CNE Splenic Artery Aneurysm Rupture During Pregnancy Cathi Phillips, MSN, RN-OB Jean Bulmer, DNP, RN-BC

Objectives Upon completion of this activity, the learner will be able to:

1. Describe risk factors, management and sequelae of splenic artery aneurysm rupture during pregnancy. 2. List key points in the assessment of abdominal pain during pregnancy. 3. List and describe appropriate interventions for women and families who have experienced perinatal loss following splenic artery aneurysm rupture, as well as interventions for health care providers who have cared for these women.

Continuing Nursing Education (CNE) Credit A total of 1.1 contact hours may be earned as CNE credit for reading “Splenic Artery Aneurysm Rupture During Pregnancy” and for completing an online post-test and participant feedback form. To take the test and complete the participant feedback form, please visit http://JournalsCNE. awhonn.org. Certificates of completion will be issued on receipt of the completed participant feedback form and processing fees. Association of Women’s Health, Obstetric and Neonatal Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Accredited status does not imply endorsement by AWHONN or ANCC of any commercial products displayed or discussed in conjunction with an educational activity. AWHONN is approved by the California Board of Registered Nursing, provider #CEP580.

Cathi Phillips, MSN, RN-OB, is a maternal/child health nurse at Saint Vincent Health Center in Erie, PA, and is adjunct faculty in Nursing at Gannon University in Erie, PA. Jean Bulmer, DNP, RN-BC, is director of organizational development and provides education support to maternal child services at UPMC Hamot in Erie, PA. The authors and planners of this activity report no conflicts of interest or relevant financial relationships. No commercial support was received for this learning activity. Address correspondence to: [email protected].

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Introduction With the emergence of obstetric triage, perinatal nurses encounter women with a multitude of concerns not related to labor. Abdominal pain is one of the most common symptoms among pregnant women seeking urgent care in obstetric triage or labor and delivery units (Angelini, 2006). When a woman presents with abdominal pain, triage nurses must differentiate between obstetric and nonobstetric causes (see Box 1). This assessment can be challenging, because pregnancy symptoms can occur concurrently with abdominal pain or gastrointestinal symptoms that are not pregnancy related. Because perinatal nurses are highly specialized, it is possible to develop “tunnel vision” and fail to recognize signs and symptoms outside their area of expertise (Doe, 1991). Nurses are familiar with obstetric causes of abdominal pain, such as chorioamnionitis, preterm labor, placental abruption, ruptured uterus or ectopic pregnancy. They know the red flags that accompany abdominal pain that require further evaluation, including decreased fetal movement, vaginal bleeding, foul-smelling discharge and non-reassuring fetal heart rate tracing. Fortunately, mild abdominal pain is often benign and may be due to the enlarging uterus, fetal position and/or movement, Braxton-Hicks contractions or round ligament pain. Nonobstetric but more serious causes of abdominal pain are trauma (including from intimate partner violence), pyelonepritis, hydronephrosis, pancreatitis, bowel obstruction, hepatic rupture, HELLP syndrome, acute fatty liver and cholecystitis. A rarely encountered cause of abdominal pain is ruptured splenic artery aneurysm (see Box 2). The presentation of ruptured splenic artery aneurysm may be sudden and severe, necessitating urgent diagnosis and prompt intervention, or it may more vague and confusing, a puzzling dilemma. Below, we describe the case of a woman who presented to triage with left upper quadrant abdominal pain and experienced catastrophic sequelae.

