Complications of Haemoperitoneum due to Sexual Encounter in Pregnancy: A Case Study

Ni Ni Soe¹, Mon Mon Yee², Khin May Thaung³

¹Department of Obstetrics and Gynaecology, KK Women’s and Children’s Hospital (KKH), Singapore.

²Newcastle University Medicine Malaysia, Johor, Malaysia.

³Department of Obstetrics and Gynecology, Ripas Hospital, Bandar Seri Begawan, Brunei.

*Corresponding Author E-mail: nnisoe@gmail.com

ABSTRACT:

Haemoperitoneum secondary to a rupture of tortuous vessels from the serosal surface of the right uterine fundal region after coitus is a rare but life-threatening condition. This case demonstrates that even a very rare diagnosis should be considered, especially when dealing with patients with atypical presentations. This case report evidences a 31-year-old woman in her first pregnancy, presenting to our hospital triage at night for abdominal pain after sexual intercourse at a gestational age of 33 weeks and 4 days, and there was no history suggestive of endometriosis or fibroids. Apart from mild pain and slight pallor, she was stable. Her initial CTG was normal, but we noted two unprovoked decelerations about 8 and 10 hours after admission. During the morning rounds review, intra-abdominal bleeding was highly suspected and an emergency caesarean section was arranged. The on-call surgeon was also alerted, and a class I caesarean section was performed through the midline sub-umbilical incision. About 800 ml of intraoperative hemoperitoneum was noted upon opening the peritoneum. A male infant weighing 2.3 kg was delivered. Clear liquor was noted. Meanwhile, a small defect of about 1 cm in diameter with active bleeding from the underlying tortuous vessel was noted over the right posterior wall of the fundus. The underlying myometrium was intact and there was neither through nor through tear nor perforation. Discussion: The precise mechanism for postcoital haemoperitoneum due to rupture of uterine subserosal vessels is not known, but it is hypothesized that: pregnancy-with the increased friability of the tissues and fixation of the genital tract coincident with gestation; vigorous intercourse; coital positions; vaginismus and genital disproportion are the possible explanations. A complete gynaecological history, including endometriosis, fibroids, pelvic inflammatory disease, and any recent surgical procedures, is required to make a diagnosis. Ruptured ectopic pregnancy and ruptured corpus luteal cyst are on the top of the list of diagnoses in the early stage of pregnancy. The majority of such cases do not voluntarily admit the preceding act of coitus during initial presentation, and care must be taken to elicit a detailed sexual history. Interestingly, spontaneous haemoperitoneum in pregnancy complicated by endometriosis may occur during pregnancy. Conclusion: The study concludes that pregnant women with a history of the recent coitus present with acute abdominal pain, even in the absence of vaginal bleeding, haemoperitoneum has to be considered. On the other hand, idiopathic or spontaneous bleeding should be kept in mind even if there is no possible explanation.

KEYWORDS: FF, pregnancy, Coital injury, Subserosal vessels, Abdominal pain.

INTRODUCTION:

Haemoperitoneum, also known as an intra-abdominal haemorrhage or intraperitoneal hemorrhage, is a type of internal bleeding in which blood gathers in your peritoneal cavity, which is a space between your organs and the inner lining of your abdominal wall. Coitus in a pregnant woman with Haemoperitoneum can cause serious complications for mother and child. Human sexual intercourse, even biologic propagative functions, can be life-threatening and can result in serious complications of a resulting pregnancy. Researchers of the current case study recently treated a woman with haemoperitoneum that resulted from sexual intercourse.

CASE REPORT:

A 31-year-old woman presented to our hospital triage on August 23, 2021, at 18:53 hours for abdominal pain after sexual intercourse at a gestational age of 33 weeks and 4 days, without any with no history suggestive of endometriosis or fibroids. She experienced pain that started in the right hypochondrial region and then passed down to the right flank to the right iliac fossa. She claimed that her pain occurred about 10 minutes after the sexual intercourse. It was stretching in nature and gradually spread to the whole abdomen. On examination, she was in mild pain and slightly pale. Her vital signs were stable and an abdominal examination revealed a soft and lax abdomen with mild generalized tenderness without guarding or rigidity. There was no vaginal bleeding or leaking, as well as no cervical changes. The bedside scan revealed a cephalic presentation; amniotic fluid was normal; and the placenta was upper. The estimated foetal weight was 2.3 kg and no free fluid was detected.

Her haemoglobin (Hb) was 8.2 gm (9.2 gm in May). Her liver function tests, amylase, and renal panels were normal, and C-reactive protein was 7. Her initial CTG was normal and continuous CTG monitoring was arranged. Two unprovoked decelerations were noted at 02:10 and 04:01 hours, about 8 and 10 hours after admission. (Image 1)

During the morning round, she looked slightly pale, in mild distress, and tachycardiac (PR: 106/min), but her BP remained stable. She complained about pain in both shoulder tips. Abdominal examination revealed the uterus was irritable but not hard. Tenderness was noted, especially over the lower abdomen, and there was rebound tenderness and slight guarding.

