Post-Coitus Blood Loss – A Rare Reason For Apoplexy In The Abdomen

Abdominal apoplexy is an atypical condition that occurs when there is impulsive intra-peritoneal hemorrhage. Rare cases have been reported that have intraperitoneal postcoital blood loss in the absence of any related hurt or damage to the vagina.

In an uncommon case cited of a married woman in her late twenties who sought medical assistance with complaints of excruciating pain on the right side of the abdomen and vomiting. The woman had normal period cycles and had two natural deliveries. Her last delivery was five years back following which she opted for sterilization.

During the course of medical examination her appearance was noticeably pale with a pulse of ninety per minute and normal BP was 90/60 mm Hg in the vertical position. There was distension in the abdomen and on palpating deeply the doctor noted the presence of iliac fossa tenderness noted on the right side in the absence of any firmness. The bowel noises were noted to be slothful during auscultation. The bimanual pelvic exam showed the presence of an anteverted normal size uterus with motion tenderness in the cervical region. A posterior fornix felt full on examination.

An emergency ultrasound scan showed nearly two hundred millilitres of free fluid noted in the pelvis. The uterus was normal in size and endometrium displayed posterior augmentation that indicated secretory phase. Hemoglobin was noted to be low though leukocyte count, bleeding time and clotting time were observed to be normal.

The woman was diagnosed with hemoperitoneum and was sent for urgent diagnostic laparoscopy. During the procedure hemoperitoneum was observed and nearly four hundred millilitres of blood was drawn out. Uterus and both the tubes appeared normal. The active haemorrhage location was cited in the right ovary that was halted with electrocautery. There were two transversely placed rips measuring two centimetres lengthwise located at the base of the left broad ligament and were near the connection of the left uterosacral. Blue tinged bruising was seen along the perimeters of the rips with active blood loss. Some structured blood clots were additionally seen near the broad ligament that was untouched during the procedure. A peritoneal lavage was carried out and slits on the abdomen closed subsequent to securing ideal hemostasis.

This case has been illustrated to shed light on the difficulty experienced in diagnosis when the blood loss is gradual, with no associated pain and with no clear etiology. In the present case, the reason for the tears after taking into account the time of pain onset was subsequent to intercourse. In the present case, bleeding was due to ovarian tear and broad ligament rips.

In such cases the diagnosis of unexplained intra-abdominal blood loss, a past of earlier intercourse, is normally not easily acknowledged by the patient, though ultrasonography helped decipher crucial facts.

This diagnosis is to be carried out in patients with post-intercourse blood loss despite the absence of any injuries in the vulvar or vaginal region.

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