Case Example A 33-year-old gravida 4, para 2 at 37 3/7 weeks gestation presented to obstetric triage with report of severe and sudden

Abstract: Abdominal pain is commonly reported by women seeking care in obstetric triage, and although it it is often benign, careful assessment is warranted. A rare cause of left upper quadrant pain during pregnancy is splenic artery aneurysm rupture, which can result in massive hemorrhage and maternal and fetal mortality. In women who survive, serious complications from bleeding and multiple transfusions require intensive care. There have been reports in the literature of improved outcomes with utilization of hemostatic resuscitation protocols. Nurses and other health care providers must be prepared to support families in the aftermath of this critical event. This article includes a case example of splenic artery aneurysm rupture that resulted in perinatal loss. DOI: 10.1111/1751-486X.12079 Keywords: catastrophic hemorrhage | massive transfusion | non-obstetric abdominal pain assessment | splenic artery aneurysm | pregnancy

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Conduct complete history and thorough physical assessment Obtain chronological sequence of events preceding admission Do not discharge woman before laboratory results are reviewed Do not triage woman over the phone

Woman may have concurrent pregnancy and abdominal pain symptoms Consults should be done in a timely manner and be documented Physiologic changes of pregnancy could mask symptoms

episode of left upper quadrant and epigastric pain with vomiting, which started as she was preparing dinner at home. On admission, she was afebrile with a temperature of 97.6°F. Pulse was 96, respiration 22, blood pressure 100/57. Fetal heart rate monitoring showed a reassuring tracing. The woman’s pain was decreased somewhat since admission. Ninety minutes after admission, the woman reported severe left side rib pain, became pale and diaphoretic and experienced loss of vision. The pulse oximeter stopped registering; her blood pressure dropped to 67/31 and her pulse became rapid and thready. A rapid response team was called. Prolonged fetal heart rate deceleration was noted and the patient was sent to the operating room stat. A total of 2,000 cc frank blood was found in the abdominal cavity. No abruption or uterine rupture was found. A trauma surgeon was called, and he created a vertical incision and identified a ruptured splenic artery aneurysm. The patient underwent an exploratory laparotomy, splenectomy and emergency cesarean. The baby had Apgar scores of 0/1 and expired within 1 hour. Postoperatively, the patient recovered in the intensive care unit (ICU). She developed metabolic acidosis, metabolic derangement and transfusion-related acute lung injury. She required a transfusion of 10 units of packed red blood cells and clotting factors. She eventually recovered, requiring counseling for complicated bereavement. She was discharged to home after 7 days.

Hormonal and anatomic changes during pregnancy can make assessment and diagnosis of abdominal pain more complicated abdominal discomfort and lead to an increased risk for bowel obstruction. Decreased gallbladder motility can lead to stasis and formation of gallstones, increasing the risk for pancreatitis as well. Changes in hematologic parameters can mask infection

box 2 Signs and symptoms of Splenic Artery Aneurysm Rupture Kehr’s sign Sharp epigastric of left hypochondrial pain Nausea and vomiting Sudden collapse Shortness of breath or left-sided chest pain Breakthrough pain with regional anesthesia

Assessment of Abdominal Pain

Hypotension resistant to vasoactive drugs

Assessment of the pregnant abdomen is a critical skill. Nurses working in obstetric triage need to continually update

Diffuse abdominal tenderness

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Do not assume lack of physical findings is lack of diagnosis

knowledge of abdominal assessment and expand these assessment skills. Approximately 1 in 500 pregnancies are complicated by a nonobstetric surgical abdominal condition (Angelini, 2003), and nurses need to recognize potentially life-threatening scenarios of acute pain as they are most often involved in the initial patient encounter. Hormonal and anatomic changes during pregnancy can make assessment and diagnosis of abdominal pain more complicated. Many women report abdominal discomfort, especially as the pregnancy progresses. Pain can result from increased fetal movement and fetal position, Braxton-Hicks contractions, stretching of the uterine ligaments and compression of abdominal organs by the enlarging uterus. There can be difficulty in localizing pain, and some anatomical structures can become distorted during pregnancy (McGahan, Lamba, & Coakley, 2010). Clinical signs and symptoms may be masked or less apparent during pregnancy. There is displacement of abdominal viscera by the gravid uterus. An increase in progesterone results in decreased esophageal sphincter tone, with pregnant women experiencing gastroesophogeal reflux more often as well as being at increased risk for aspiration during surgery. Decreased small bowel and colonic mobility can cause increased

