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Spontaneous rupture of utero-

ovarian vessels in pregnancy

Prithiviraj, final year MBBS


Govt omandurar medical college
Chennai
Dr.Kasthuri M.D,D.G.O, (Professor)
Dr. Sowmya M.D. (Asst. Professor)
Introduction
 Spontaneous rupture of utero ovarian
vessels is a potentially lethal complication
of pregnancy
 There are three types of rupture mainly -
intraperitoneal,retroperitoneal and
combination of both.
 Though it is said to be seen as early as
10th week of gestation,but most commonly
observed during 3rd trimester of
pregnancy
 50 % cases are found in primigravida and
over 60 % are related to labour
 Maternal mortality rate ranges from
10 to 40 %
 Perinatal mortality rate are high as 30 %
Case report
 A 29 yr old ,G2P1L1 ,came to our
emergency department with complaints
of lower abdominal pain at 37 weeks of
gestation
 Her antenatal period was uneventful
 No history of bleeding per vaginum
 No history of draining per vaginum
 No history of recent abdominal trauma
 No history of pelvic surgery
General Examination
 Pallor was present
 Hemodynamically stable with blood
pressure of -120/70 mmhg and pulse rate of
102 bpm.
Obstetric examination
 The size of uterus corresponds to 36
weeks of gestation
 Not acting ,not tense , tender
 head is mobile
 Fetal heart rate - 186 beats / minute
 Per vaginal examination - cervix
uneffaced,OS closed,head is above the brim
,pelvis Gynecoid
 No active bleeding /draining per vaginum
Ultrasonogram
Intraperitoneal collection was seen
Single cephalic fetus
Fetal movement present
Fetal tachycardia
Placenta anterior and not low lying
Amniotic fluid index of 10
No sign of abruption
Laboratory analysis
 Hemoglobin level was found to be 6.9 g/dl
 Bleeding time and clotting time is within
normal limit
 Other investigation within normal limit.
Management
 Emergency laparotomy was performed
immediately under suspicion of
hemoperitoneum.
 Intraoperative Finding - hemoperitoneum of
1000 ml and clots of 300 gram.
 The fetus was delivered via lower segment
caeserian section.
 On careful exploration of the pelvic cavity, a
rupture of left utero ovarian vessels, a tear in
the left latero-posterior uterine wall and
marked adhesion between uterus and left
ovary.
 No communication between tear and
uterine cavity was found
 No signs of underlying condition for
adhesion such as endometriosis was found.
 Assistance of general surgeon was
requested.
 The exploration of abdominal cavity was
done to rule out the other cause of
hemoperitoneum.
 Adequate haemostasis was achieved by
suturing .
 The estimated blood loss was 2 liters
 4 units of red cell and 4 units of FFP
Where transfused perioperatively
 The patient was shifted to intensive care
unit
 Postoperative period was uneventful and
the patient was discharged on the 9 th
day after admission
Discussion
 Spontaneous rupture of utero ovarian
vessels during pregnancy is such a rare
complication that is not mentioned in the
standard textbook

Etiology
 Arteriovenous malformation
 Uterine artery aneurysm
 Endometriosis
 Increase in venous pressure
 Free anastomosis of uterine and ovarian
vessels within broad ligament
 Absence of valves of ovarian veins and
weakness of vessels
Presenting symptoms
 Acute onset abdominal pain
 Maternal hypovolemic shock
 There is no revealing hemorrhage
 Marked decrease in hemoglobin and
hemotocrit is a common finding
Hurdles in diagnosis
 During labour,pain can be subjective
 Hypotension can be attributed
erroneously to uterine rupture
Differential diagnosis
 Abruption placenta
 Uterine rupture
 Abdominal pregnancy
 Spontaneous rupture of maternal
umbilical vein or aneurysmal vessels
 Rupture of liver,spleen
 Appendix rupture
 HELLP syndrome
Diagnosis
 Mostly done during laparotomy
 Preservation of an intact preterm
pregnancy is essential.
 In our case , the patient presented with a
mild abdominal pain and was
hemodynamically stable with normal findings
in her physical examination
 The gravity of the situation was realised by
seeing the low hemoglobin value
 After which immediate laparotomy was
performed and confirmed hemoperitoneum
,revealing intraperitoneal bleed.
 Although haemostatic sutures were
applied to the bleeding site ,extensive
bleed had made haemostasis extremely
difficult
 a rapid and fortunate recovery was
registered.
Conclusion
 This is a case of hemoperitoneum in
pregnancy resulted from spontaneously
ruptured utero ovarian vessels.
 After having encountered such a rare
condition with an atypical presentation, we
feel the need to consider a more rigorous
fetal and maternal monitoring in case of
nonspecific maternal abdominal pain.
References
 William's JW, intrapelvic hematoma following labour
not associated with lesion of uterus. Am J Obstet
1904
 Giuliani S,Zanin R,Volpe A. Hemoperitoneum in
pregnancy from a ruptured varic of broad
ligament.Arch gynecological on-set 2010
 Mantymaa MI,Ekblad U spontaneous rupture of liver
during pregnancy .Ann Chir Gynaevol supply 1994
 Steinberg LH,Goodfellow C, Rankin L.spontaneous
rupture of the uterine artery in pregnancy .Br J obst
gynaecol 1993
 Aziz U,kulkarni A,Lazic D et al .spontaneous rupture
of uterine vessels in pregnancy.obst gynaecol 2005