Endometriosis as a Reason of Intraabdominal Bleeding in Pregnancy. Clinical Case

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Abstract


The article defines the significance and relevance of the problem of endometriosis during pregnancy. 10% of women in the reproductive period have different localization of endometriosis. 25% of pregnancies with endometriosis are complicated by preterm labor. The article presents a clinical case of intra-abdominal bleeding in a 28-year-old pregnant woman with retrocervical endometriosis at gestation age of 32 weeks and 6 days. The article covers the results of examination and special diagnostic procedures of intra-abdominal bleeding in pregnant women with retrocervical endometriosis. The main diagnostic methods were the study of past medical history, ultrasound examination, and laboratory tests. Due to their infrequency during pregnancy internal bleedings present difficulties in their diagnosis. Ultrasound reliably revealed a large amount of fluid in the abdominal cavity and small pelvis and excluded the presence of intrauterine bleeding. Clinical and laboratory tests indicated the severity of the patient's condition. Symptoms of moderate fetal distress were also identified. Therefore, a decision was made about an emergency delivery by the cesarean section followed by an abdominal revision. During the cesarean section, 500 ml of blood in the form of dark blood clots was found in the abdominal cavity. The condition of the premature newborn was in conformity with his gestational age. The source of bleeding were the of endometriosis on the back wall of the uterus. These focuses most likely caused hemoperitoneum. The revision of the abdominal cavity did not find any other foci of bleeding. The postoperative period was uneventful. The article provides general guidelines for the management of pregnant women with severe forms of endometriosis.