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box 1 Considerations for Obstetric Triage of Abdominal Pain

and hemorrhage. During pregnancy, women experience expanded blood volume resulting in physiologic anemia and an increased cardiac workload. Pregnant women are therefore increasingly vulnerable to cardiac stress. Mild leukocytosis and an increased erythrocyte sedimentation rate are normal during pregnancy and this should be taken into consideration when diagnosing infection (Cappell & Friedel, 2003). Diagnostic imaging is utilized judiciously during pregnancy to decrease the risk of exposing the developing fetus to teratogens. Abdominal pain assessment is more challenging during pregnancy owing to the complex network of nerve fibers conducting pain sensation to the central nervous system. Visceral (organ) pain is deeper and not well-localized, with patients

Assessment of abdominal pain during pregnancy requires a comprehensive history and careful physical assessment along with laboratory tests often reporting dull, aching and sometimes cramping pain. Visceral pain can be caused also by the rapid stretching of peritoneum or organ capsule with accumulation of fluid or blood (Cappell & Friedel, 2003). Assessment of abdominal pain during pregnancy requires a comprehensive history and careful physical assessment along with laboratory tests. Circulation, airway and breathing (CAB) should always be rapidly evaluated initially in any patient presenting with a complaint of abdominal pain. Women should not be discharged from a triage unit until laboratory test results are reviewed. Pregnant women with abdominal pain should not be triaged over the phone. Box 3 lists information to obtain when assessing abdominal pain in pregnant women. It should be noted that when assessing a woman with report of abdominal pain, the absence of abnormal physical assessment findings should not delay care (Miller & Alpert, 2006). Left upper quadrant abdominal pain can stem from the left lobe of the liver, the stomach, spleen, pancreas or descending or transverse colon, and is less frequently reported during pregnancy. Women should be assessed for a positive Kehr’s sign—sharp pain at the tip of the left shoulder. This is caused by diaphragmatic irritation, particularly when in a supine position. Balances’s sign is present when there is dullness with percussion to the left upper quadrant. This results from accumulation of blood in upper quadrants. An irregular blue-tinged hemorrhagic patch around the umbilicus (Cullen’s sign) may be seen in women with hemoperitoneum (Wright, 1997). Severe pain accompanied by tachycardia, diaphoresis and/or pallor is indicative of a clinical emergency and the woman should be rapidly triaged.

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While women with abdominal pain frequently report nausea, it is important to note that severe vomiting without nausea is a response to visceral pain and the pain will precede the nausea. Any pregnant woman presenting with left upper quadrant or epigastric pain should raise suspicion for a possible diagnosis of ruptured splenic artery aneurysm.

Splenic Artery Aneurysm Rupture Rupture of splenic artery aneurysms is rare, although incidence may be underdocumented, as most splenic artery aneurysms are asymptomatic and found incidentally, although disproportionate numbers of this potentially catastrophic event occur during pregnancy (Richardson, Bahlool, & Knight, 2006). More than 400 cases of splenic artery aneurysm have been reported in the literature, with approximately one-third of these occurring during pregnancy (Richardson et al., 2006). An aneurysm is a weakening in the wall of an artery, inviting rupture. Physiologic changes of pregnancy contribute to alteration of the structure of arterial walls, with the splenic artery being more vulnerable as a result of physiologic changes in pregnancy. Increased levels of estrogen, progesterone and relaxin can lead to dilation and increased elasticity in the arterial walls. Increased cardiac output, increased blood volume and relative portal hypertension of pregnancy stress the splenic artery (He et al., 2010), there is also increased flow velocity

box 3 Assessment of Abdominal Pain in Pregnancy When assessing abdominal pain during pregnancy, question the woman about the following: Onset of pain (sudden or gradual) Type of pain (sharp, dull, throbbing, burning, cramping) Location of the pain Whether the pain radiates Any precipitating factors Any associated symptoms, such as nausea and vomiting, diarrhea, vaginal bleeding, fever or burning with urination Relevant past medical history, such as previous abdominal surgery, medical conditions such as gastroesophageal reflux disease or gallbladder problems, and history of any trauma to the abdomen Significant obstetric history, such as history of preterm labor, pyelonephritis or urinary tract infections, and history of preeclampsia or pregnancy-induced hypertension

