A Case of Maternal and Fetal Death by Idiopathic spontaneous intraperitoneal hemorrhage in a nulliparous Pregnant at the Second Trimester.

Abstract

Background: Spontaneous intraperitoneal hemorrhage is a rare and potentially fatal condition historically known as "abdominal apoplexy". It refers to the non-traumatic and non-iatrogenic rupture of one or more small splanchnic vessels causing massive abdominal bleeding. In general, hemoperitoneum can be associated with various causes, however, in other cases, known as spontaneous hemoperitoneum during pregnancy, the etiology remains unidentified.

Case report: The case of a 33-year-old, otherwise healthy and with no traumatic history, primigravida-23-week pregnant is presented. It dealt with a suddenly developed shock status, during a dinner in a public place. At Emergency Service arrival, she was already dead. A judicial autopsy was decided, in suspect of a rescue delay. The full autopsy showed a massive hemoperitoneum, with no origin of hemorrhage; the histological examination confirmed the hypovolemic shock with hypoxic-ischemic suffering of the intestinal mucosa. In conclusion, the cause of death was attributed to a hypovolemic shock due to idiopathic spontaneous intraperitoneal hemorrhage. Any responsibility in Rescue Emergency was excluded.

Discussion: In similar cases of unknown bleeding etiopathogenesis, the hypothesis is that the repeated distension of the vessels during pregnancy, together with defects or thinning of the vascular wall, predisposes to its rupture, causing bleeding with no identifiable origin, probably involving branch of the celiac axis. The present case suggests the need to consider the diagnostic suspicion of this condition when atypical and unrelated symptoms in pregnant women appeared. To the best of our knowledge not many cases reported as much ble-eding as in this case whereby the bleeding point was obscured. As a result of these assessments, the liability of healthcare professionals was excluded. Therefore, in all analogous cases the autopsy, clinical or judicial, is mandatory both for the analysis of the process as a tool for risk management, and for the economic evaluation from a medico-legal perspective.