Spontaneous haemoperitoneum in pregnancy complicated by a pulmonary embolus: a case report

Spontaneous haemoperitoneum in pregnancy is defined as a sudden non-traumatic intra-abdominal haemorrhage in pregnancy or the postpartum period. With an incidence of 1/25000, it has been associated with endometriosis and assisted reproductive technology, and with significant perinatal morbidity and mortality. This report describes a postpartum case of spontaneous haemoperitoneum in pregnancy complicated by pulmonary embolism. The patient, who had a history of endometriosis, underwent a ventouse birth following term induction of labour. Six hours later she developed abdominal pain and bilateral pain in the shoulder tips, associated with a drop in haemoglobin. A computerised tomography scan of the abdomen demonstrated a haemoperitoneum with no actively bleeding vessels. She was managed conservatively with blood transfusion, tranexamic acid, and analgesia. Anticoagulation was withheld due to concerns over bleeding risk. On day 4 postpartum, she developed chest pain and was diagnosed with a pulmonary embolus. Most previously reported cases occurred antenatally and required an emergent laparotomy for fetal concerns. As this case occurred postnatally, fetal well-being did not need to be considered, and non-surgical management was successfully employed. This case also highlights difficulties with decisions regarding anticoagulation in patients at high risk of both bleeding and venous thromboembolism.