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box 4 Nursing Management of Hemorrhage Remember CAB: circulation, airway and breathing Secure airway, oxygenation Replace volume/establish IV access with two large bore catheters Early notification of blood bank Obtain labs Warm IV fluid Blood warmer for multiple transfusions Keep patient warm Insert Foley catheter and monitor urine output Call for additional help Left tilt or Trendelenburg position Provide clear and factual information to woman and family

Differential diagnosis is challenging in pregnancy when obstetric emergencies need to be considered, possibly resulting in delayed intervention. Surgical intervention involves ligating the splenic artery, and possible splenectomy. Simpson (1995) notes that it is preferable to save the spleen if collateral circulation is established because women who have a splenectomy develop a decreased immune response and are at risk for postoperative sepsis.

Catastrophic Hemorrhage Ruptured splenic artery aneurysm results in catastrophic bleeding leading to irreversible shock if prompt intervention does not occur. Pregnant women are particularly vulnerable due to changes in hemodynamics during pregnancy, resulting in less likelihood of a woman exhibiting classic symptoms of hypovolemic shock. Vital signs may remain within normal parameters until there has been significant blood loss. Many pregnant women are also anemic during pregnancy, resulting in a higher rate of mortality with hemorrhage. In response to blood loss and hypovolemia, blood is diverted to more critical organs, such as the heart and the brain, shunting blood away from the uterus. An early sign of shock may be changes in the baseline rate (initial tachycardia then bradycardia), repetitive decelerations and loss of fetal heart rate variability as the fetus is compromised (Simpson, 1995). Delayed intervention for a ruptured splenic artery aneurysm with concealed hemorrhage can lead to ischemic injury, multisystem organ failure and irreversible shock. Shock results in a cascading effect in which inadequate perfusion leads to in-

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to the splenic artery as a result of distal aortic and iliac artery compression from the gravid uterus (Richardson et al., 2006). Khurana and Spinello (2012) report that the size of the uterus, particularly in the second and third trimester, causes increased pressure in the splenic artery. Any condition that predisposes a woman to increased portal hypertension, such as systemic hypertension, increases the risk for development of splenic artery aneurysm (Richardson et al., 2006). A splenic artery aneurysm is usually asymptomatic until rupture. When rupture occurs, a woman may develop sharp abdominal, epigastric or hypochondrial pain, often followed by severe vomiting. Women may also present with left-sided chest pain and shortness of breath that would appear to be indicative of a pulmonary embolism or cardiac arrest (Khurana & Spinello, 2012). Most commonly, the initial clinical presentation is sudden collapse with symptoms of hypovolemic shock, leading clinicians to mistakenly diagnosis a uterine rupture or placental abruption. The presentation is sometimes more vague, including nonspecific pain, dyspepsia and/or abdominal tenderness, all of which can be attributed to the normal changes of pregnancy (Cressey & Reid, 1996). Approximately one-fourth of patients experience a “double rupture” phenomenon with an initial, concealed hemorrhage into the lesser omental sac and symptoms of pain and hypotension. These subside as a temporary tamponade—usually a clot—stabilizes the hemorrhage. The second hemorrhage or rupture into the foreman of Winslow usually occurs within 48 hours and results in massive bleeding with hemoperitoneum (Sadat, Dar, Walsh, & Varty, 2008). This “sentinel” period between the initial rupture and subsequent massive hemorrhage allows an opportunity to diagnose and intervene (He et al., 2010). Diagnosis of an unruptured splenic artery aneurysm is difficult and often incidental. A high degree of suspicion and anticipatory management are required in diagnosing ruptured splenic artery aneurysm, as the resulting hemorrhage can be life-threatening (see Box 4). Anticipatory management involves mobilizing resources, including a general surgeon, and preparing to implement massive hemorrhage protocols. An ultrasound may reveal the presence of free fluid in the abdomen and the diagnosis is then confirmed with emergency laparotomy and cesarean delivery (Sadat et al., 2008). Intervention goals are to stop the bleeding and restore hemodynamic stability. Rupture of the splenic artery aneurysm usually occurs during the third trimester, with potentially catastrophic consequences for the woman and fetus. It can also occur in the immediate postpartum period when symptoms of rupture, such as hypotension, could be mistaken as effects of regional anesthesia. Maternal mortality is reported to be as high as 75 percent, compared with 25 percent for the nonpregnant population. Fetal mortality is reported by Sadat et al. (2008) to be as high as 95 percent.