Intra-abdominal bleeding was highly suspected and a class I caesarean section was carried out through the midline sub-umbilical incision. About 800 ml of haemoperitoneum was noted upon opening the peritoneum. A male infant weighing 2.3 kg was delivered. Clear liquor was noted and Apgar was 7 at birth and at 5 minutes. Meanwhile, a small defect of about 1 cm in diameter with active bleeding from the underlying tortuous vessel was noted over the right posterior wall of the fundus. The underlying myometrium was intact and there was neither through nor through tear nor perforation. (Image 2)

Image 1. (A) CTG at 02:10 (B) at 04:01(8 and 10 hours after admission).

Image 2. (A) Active bleeding from the right posterior wall of the fundus, (B) After application of hemostatic suture and dilated vessels over the cornu.

Firm pressure was applied and then an undermined suture was inserted into the base of the defect. There was no more active bleeding after the suture. An abdominal survey showed no evidence of endometriosis, and there was no more active bleeding after that. Prominent, tortuous dilated vessels were noted near the bilateral cornu of the uterine serosa. No abnormality was found apart from that. One unit of packed cell was given intra-operatively and the mother and the child recovered well and were discharged on the fourth post-operative day.

DISCUSSION:

Haemoperitoneum associated with rupture of dilated vessels over uterine serosa as a consequence of sexual intercourse during pregnancy is very rare but serious and life-threatening. If a timely diagnosis is not reached or the delay in treatment can be life-threatening for the mother and the fetus. Haemoperitoneum as a result of coital injury without associated vaginal injury is an extremely rare entity and is evidenced by only a few cases that have been reported in the medical literature to date. Haemoperitoneum after coital injuries may result from the following causes: a tear in the peritoneum over the superior aspect of the vagina and rupture of the corpus luteum cyst.

Two of the related cases were observed in one of the previous studies, and the first reported case of haemoperitoneum is in 1996 by Bernard. A 36-year-old woman experienced a sudden sharp pain in the anterior part of her chest during coitus, and within an hour the increased pain intensified and she underwent an emergency laparotomy. Approximately 1.2 liters of blood and clots were removed from the peritoneal cavity. Researchers have revealed that the only visible site of bleeding was a 1-cm tear in the peritoneum over the superior aspect of the vagina on the right side anterior to the rectum. The study also indicated that there were lateral pelvic adhesions between the vagina and rectum on the right side that were torn through the peritoneum, with consequential haemorrhage. Researchers assumed that the upward thrust of the penis elevated the vagina superiorly, tearing the adhesion that bound the vagina to the rectum posterolaterally. ¹

Their second explored study sheds light on one of the 1930 reports concerning a case of haemoperitoneum complicating sexual intercourse, in which the patient during coitus experienced abdominal pain that was unremitting. Further, the patient developed shock during laparotomy, and the right adnexa had prolapsed into the pouch of Douglas, and also a large par-ovarian cyst in opposition to a ruptured corpus luteum cyst. Researchers presumed that the penis compressed the para-ovarian cyst against the corpus luteum cyst, causing rupture. ^1.

In the recent past, Chaar A, et al., recently reported an extremely rare case of haemoperitoneum after vaginal intercourse as a result of splenic rupture in a pregnant woman. The report described how a 33-year-old pregnant woman presented at 36 weeks of gestation to the emergency with acute abdominal pain that started after vaginal intercourse. It further led to an emergency cesarean delivery for resistant hypotension and collapse. In this case, a fetus with cardiac arrest was delivered, and active spleen bleeding was identified at the spleno-colic and gastrosplenic ligament insertion. The patient had conservative treatment of the spleen and an uncomplicated postoperative course. ^2. In another study by Sterling et al., five additional cases were encountered in two medical centers. Two of these were ruptured right and left corpus luteum cysts; the third one was a laceration of the right round ligament; the fourth one was a laceration of the right ovary; and the fifth was a rupture of a left serous cystadenoma. This diagnosis should be considered in patients with haemoperitoneum after coitus. ^3. As per the above findings, nearly almost all injuries to the female genital tract occurred on the right side. Dickinson describes female genital injuries as being more common on the right because of dextrorotation of the uterus and an increased distensibility of the vagina in this area during pregnancy. ⁴