According to the World Bank’s statistical group, every 10 women of reproductive age suffer from endometriosis, that is, 176 million women aged 15 to 49 years. The statistics makes it possible to classify this pathology as an epidemic and include it in the group of national security threatening diseases. As a result of surgical treatment, 20-53% of women restore fertility. The recurrence rate is high, up to 40%, the risk of miscarriage is 30-50%, the frequency of premature labor is 25%, and the frequency of cesarean section is 35%. There is a high risk of placenta previa [1]. The leading causes of endometriosis risk during pregnancy are not known in most cases. Nowadays, endometriosis is the major risk factor for the development of spontaneous hemoperitoneum during pregnancy, which is associated with the rejection of highly vascular endometrioid tissue, induced by low levels of progesterone [1-4]. It is believed that coagulation of endometriosis foci in the uterine isthmus or surgical excision of the rectovaginal lesion can weaken the posterior wall of the uterus, and therefore the uterus is at risk of rupture during pregnancy or labor [1, 3, 5]. According to the American Fertility Society, if external endometriosis is detected during laparoscopy, it is necessary to determine the stage of its spread [6, 7]. Case Report Patient D., 28 years old, a resident of the city, married, having a job. She has chronic iron deficiency anemia. Obstetric and gynecological history: menstrual function is not impaired. She started her sexual life at the age of 23. Endometrioid cyst of the left ovary was detected in 2016. Operative laparoscopic treatment for external genital endometriosis stage IV (endometrial infiltration of the sacro-uterine ligaments and recto-vaginal septum, sigmoid endometriosis, pelvic peritoneum, endometrioid cyst of the left ovary) was made in 2017 at Federal State Budgetary Healthcare Institution named V.A. Almazov. Endometrioid infiltration of the recto-vaginal septum and sigmoid colon infiltration were excised. Ovariocystectomy on the left was performed. The result of histological examination: fibrous and adipose tissue with foci of endometriosis. Medication: Visanne for 6 months. The patient received informed consent to the processing of personal data. The current pregnancy was under medical supervision since the 8th week. At 6 weeks - threat of spontaneous abortion, infection of the genital tract. Treatment received: progestin (Duphaston 20 mg per day) up to 12 weeks. Ultrasound at 12.1 and 20.1 week was normal. Her Exchange Card did not contain summary from the history of the disease or the protocol of surgical treatment at the Federal State Budgetary Healthcare Institution named V.A. Almazov. 09.15.2018, at 11 am 40 min. she was taken by ambulance to the emergency room of the Republican Perinatal Center (RPC) to exclude obstetric pathology with a diagnosis of: Pregnancy 32 weeks 6 days. Syncopal state? Patient was examined by the doctor of the emergency room. The patient complained of lightheadedness (presyncope), which appeared at home at 10 am, after an act of defecation, accompanied by vertigo, nausea, followed by a short-term loss of consciousness (syncope). The lower abdomen not painful, no pathological secretions from the genital tract. The movement of the fetus was felt well. Clinical condition. In full awareness. The skin is clean and pink. Pulse is rhythmic. Heart rate - 80 bpm. Blood pressure - 100/60 mm. Body temperature of 36.5 °C. The abdomen is enlarged due to the pregnant uterus, soft, painless on palpation. No symptoms of peritoneal irritation. The tone of the uterus is normal, painless palpation. The position of the fetus is longitudinal, presents the head, is mobile above the entrance to the small pelvis. The fetal heart beat is clear, rhythmic, 140 bpm. The portable ultrasound did not find convincing data on placental abruption at the time of the examination. Considering the previous vertigo and syncope, she was referred to an emergency medical care hospital to rule out acute vascular and neurological disorders. From 11 am 50 min up to 14 am 40 min in the emergency room she was examined by a general practitioner, neurologist, and surgeon. Complete blood count - anemia I degree. Urinalysis - leukocyturia. ECG - sinus rhythm. The conclusion of the neurologist: no data received for cerebrovascular accident, subarachnoid hemorrhage, brain masses, or acute infection of the brain. Surgeon: acute cystitis, urinary tract infection. General practitioner: urinary tract infection, pregnancy 33 weeks, threat of termination of pregnancy, mild anemia of pregnancy. Sodium chloride solution was started. The patient was sent back to the RPC by ambulance. At 14 am. 50 min. she was taken to the emergency room of the RPC. Complaints of severe weakness and vertigo persist; her general condition worsens in an upright position. Headaches, vomiting, visual disturbances are not present. In full awareness. General condition of moderate severity. Pulse is clear, rhythmic, heart rate 88 bpm. Normal breathing, no wheezing. Blood pressure is 100/60 - 95/55 mm. Respiratory rate is 18 per minute. The abdomen is soft, is involved in the act of breathing, sensitive to palpation above the womb. The tone of the uterus is normal, painless palpation. Fetal heart beat is clear, rhythmic, 140 bpm. Amniotic fluid are intact. There are no abnormal secretions. Internal examination: the birth canal is saved, the vaults do not hang, examination is painless. Taking into consideration the condition of the pregnant woman, an ultrasound of the fetus, placenta and abdominal cavity was performed urgently to clarify the diagnosis. US: pregnancy 32 weeks 6 days, Doppler - reduction of the compensatory capacity of the fetus due to episodes of bradycardia up to 100 bpm; no signs revealed for placenta abruption; significant amount of free fluid In the abdominal cavity; kidneys and liver are normal. Blood count: mild anemia (decrease in hemoglobin from 103.0 G/l to 96.0 G/l, hematocrit 25.5%), leukocytosis 26.8 G/l). Blood biochemical parameters within the normal range. The urine protein is 0,26 g/l, urinary sediment is normal. Diagnosis: Pregnancy 32 weeks 6 days. Burdened gynecological history. Fetal hypoxia. Intra-abdominal bleeding? Chronic iron deficiency anemia. Endometrioid disease. Mild myopia. Because of the signs of intrauterine hypoxia of the fetus and suspicion of intra-abdominal bleeding, a cesarean section is urgently indicated; it is expected that the surgery will be expanded and, possibly, require participation of general surgeons. Surgery. Middle and lower median laparotomy. Cesarean section. Drainage of the abdominal cavity. Endotracheal anesthesia. After laparotomy, we found 500 ml of dark-bloody clot and liquid blood in the abdominal cavity. The source of the bleeding was not clear yet. A pregnant uterus appeared in the wound. The walls of the uterus are pink, not changed, adhesions are not pronounced. Keru-Gusakov hysterectomy was performed. Amniotic fluid was light. Alive premature girl with was extracted for the head. Weight is 2080,0 gr., length is 44 sm, Apgar score is 4/6. Carbetocin 1.0 ml IV was preventively administered. The placenta was separated and removed. Placental bed was on the back wall. The walls of the uterus are intact, the uterus without disturbances. The uterus is sutured, reduced, removed in the wound. A moderate adhesive process was found along the back wall in the region of the lower segment between the uterus and sigmoid colon. There, on the wall of the uterus, 2 lesions of endometriosis were found with sizes of 2.0 ´ 3.0 and 2.0 ´ 1.5 cm with large bleeding vessels. Hemostasis was performed by suturing, Hemoblock was used, and the bleeding was stopped. Surgeons performed a revision of the abdominal organs, other sources of bleeding were not identified. There are small foci of spread endometriosis on the uterine adnexa, intestines and peritoneum. Total blood loss was 1200 ml. In the postoperative period: moderate anemia. The patient received iron IV. Ultrasound of the pelvic organs was normal. The postpartum period was uneventful. On the 6th day, the patient and the newborn were transferred to the neonatal ward of the children's hospital to continue the treatment of the baby. Conclusions The diagnostic process of external forms of endometriosis is extremely difficult. Pregnant women with endometriosis have a high percentage of various complications. Complications such as spontaneous hemoperitoneum, intestinal perforation, and uterine rupture are life-threatening, infrequent and unpredictable. These patients should be assigned to a high risk group and observed in specialized hospitals. It is mandatory to include in pregnant women’s Exchange Cards the data on endometriosis from their past medical history, protocols of surgical interventions for endometriosis or any other surgical intervention.

Y. A. Revzoeva

Republican perinatal center

Author for correspondence.
Email: Shakurova.ru@mail.ru
Republic of Karelia, Petrozavodsk, Russia

E. Y. Shakurova

Republican perinatal center

Email: Shakurova.ru@mail.ru
Republic of Karelia, Petrozavodsk, Russia

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