sufficient tissue oxygenation, inducing a catabolic state. There is decreased systemic vascular resistance and pooling of blood in the capillary beds. Inflammation and endothelial dysfunction manifest as multisystem organ damage (Santoso, Saunders, & Grosshart, 2005). Clinical correlates of life-threatening hemorrhage (40 percent or greater loss of total volume) are depressed mental status, severe hypotension, minimal urine output, peripheral vasoconstriction, narrowed pulse pressure and tachycardia. With massive bleeding, platelets and clotting factors are depleted. Massive uncontrolled hemorrhage unleashes a lethal triad of hypothermia, acidosis and coagulopathy and a “bloody vicious

A splenic artery aneurysm is usually asymptomatic until rupture cycle” results as each of these life-threatening entities exacerbates the other (Sihler & Napolitano, 2009). Hypothermia is the consequence of decreased metabolic activity resulting from impaired tissue perfusion. When the core body temperature drops below 32°C (89.6°F), people are prone to cardiac arrhythmias and coagulopathy. Coagulopathy will also result from hemodilution and the use of unfractionated blood products (Santoso et al., 2005).

Medical and Nursing Management Priorities Traditional hemorrhage protocols use crystalloids to maintain normovolemia and normotension, along with transfusion of packed red blood cells to correct anemic hypoxia. This protocol can lead to dilutional coagulopathy and may worsen bleeding as intravascular hydrostatic pressure is increased (Pacheco, Saade, Gei, & Hankins, 2011). Hemorrhaging women may actually have an early coagulopathy resulting from tissue hypoperfu-

A high degree of suspicion and anticipatory management are required in diagnosing ruptured splenic artery aneurysm, as the resulting hemorrhage can be life-threatening sion, which activates the protein C pathway. Because protein C is a natural anticoagulant, early replacement of clotting factors may be more appropriate (Pacheco et al., 2011). Pacheco et al. (2011) recommend a newer hemostatic re-

