The Missing Culprit: Spontaneous Postpartum Hemoperitoneum With an Intact Uterus and No Identifiable Bleeding Source During Surgical Exploration

Spontaneous hemoperitoneum in the postpartum period is a rare and potentially life-threatening obstetric emergency that may present with sudden hemodynamic collapse. We report the case of a 30-year-old gravida 3, para 1, living 1, abortion 1 woman at 39 weeks of gestation with a previous lower-segment cesarean section who underwent a successful vaginal birth after cesarean (VBAC) of a healthy female neonate weighing 2.95 kg. One hour after delivery, despite stable vital signs and absence of vaginal bleeding, she developed sudden circulatory collapse with abdominal distension and hypovolemic shock. Laboratory investigations revealed severe anemia with hemoglobin of 6.7 g/dL, thrombocytopenia, and metabolic acidosis with elevated lactate levels. Bedside ultrasonography demonstrated significant intraperitoneal free fluid, and diagnostic tapping confirmed hemoperitoneum. Emergency exploratory laparotomy revealed approximately 3.8 liters of hemoperitoneum with clots. The uterus was exteriorized and systematically examined; the previous cesarean scar was intact, with no evidence of uterine rupture or dehiscence. The adnexa, broad ligaments, pelvic and retroperitoneal regions, and upper abdominal viscera were carefully examined, but no definite source of bleeding could be identified. Stepwise surgical devascularization with bilateral uterine artery ligation and descending cervical artery ligation was performed as an empirical hemorrhage-control measure. The patient received massive transfusion support, recovered satisfactorily in the intensive care unit, and was discharged in stable condition. This case highlights the importance of maintaining a high index of suspicion for spontaneous hemoperitoneum in postpartum women presenting with unexplained shock, even in the absence of vaginal bleeding.