Case Report Recurrent Hemoperitoneum During Pregnancy in Large Deep Endometriosis Infiltrating the Parametrium Emanuela Stochino Loi, MD, Basma Darwish, MD, Carole Abo, MD, Anne-Elodie Millischer-Bellaiche, MD, Stefano Angioni, MD, PhD, and Horace Roman, MD, PhD* From the Department of Gynecology and Obstetrics (Drs. Loi, Darwish, Abo, and Roman), Rouen University Hospital, Rouen, France, Imaging Medical Center (Dr. Millischer-Bellaiche), Paris, France, Department of Surgical Sciences (Dr. Angioni), Cagliari University Hospital, Cagliari, Italy, and Research Group 4308 ‘‘Spermatogenesis and Gamete Quality’’, IHU Rouen Normandy, IFRMP23, Reproductive Biology Laboratory (Dr. Roman), Rouen University Hospital, Rouen, France. ABSTRACT We present the case of a young woman at 16 weeks’ gestation who presented to a peripheral hospital with severe recurrent hemoperitoneum related to severe deep endometriosis infiltrating the left parametrium. She underwent 2 surgical open pro- cedures in emergency, followed by pregnancy loss. Deep endometriosis infiltrated the rectum, the vagina, and the left para- metrium, leading to stenosis of the left ureter and advanced destruction of the left kidney. Ovarian reserve was low with an antimullerian hormone level at .6 ng/mL. To improve endometriosis-related symptoms and preserve fertility, a laparoscopic conservative rectal and ureteral management was proposed with an aim to relieve symptoms, avoid further destruction of the left kidney, preserve the right splanchnic nerves and inferior hypogastric plexus, and enhance spontaneous conception. We performed a combined vaginal–laparoscopic approach that consisted of vaginal infiltration resection, adhesiolysis, rectal shaving, ureterolysis, and restoration of the permeability of the fallopian tubes. Seven months after surgery the patient spon- taneously conceived and is doing well. Journal of Minimally Invasive Gynecology (2016) 23, 643–646 Ó 2016 AAGL. All rights reserved. Keywords: Colorectal endometriosis; Deep endometriosis; Hemoperitoneum; Pregnancy; Shaving; Ureteral endometriosis; Ureterolysis Although pregnancy is generally associated with regres- sion of endometriosis-related symptoms, spontaneous he- moperitoneum during pregnancy may occur as a rare and severe complication. We present a case of a massive sponta- neous recurrent hemoperitoneum in a pregnant woman with deep endometriosis infiltrating the rectum, the left parame- trium, the left ureter, and the vagina and discuss complete management of her severe disease. Case Report A 26-year-old gravida 2 para 0 with a single pregnancy at 16 weeks’ gestation was admitted with severe brutal pelvic pain to the emergency department of a peripheral hospital. Abdominal and pelvic ultrasonography showed a volumi- nous intra-abdominal fluid collection. Emergency laparos- copy revealed the presence of a massive hemoperitoneum, with rapid aspiration of 3000 mL of blood. The intervention was then converted to an open procedure by a midline skin incision. Pelvic exploration revealed the existence of an active hemorrhage originating from the left parametrium, which was infiltrated by a large 5-cm endometriosis nodule involving the left uterine artery and the posterior wall of the uterus and the left uterosacral ligament. Complete hemosta- sis was achieved by several interrupted sutures performed on both the left uterine parametrium and uterine vessels. The patient was transfused 4 units of packed red blood cells dur- ing the procedure. She was then transferred to the intensive care unit postoperatively. Dr. Roman reports personal fees for participating in a symposium and a masterclass presenting his experience in the use of PlasmaJet. The authors declare that they have no other conflicts of interest. Corresponding author: Horace Roman, MD, PhD, Department of Gynecol- ogy and Obstetrics, Rouen University Hospital-Charles Nicolle, 1 rue de Germont, 76031 Rouen, France. E-mail: horace.roman@gmail.com Submitted November 17, 2015. Accepted for publication January 21, 2016. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2016 AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2016.01.018