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suscitation protocol for treatment of massive hemorrhage. The principles of this protocol are to limit initial aggressive crystalloid infusion and administer clotting factors early using a 1:1:1 ratio (packed red blood cells, fresh frozen plasma and platelets). The use of recombinant factor VIIa is also advocated in the literature, particularly with postpartum hemorrhage, although there is a lack of randomized studies to support its use. Pacheco et al. (2011) note that more than 75 percent of level I trauma centers in the United States recommend use of recombinant factor VIIa in their massive transfusion protocols. Permissive hypotension is also advocated in the literature (Sihler & Napolitano, 2009). With permissive hypotension, systolic blood pressure is maintained at 80 to 100 mmHg until the hemorrhage is controlled. Its use with women antenatally is controversial as uterine perfusion may be compromised. Nursing responsibilities include securing the airway and delivering oxygen by mask, establishing intravenous (IV) access with two large bore catheters, administering and monitoring fluid boluses and collection of laboratory specimens (CBC, PT/PPT, fibrinogen, antithrombin III and type and cross for four units). Pacheco et al. (2011) advocate using the thromboelastograph (TEG) test, which is a more accurate indicator of specific clotting factor requirements. Nurses should also notify the blood bank as soon as possible, as it takes 30 minutes to 1 hour to type and cross-match blood and to thaw cryoprecipitate. The woman should be kept warm with heated blankets and a blood warmer should be utilized if more than three units are transfused. A Foley catheter should be inserted and urine output monitored. Vital signs, oxygen saturation, cardiac rhythm and mental status should be monitored at frequent intervals. Massive transfusion increases the risk for complications. Thromboembolic events are a common risk with massive hemorrhage and transfusion, and women should have sequential compression devices for prophylaxis and, when stable, may need pharmacologic prophylaxis. Oliguria and hypotension may persist, prompting providers to increase IV fluids. Third spacing often results from massive fluid infusion and can cause bowel edema and ascites, which increases abdominal pressure. Increased abdominal pressure causes compression of abdominal and retroperitoneal vessels, ultimately leading to decreased cardiac output. This is known as compartment syndrome. Extensive abdominal surgery also increases the risk for development of an ileus. Hemolytic reaction, although rare, can be fatal with as little as 30 mL transfused blood and is usually the result of process error. Symptoms of hemolytic reaction include fever, chills, substernal or back pain, mental status changes, dyspnea, cyanosis and disseminated intravascular coagulation (DIC). Common allergic reactions are urticaria and pruritus, but anaphylactic shock may occur. Transfusion-related acute lung injury is the leading cause of transfusion-related death. Symptoms include respiratory distress, hypoxemia, hypotension and pulmonary edema without left-sided heart failure.

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box 5 Interventions for Grieving Family Bereavement plan (involves family in decisions):

Follow-up care

Healing communication

Phone call from bereavement counselor or nurse

Answer questions

Visit by physician, with office follow-up to answer questions Referrals for counseling, support groups Creating memories Seeing, holding baby Hair, footprints, name card Religious traditions

Electrolyte imbalances are a common side effect with massive transfusion. Because blood is anticoagulated with citrates and citric acid, metabolic acidosis and hypocalcemia are potential complications. If uncorrected, hypocalcemia may lead to cardiac arrhythmia. Calcium replacement with calcium gluconate of calcium chloride may be necessary. Hyperkalemia can develop because of potassium leakage in stored blood (Santoso et al., 2005). Women should be monitored for fluid overload and pulmonary edema. Although those with impaired cardiac and renal function are at increased risk, any woman receiving multiple blood components, particularly fresh frozen plasma, is at risk for significant intravascular expansion. In addition, a woman receiving more than 2 L of fluid is at risk for fluid overload (Santoso et al., 2005).

Traumatic Loss Sudden perinatal death (maternal and/or fetal) is a traumatic experience for the parents, family members and health care providers. Providers must not only deliver emergent medical care, but also be prepared to offer emotional support despite the adverse and unanticipated circumstances surrounding the loss. Perinatal loss has significant psychologic impact and is associated with an increased risk of post-traumatic stress disorder, depression, anxiety and sleep disturbances (Kersting & Wagner, 2012). Complicated grief can be triggered by the sudden loss of a fetus. While grief is considered to be a normal process after a loss, complicated grief is more intense and prolonged, causing greater life disruption (Kersting & Wagner, 2012). Walsh (2007) notes that the word “trauma” comes from the Latin word for “wound.” “With traumatic experiences the body, mind, spirit and relationships with others can be wounded” (p. 210). Traumatic losses are harder to cope with. The parents have no time to prepare for the loss and they have no direct life experiences with the infant. This child who was a part of the

