Haemoperitoneum in a pregnant woman with peritoneal dialysis

Sir, Fertility is markedly reduced in patients on chronic dialysis. Estimates of the frequency of pregnancies on chronic dialysis range from 1% to 7% [ 1 ]. Among the pregnancies that are not electively terminated, only 30–50% of them result in surviving infants. This may be due to specific obstetric complications in the patients on dialysis, including polyhydramnios, pre-term labour and intrauterine growth retardation [ 2 ]. In addition, there are some specific complications of peritoneal dialysis, including peritonitis and mechanical difficulties [ 1 , 2 ]. We present a rare complication of severe haemoperitoneum in a pregnant woman on continuous ambulatory peritoneal dialysis (CAPD). The 35-year-old female had end-stage renal disease and had undergone CAPD for 1 year. She became pregnant and tolerated the peritoneal dialysis well with 1500 ml dialysate (four exchanges of 1.5% dextrose and two exchanges of 2.5% dextrose per day) after the second mid-trimester. She was adequately dialysed. She received amniocentesis at 18 weeks’ gestation due to advanced maternal age. Unfortunately, blood-tinged dialysate drainage and pre-term uterine contractions were noted after amniocentesis. She received tocolysis and the dialysate drainage became progressively clear. However, the dialysate drainage then turned bloody with continuous fresh blood draining out from the catheter on the 9th day of admission. Abdominal rebounding pain developed and haemoglobulin dropped from 8.8 to 7.4 mg/dl. Under suspicion of internal bleeding, an exploratory laparotomy was performed and revealed serosal tearing on the uterine fundus, with a well-located Tenckhoff catheter ( Figure 1 ). The tearing wound measuring 1 cm in length was bleeding actively and an 800 ml blood clot was noted in the peritoneal cavity. The primary suture failed to approximate the wound and the haemostasis was ineffective. Continuing the pregnancy seemed impossible under the condition of active bleeding. A hysterostomy was then performed to deliver a dead immature baby. The post-operative course was uneventful. The patient received haemodialysis for 2 weeks and restarted peritoneal dialysis again, 2 weeks later. A serosal tearing wound with irregular margin was noted on the uterine fundus (arrow). Active bleeding was also noted. Haemoperitoneum is an infrequent complication of peritoneal dialysis. Usually, it is the consequence of mild or severe bleeding of intraperitoneal organs [ 3 ]. The causes that have been reported included rupture of a kidney or an ovarian cyst, peritoneal calcification, disordered blood coagulation and trauma. Two cases have been described previously, where surgical intervention was needed. One case had a ruptured spleen due to the peritoneal catheter [ 4 ]. Another case was due to spontaneous liver rupture and required embolization of the hepatic artery [ 3 ]. In our case, severe intraperitoneal bleeding from the serosal tearing of the pregnant uterus led to inevitable surgical intervention. The wound may have been caused by tip of the catheter or it may have been induced by topical pressure of the tocometer. Spontaneous serosal tearing due to the enlarging uterus was another possibility. This complication of haemoperitoneum should be taken into consideration in pregnant women on CAPD. Conflict of interest statement . None declared. 1Department of Obstetrics and Gynecology2 Department of Internal Medicine National Taiwan University Hospital Taipei, Taiwan