Acute abdomen in pregnancy with endometriosis

Sir, I would like to call attention to the case of a 34-year-old primipara, at 32 weeks of pregnancy, with a history of surgery for ovarian endometriosis (stage IV), who presented with a subacute abdominal condition and hemoperitoneum due to loss of integrity of the uterus at the site of a prior endometriosis surgery scar. She had prior laparoscopic surgery in 2005, when two ovarian endometriotic cysts, prolapsed into the pouch of Douglas, were seen along with endometriotic foci on the pelvic peritoneum and thick adhesions on the posterior wall of the uterus from the level of the isthmus down to the pouch of Douglas, surrounding the two ovaries and extending to the rectosigmoid wall. The lesions were coagulated and excised as possible removing the adhesions with a bipolar probe and scissors, paying attention not to create damage to the intestinal loop by cutting closer to the uterine wall. Histological examination confirmed endometriosis. Now, an ultrasound scan before pregnancy had shown a small endometriotic cyst on the right ovary. She had been sent from a nearby hospital because of sudden, acute pain in the right adnexal area, which had spread over the abdomen, causing difficulty in breathing. On arrival, an electrocardiogram, obstetric examination, ultrasound for fetal well-being and growth and cardiotocography were all normal and SpO2 was 98%. Abdominal examination provoked pain and Murphy's sign was positive. General abdominal ultrasound, with the differential diagnoses of appendicitis, torsion or rupture of ovarian cyst or placental abruption in mind, showed free fluid. With a fall in hemoglobin in only two hours from 9.4 to 6.9 g/dl and hematocrit from 29.4 to 21.1%, a low blood pressure (90/50 mmHg) and maternal tachycardia (110 bpm), intra-abdominal bleeding was suspected. Just before emergency surgery the patient's condition worsened, with early signs of shock. She was given betamethasone. During surgery, about 4 litres of blood were evacuated. A cesarean section was carried out. In the posterior wall of the uterus, at the level of the lower segment, there was a loss of integrity involving about two-thirds of the wall thickness from the outside, with widespread bleeding also around the intestinal adherences and the right tube. The uterine lesion was stitched. Hemostasis of all superficial intestinal and tube bleeding was performed. Two possible causes of the bleeding can be considered, that is, that the uterus had put pressure on the intestinal adherences during pregnancy causing their partial detachment, or a near fall the previous evening, when the patient executed a very sudden movement to regain balance, without actually hitting anything. On detachment of the intestinal adherences bleeding could have started with consequent acute pain the following morning before admission. A reduction in the thickness of the posterior uterine wall might have been the result of her previous surgery and/or the scar may have stretched and ruptured. Acute abdomen in the later stages of pregnancy is dangerous and fetal distress and preterm delivery may occur (1). Uterine rupture is rare but when it occurs, it is generally associated with prior uterine surgery, trauma, abnormal placentation or induction of labor. Spontaneous rupture during the second trimester is particularly rare (2), as is spontaneous rupture of uterine vessels (3). Previous endometriotic surgery involving the uterus must be kept in mind in such cases.