Article, Gynecology

A healthy young woman with massive hemorrhagic ascites

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American Journal of Emergency Medicine

journal homepage: www. elsevier. com/ locate/ajem

A healthy young woman with massive hemorrhagic ascites?,??,?,??,???

Abstract

Retrograde menstruation is the backward movement of menstrual fluids. The underlying mechanisms remain unknown. The converse current itself is benign, but the result can be abdominal pain caused by peritoneal irritation and, eventually, endometriosis. The case was of a 25-year-old woman with lower abdominal pain accompanied by sig- nificant hemoperitoneum. Physical examination and inspection using Abdominal ultrasonography and computed tomography failed to reveal a differential diagnosis. Detailed History taking revealed sexual activities during her menstrual period, which allowed for a diagnosis of retro- grade menstruation. These findings emphasize the importance of exten- sive history taking.

Retrograde menstruation is the backward movement of menstrual fluids through the fallopian tubes into the peritoneal cavity. It is impli- cated as a cause of endometriosis [1], although the precise pathogenesis remains unknown [2]. The backward flowing blood volume changes throughout the menstrual cycle, peaking during ovulation [3]. The blood volume can be slightly greater in women with endometriosis than in those without [4]. Retrograde menstruation clinically pre- sents as benign hemoperitoneum, but abdominal pain and fever caused by peritoneal irritation can occur. A differential diagnosis is therefore essential in emergency departments, and determining a history of symptom recurrence with every menstrual period is helpful in the differential diagnosis [5]. Here, we report a patient with abdominal pain and hemoperitoneum after sexual intercourse during menstruation.

A 25-year-old woman was admitted to the emergency department with a 2-day history of fever, nausea, and lower abdominal pain. She had irregular menstrual cycles without hypermenorrhea. Her menstrual period had begun 2 days before admission. She denied insect bites, trau- ma, travel, new medication, or disease exposures. On admission, she was in distress with a blood pressure of 99/61 mm Hg, pulse rate of 82 beats per minute, respiratory rate of 28 breaths/min, and temperature

? Financial disclosure: None of the authors has any conflict of interest to disclose.

?? Conflict of interest: The authors declare no conflicts of interest.

? Acknowledgment: We would like to acknowledge Mrs Takako Sakamaki for

her assistance.

?? Consent: Written informed consent was obtained from the patient for publication

of this case report and any accompanying images.

??? Authors’ contributions: RI, YK, NT, and MY contributed to patient management. FK

drafted the initial manuscript. RI, SN, and NY critically reviewed the manuscript. All of the authors have provided written consent for publication.

of 99.86?F. Her abdomen was soft and flat, with epigastric tenderness but without cervical motion tenderness. Transabdominal sonography revealed massive hemorrhagic ascites in the Douglas pouch, and transvaginal sonography was performed immediately (Fig. 1). There was no evidence of Pelvic inflammatory diseases, ovarian rupture, cysts, endometriosis, or Ectopic pregnancy. A qualitative human chori- onic gonadotropin test was negative. An abdominal computed tomogra- phy (CT) scan demonstrated no signs of organ injury or inflammation (Fig. 2). Additional history taking revealed sexual intercourse during menstruation. Retrograde menstruation exacerbated by sexual inter- course was diagnosed. The patient’s condition and hemorrhagic ascites improved without treatment.

To best of our knowledge, this is the first case of massive hemor- rhagic ascites with retrograde menstruation. A finding of he- moperitoneum can aid differential diagnoses of abdominal pain in emergency departments. For female patients, lower abdominal pain can suggest reproductive system diseases such as pelvic in- flammatory diseases, ovarian rupture, cysts, endometriosis, or ec- topic pregnancy. Abdominal ultrasonography and CT are often effective for diagnosis [6,7], but they failed to reveal a diagnosis in this case. Although history taking is less sensitive than diagnostic imaging for making diagnoses, this case highlights the importance of extensive history taking. It also suggests the importance of con- sidering retrograde menstruation as a differential diagnosis in cases of abdominal pain.

Image of Fig. 1

Fig. 1. Transvaginal sonography with visualization of the uterus (*), urinary bladder (+), and hemorrhagic ascites (arrow).

Image of Fig. 2

Fig. 2. An axial abdominal CT scan demonstrating the urinary bladder (+), ovaries (arrow- heads), and massive hemorrhagic ascites (*).

Nobuhiro Takaya, MD

Department of Emergency and Critical Care Medicine, JR Tokyo General

Hospital, Yoyogi, Shibuya-ku, Tokyo, Japan

Miyuki Yamamoto, MD Susumu Nakajima, MD, PhD Naoki Yahagi, MD, PhD

Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku

Tokyo 113-8655, Japan

http://dx.doi.org/10.1016/j.ajem.2015.04.039

References

Fumiaki Kishino, MD

Department of Emergency and Critical Care Medicine, JR Tokyo General

Hospital, Yoyogi, Shibuya-ku, Tokyo, Japan

Ryota Inokuchi, MD, PhD? Yohei Komaru, MD

Department of Emergency and Critical Care Medicine, JR Tokyo General

Hospital, Yoyogi, Shibuya-ku, Tokyo, Japan Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan

?Corresponding author. Department of Emergency and Critical Care

Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku

Tokyo 113-8655, Japan Tel.: +81 3 5800 8681; fax: +81 3 3814 6446

E-mail address: [email protected]

AJEM

A healthy young woman with massive hemorrhagic ascites

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