A search of the literature showed cases of spontaneous haemoperitoneum resulting from ruptured superficial uterine veins during pregnancy without proceeding coitus are extremely rare, and in 2020, Yukyoung et al. reported a haemoperitoneum in pregnancy with pre-existing endometriosis resulting from spontaneous rupture of uterine-ovarian vessels. In this literature study, a 31-year-old primigravida presented to the hospital at 27 weeks’ gestation with acute abdominal pain that started during a defecation attempt. Besides this fact, she also underwent laparoscopic surgery because of severe endometriosis and bilateral ovarian endometriomas two years previously. Active bleeding was discovered in the fragile veins of the left-posterior uterine-ovarian vessels, which were then sutured to achieve haemostasis. ⁵ In one of the 2019 literature Emmanuel reports, that a 26-year-old primigravida with twin gestation at 34 weeks presented in labour with footling breech at cervical dilatation of 5 cm and fetal tachycardia. During an emergency caesarean section, incidental hemoperitoneum of 1.1 litres as well as bleeding anterior and posterior uterine serosa veins were encountered. However, in this case, there was no history of preceding coitus. ⁶

The precise mechanism for post-coital haemoperitoneum due to rupture of uterine subserosal vessels is not known, but it is hypothesized that Pregnancy—with the increased friability of the tissues and fixation of the genital tract coincident with gestation. Vigorous intercourse may cause increased intra-abdominal pressure in the female partner and may tend to make the cul-de-sac tense and lessen the elasticity of the posterior fornix during deep penetration; Coital positions in which unusually deep penetration is experienced, such as the dorsal decubitus position with hyperflexion of the thighs and the sitting positions; Vaginismus, a shortening, and narrowing of the vaginal tube that can cause injury; Genital disproportion.^3.

The common causes of intraperitoneal haemorrhage associated with pregnancy are abortion or rupture of ectopic pregnancy, rupture of uterine scar, penetrating implantation of placenta, and rupture of corpus luteum in early pregnancy. However, intraperitoneal haemorrhage with uncommon causes has also been reported, and rare causes are associated with rupture of uterine-ovarian vessels, bleeding of varicose veins on the uterine surface, and haemorrhage of splenic vein, celioaneurysm, or hemangioma. ⁷

Patients may present a wide range of clinical signs and symptoms and are often misdiagnosed as ovarian torsion, endometriosis, acute appendicitis, and other conditions. However, a clear history of gynaecological issues such as endometriosis, fibroids, pelvic inflammatory disease, and any recent surgical procedures is essential. The diagnosis is based on a high suspicion from history, but the majority of such cases do not voluntarily admit the preceding act of coitus during initial presentation and examination. Therefore, care must be taken to elicit a detailed sexual history. Interestingly, spontaneous haemoperitoneum in pregnancy without preceding coitus must be kept in mind to prevent delay in diagnosis and management.

CONCLUSION:

From the experience of this case and literature, the haemoperitoneum should be considered if the patient presented with abdominal pain after coitus, and early suspicion of rare causes of haemoperitoneum must be kept in mind and emergent surgical management are the key to optimizing maternal and perinatal outcomes.

INFORMED CONSENT:

The author certifies that consent to write up this case as well as the inclusion of photographs was obtained from the patient.

ACKNOWLEDGEMENT:

Authors, hereby, would like to express our gratitude to all senior and junior colleagues who worked together to reach the diagnosis of haemoperitonuem and managed the case together. Our special thanks to the patient who gave the wonderful opportunity to allow to write this case study.

CONFICT OF INTEREST:

There is no conflict of interest between authors.

REFERENCES:

1. Ferrara BE, Murphy WM. The pains of love: hemoperitoneum following sexual intercourse. JAMA. 1986 Apr 4; 255(13):1708-9.

2. Chaar A, Abdallah W, Kharrat R, Nassar M. Splenic rupture after sexual intercourse in a pregnant woman: an extremely rare case. Future Science OA. 2021 Oct; 7(9):FSO741.

3. McColgin SW, Williams LM, Sorrells TL, Morrison JC. Hemoperitoneum as a result of coital injury without associated vaginal injury. American Journal of Obstetrics and Gynecology. 1990 Nov 1; 163(5):1503-5.

4. Dickinson RL. Human Sex Anatomy: a Topographical Hand Atlas. Williams & Wilkins; 1949.

5. Sim Y, Kim J, Jeong Y, Rheu C, Chae H. Spontaneous Hemoperitoneum in Pregnancy (SHiP) complicated by endometriosis: A case report. Obstet Gynecol. 2020; 4:1-2.

6. Owie E. Incidental hemoperitoneum from ruptured superficial uterine veins in twin pregnancy. Tropical Journal of Obstetrics and Gynaecology. 2018; 35(3):367-9.

7. Xu Y, Zhou Y, Xie J, Yin X, Zhang X. Intraperitoneal hemorrhage during pregnancy and parturition: Case reports and literature review. Medicine. 2019 Aug; 98(35).

Received on 10.06.2022           Modified on 15.07.2022

Accepted on 19.08.2022         © RJPT All right reserved

Research J. Pharm. and Tech. 2022; 15(8):3659-3662.

DOI: 10.52711/0974-360X.2022.00613