Aust. Nz J Obsret Gynaecol 19%: 3 6 4 490

Acute Massive Haemoperitoneum Due to Mild Pelvic Endometriosis

Sailesh Kumar' Department of Obstetrics and Gynaecology, King Edward Memorial Hospital for Women,

Perth, Western Australia

EDITORIAL COMMENT: This is a strange case and informs us that bleeding fmm endometriosis can be life-ihreatening. We are given no clue concerning the apparently ermneous ulirasonographic finding of a 9 x 5 x 4 cm adnexal mass, the presence of which was not confirmed at laparotomy. Our reviewer commented that a haemoperi- toneum without adequate explanation requires careful exclusion of upper abdominal pathology such as ruptured spleen or haemorrhage from a splenic artery aneurysm which are well-documented causes of morbidily and death in obstetrics and gynaecology.

Endometriosis may present with a variety of symptoms, however it is rare that it presents as an acute abdomen, and when it does it is usually due to a ruptured endometriotic cyst. A case of acute massive intraabdominal haemorrhage from bleeding endomet- riotic peritoneal deposits is presented here. To the author's knowledge this has never previously been reported.

CASE REPORT A 25-year-old nullipara f i t presented with lower

abdominal pain of 3 days duration, increasing in severity on the day of admission. The pain was constant and localized mainly in the suprapubic region and left iliac fossa. There was no history of vaginal discharge or bleeding or of shoulder tip discomfort.

She had had a laparoscopy 20 months previously for the investigation of irregular painful periods. This was normal and she was subsequently prescribed the contraceptive pill to be taken continuously for 3 months at a time which resulted in regular 3-monthly periods. Her dysmenorrh0e.a improved on this therapy. Her last period had been 10 weeks previously. A pregnancy test was negative.

On examination she appeared well. Her pulse and blood pressure were normal and she was not pale. The abdomen was generally soft with moderate tenderness suprapubically and in both iliac fossae. There was no guarding or rebound tenderness. Vaginal examination revealed a small uterus and tender left adnexa. No masses were felt. A provisional diagnosis of retrograde tubal bleeding or an ovarian cyst accident

I . Senior Registrar. Address for correspondence: Lh Sailesh Kumar, King Edward Memorid Hospital for Women. 374 Bagol Road, Subiaco, Perth 6008.

was made and the patient was admitted for observation. A transvaginal ultrasound done the next morning revealed a small anteverted uterus with a 3 mm thick endometrium. A mass of mixed echogeni- city occupying the Pouch of Douglas (POD) and left adnexal region measuring 9 cm x 5 cm x 4 cm was noted. The right ovary measured 3 cm x 2.6 cm and the left ovary was not visualized. Free fluid was seen in both flanks. The appearance of the scan was consis- tent with a haemorrhagic left ovarian cyst.

Twenty hours after admission there was a marked deterioration in the patient's clinical condition. She became pale and tachycardic and experienced 2 hypotensive episodes which responded to intravenous fluids. Her abdomen became distended with guarding and rebound tenderness over the entire abdomen. Her haemoglobin value had fallen from 1 1 g d n to 8.3 gdn. The coagulation profile was normal.

At laparotomy she was found to have 1.3 litres of frank blood in the abdominal cavity. The uterus, Fallo- pian tubes and ovaries appeared entirely normal. There was no ovarian cyst or any evidence of a recently ruptured cyst. There was active bleeding from classical endometriotic deposits in the POD and along both uterosacral ligaments. These were electro- cauterized and haemostasis was secured. There were also a few other foci of endometriosis in the ovarian fossae. The rest of the abdomen was normal.

She was transfused 2 units of blood and made an uneventful postoperative recovery. She was dis- charged after 5 days and advised to take the oral contraceptive pill cyclically.

DISCUSSION Endometriosis is a very common condition found in

up to 30% of women in the general population, but there is a higher incidence in infertile women. It may be completely asymptomatic, diagnosed inci- dentally at laparoscopy, or present with menstrual

SAILESH KLMAR 49 1

irregularities, dysmenorrhoea, dyspareunia and pelvic pain. Other rarer presentations have been described including cyclical epistaxis and umbilical nodules. The symptoms are thought to be caused by cyclical microscopic bleeding into the endometriotic deposits. There is no correlation between the extent of pelvic endometriosis and symptomatology as patients with minimal and mild disease may be severely incapa- citated whereas patients with extensive disease may report a paucity of symptoms (1).

Retrograde menstruation can cause blood-staining of the peritoneal fluid and is also implicated in the aetiology of endometriosis when there is implantation and growth of viable endometrial tissue in the peritoneal cavity (2). Large bloody ascites in asso- ciation with pelvic endometriosis has been reported in the English medical literature although the number of cases are few (3). Why ascites complicates endometri- osis in these patients is not clear, although Bernstein et a1 (4) hypothesized that endometrial cysts could rupture, releasing blood and cells within the peritoneal cavity. Subsequent serosal inflammation would result in ascites. Experimentally, haemoperitoneum has also been induced in the rhesus monkey with endometri- osis (5). Intraabdominal bleeding from uterine adenomyosis analogous to this case has been reported (6); however in this case there was an exudative haemorrhage from the uterine serosal surface into the peritoneal cavity which was later shown to be due to adenomyosis. Cases of frank intraperitoneal

haemorrhage from endometriosis are usually due to a ruptured ovarian endometrioma.

It appears uncertain how endometriosis developed in this patient while she was taking the oral contraceptive pill, as the pill taken continuously is supposed to have a suppressive effect on endometri- osis. This case is unique in that a clinically significant massive intraabdominal haemorrhage resulted fmm minor pelvic endometriotic deposits. Although the bleeding was easily controlled, the situation could have been different if the endometriotic deposits had been more extensive or in more inaccessible areas. Acknowledgement

advice in reviewing this case. I wish to thank Dr Panos Maouris for his help and

References 1.Speroff L, Glass RH, Kase NG. In Clinical Gynaecologic

Endocrinology and Infertility. 1989 4th Edition, Waams and Wxlkius, 547-563.

2.Sampson JA. Peritoneal endometriosis due to menstrual dissemination of endometrial tissue into the peritoneal cavity. Am J Obstet gynecol 1927; 1 4 422.

3. El-Newihi HM, Antaki JP, Rajan S, Reynolds TB. Large bloody ascites in association with pelvic endometriosix case report and literainre review. Am J of Gastroenterology 1995; 90: 632-1534.

4. Bernstein JS, Perlow V, Brenner JJ. Massive ascites due to endometriosis. Am J Dig Dis 1961; 6: 1-6.

5. Scbiffer SP, Cary CJ, Peter GK, Cohen BJ. Hemoperitoncum associated with endome~osis in a rhesus monkey. J Am Vet Med Asscc 1984, 185: 1375-1377.

6. Fujino T, Watanabe T, Sbinmura R, Hahn L, Nagata Y, Hasui K. Acute abdomen due to adenomyosis of the uterus: a case report. Asia-Oceania J Obstet Gynaecol 1992; 1 8 333-337.