcinoma.₃ Although choriocarcinoma is known to have potential for subsequent haemorrhage at secondary sites, massive haemoperitoneum due to rupture of hepatic metastasis in postpartum period is very rare.₄

Spontaneous haemoperitoneum following rupture of spleen is known in this part of world, especially when spleen is enlarged because of some medical illness like chronic malaria. But splenic rupture in pregnant female is rare and occurs most commonly in third trimester and very rarely in puerperium.₅ The ultrasonic findings of patient in consideration were suggestive of splenic rupture for which immediate laparotomy was carried out. On exploration, spleen was intact and cause of haemoperitoneum was bleeding left superficial uterine vessel. Spontaneous haemoperitoneum because of ruptured superficial uterine vessel have been reported in pregnancy but not in the postpartum period.₆

Haemoperitoneum after normal vaginal delivery is rare but life threatening to mothers. A high index of suspicion is key to rapid diagnosis and aggressive fluid resuscitation with immediate surgical intervention provides the best prognosis.

Correspondence to

Dr. Satish Dalal 9J/54, Medical Campus, PGIMS, Rohtak-124001 (Haryana) INDIA Tel. No. +91-1262-213459, Mobile : 09315326802 E-mail : drsatishdalal@rediffmail.com