SPONTANEOUS SPLENIC RUPTURE IN PREGNANCY

INTRODUCTION Spontaneous Splenic Rupture in pregnancy is a rare complication, which is misdiagnosed more often than not. It could lead to a massive hemoperitoneum, hypovolemic shock and is associated with a high maternal and fetal mortality. It is more common in the 3rd trimester but cases have been reported in 2nd trimester as well as post-partum period. The delay in recognition of this rupture can lead to catastrophic consequences for both the mother and the fetus. CAUSE The etiology remains elusive and speculative at best. However, several times it occurs in patients with pre-existing pathology of spleen such as a splenic artery aneurysm or thalassemia, or infectious etiologies such as malaria, typhoid, or infectious mononucleosis, but most commonly after a trauma. PRESENTATION Patient may appear pale and present with abdominal pain, generalized weakness, dizziness, vertigo, palpitations, fainting, hypotension, tachycardia, pallor and other signs of hypovolemic shock. DIAGNOSIS Urgent Ultrasonography would reveal hemoperitoneum/free fluid. However, what makes the diagnosis difficult is the fact that it shares signs and symptoms with other conditions such as uterine rupture and abruption of the placentae. Intraoperatively after the hysterotomy is performed, fetus delivered, uterus is repaired, if no uterine or pelvic bleeding source is identified but bleeding is on-going, splenic/hepatic rupture as the source of bleeding should be suspected. Spontaneous rupture of liver has also been reported and it is almost always associated with preeclampsia, eclampsia, and/or HELLP syndrome and can also be due to hepatic hemangiomata, hepatic metastases from choriocarcinoma, or some unknown causes. In either case, be it a spontaneous splenic or hepatic rupture in pregnancy, sudden appearance and potentially fatal outcome make it an important diagnostic and therapeutic challenge. MANAGEMENT/CONCLUSION Emergent laparotomy and splenectomy before the setting of collapse and disseminated vascular coagulation are the essential keys to enhance maternal and increase the chances of fetal survival. PLEASE SHARE YOUR THOUGHTS ON THE TOPIC! REFERENCES (1) Elghanmi A, Mohamed J, Khabouz S. Spontaneous splenic rupture in pregnancy. Pan Afr Med J. 2015;21:312. Published 2015 Aug 28. doi:10.11604/pamj.2015.21.312.6878 (2) Zhou X, Zhang M, Liu Z, Duan M, Dong L. A rare case of spontaneous hepatic rupture in a pregnant woman. BMC Pregnancy Childbirth. 2018;18(1):87. Published 2018 Apr 10. doi:10.1186/s12884-018-1713-5 (3) Troja A, Abdou A, Rapp C, Wienand S, Malik E, Raab HR. Management of Spontaneous Hepatic Rupture on Top of HELLP Syndrome: Case Report and Review of the Literature. Viszeralmedizin. 2015;31(3):205-208. doi:10.1159/000376601 (4) Dave A, Dhand H, Mujalde A. Spontaneous rupture of spleen during pregnancy. J Obstet Gynaecol India. 2012;62(6):692-693. doi:10.1007/s13224-012-0141-0 (5) Hamedi B, Shomali Z. Postpartum Spontaneous Rupture of Spleen in a Woman with Severe Preeclampsia: Case Report and Review of the Literature. Bull Emerg Trauma. 2013 Jan;1(1):46-8. PMID: 27162822; PMCID: PMC4771243. (6) Sakhel K, Aswad N, Usta I, Nassar A. Postpartum splenic rupture. Obstet Gynecol. 2003 Nov;102(5 Pt 2):1207-10. doi: 10.1016/s0029-7844(03)00676-8. PMID: 14607059. (7) Wang C, Tu X, Li S, Luo G, Norwitz ER. Spontaneous rupture of the spleen: a rare but serious case of acute abdominal pain in pregnancy. J Emerg Med. 2011 Nov;41(5):503-6. doi: 10.1016/j.jemermed.2010.05.075. Epub 2010 Sep 2. PMID: 20813482.

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Excellent case presentation though rare but important to learn Yes it is an emergency and to save mother and fetus need to go for surgery Here the question comes What is priority to save fetus first or mom Pt must be in hypovolumic shock so need to be BT Should c section should be done first to save fetus and follow ed by splenectomy

Thank you for the wonderful comment as always doctor. Though I believe a gynecologist would be the best person to answer these questions but with my limited experience in such cases I shall do my best. As to the question of priority, both the lives are important. That being said, often times you would find that with the patient in shock, the fetal life has already been compromised. However, without doing a c-section first (even if we already know the fetus is non-viable) it would be extremely difficult to locate the source of bleeding because the large size of uterus would make it challenging. Also most of the times, abdomen would be opened with a suspicion of uterine rupture (and rightfully so) rather than suspecting a splenic/hepatic tear/rupture as the cause of bleeding. With patient in shock the operating surgeon/gynecologist may not have the luxury to get additional investigations to locate the source of bleeding.
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Thanx dr Vijay Kumar Singh for concerns explained in logical way I agree it is not easy to locate bleeder and precious time may lost in that attempt and we may loose both lives . Still whatever a surgeon can do gets on work so I feel as anaesthetist BT and volume replacement with haemacele or high molecular weight substitute c section can be attempted to save fetus and follow the peritoneal lavage to locate bleeder Indeed not a easy thing and successful always but since I have come across the situation in my golden time and were able to save . My concer was to keep inotropic support and not allowing pt to land in hypoxia

Thanks for sharing

Thank you doctor
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VERY MUCH USEFUL & VALUABLE POST ON SPONTANEOUS SPLENIC RUPTURE IN PREGNANCY,,,U HAVE ELABORATED ALL THE THING'S IN DETAILED SIR,,,NOT MUCH LEFT TO SAY ANYTHING,,,THANKS ONCE AGAIN FOR SHARING.

Thank you doctor
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