A diagnostic challenge: spontaneous hemoperitoneum in pregnancy vs uterine rupture

ABSTRACT
Background. Spontaneous hemoperitoneum in pregnancy (SHiP) is a rare but life-threatening complication. SHiP typically presents with abdominal pain, hypovolemia, and decreased hemoglobin in later pregnancy.
Case presentation. A 38-year-old woman with a history of one prior cesarean section, and otherwise in good health, presented at 29 weeks of gestation with sudden onset of abdominal pain. Ultrasound revealed free fluid in her abdomen, raising concern for uterine rupture due to the previous cesarean section. However, a dedicated ultrasound examination ruled this out. Laparoscopy confirmed the absence of uterine involvement. The lower uterine segment was intact and was not the source of bleeding; indeed the source of bleeding was identified as a 2-cm clot in the left fallopian tube resulting on histology an endometriosis foci.
Conclusions. This case highlights the importance of considering SHiP in the differential diagnosis of acute abdomen during pregnancy, even in the absence of known risk factors because a high index of suspicion for SHiP is crucial for prompt diagnosis and intervention, aiming for optimal maternal and fetal outcomes.