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parents’ identity is lost forever (Callister, 2006). This may be the parents’ first experience with grief and loss. Grief is a long-term process and it may not become apparent until after hospital discharge. Often it endures long after the initial support provided by family and friends (Weiss, Frischner, & Richman, 1989). Some families lack the support of extended family and will depend on support from health care providers. The risk for depression is significant in the first year following perinatal loss. There is no “closure” for the loss of a child but rather the parents integrate the loss into their lives. Resolution of grief was once thought to involve “letting go” of the lost attachment; however, a new school of thought recognizes the need to “hold on” to the continuing emotional bond “through spiritual connections, memories, deeds, and stories that are passed on across generations” (Walsh, 2007). Interventions can be planned to meet both the immediate needs of the parents and family and the anticipatory needs after discharge. Rowland and Goodnight (2009) recommend developing a bereavement plan in collaboration with the family (see Box 5) and they recommend that the parents and family should be included in decisions. An interdisciplinary plan utilizing social services, chaplain services and counseling services may better address the family’s needs. Nursing interventions should focus on healing communication. Listening may be more valuable than talking, and nurses should offer presence rather than avoidance. Acknowledging the family’s grief and loss and allowing them to share their stories facilitates communication. The family needs clear and factual information to clarify the circumstances surrounding the loss. Families can struggle with painful emotions by questioning. They may seek to blame someone for the loss and might question whether it could have been prevented. The bereavement plan should provide opportunity for the family to have their questions answered. Rowland and Goodnight (2009) stress the importance of a follow-up phone call as well as a follow-up visit

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box 6 Stress Management for Providers Critical incident stress management team/team debriefing Relaxation or meditation room Trained peer counselors Personal reflective crucial incident review Group and humor therapy Reorganization of workplace to: • Promote collaboration • Promote communication, promote empowerment • Provide critical incident reviews that allow learning opportunities

a couple of weeks after discharge, when parents may be more receptive to information about support groups, counseling services and websites. At that point they will have had time to “process the loss and birth experience” and will likely have more questions (Rowland & Goodnight, 2009, p. 246). Families may need assistance with immediate needs, such as food and a place to stay to be near their loved ones, as well as provision of privacy to grieve. Nurses can help the family to mobilize resources. The cost of a funeral may be overwhelming for a young family and financial resources should be investigated. Finally, the family needs clear and factual information to clarify the circumstances surrounding the loss. A family conference should be included in the bereavement plan, involving the physician(s), as well as other members of the health care team, including, perhaps, a clinical nurse specialist, social worker or bereavement counselor, and a chaplain. Discharge planning involves mutual arrangements for ongoing psychotherapeutic monitoring and support.

Learning From Adverse Outcomes After the woman is stabilized and the family is supported in their grief, clinical staff members need support as well. Witnessing or being involved with a traumatic incident is stressful for staff and may have a long-lasting impact, affecting them physically, emotionally cognitively and behaviorally (Blacklock, 2012). Nurses are exposed to critical incidents on an ongoing basis and the effects are cumulative, often leading to compassion fatigue and “burnout.” Lombardo and Eyre (2011) define compassion fatigue as a “combination of physical, emotional and spiritual depletion associated with caring for patients in significant emotional pain and physical distress” (p. 1). Maloney (2012) describes burnout as a syndrome encom-

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passing emotional exhaustion and decreased sense of personal accomplishment. Stress in health care work can cause dysfunctional relationship among colleagues and family, decreased job satisfaction and an increased risk for depression. Unaddressed workplace stress can negatively impact care, which can be reflected in increased patient falls and medication errors. Maloney (2012) documents evidence of a correlation between increased work stress and increased litigation involving health care providers. In addition, the financial impact of work-related stress, including stress-related absenteeism, is extensive (Blacklock, 2012). Nurses are highly vulnerable to critical incident stress and need support to increase coping mechanisms; they also need a safe, nonthreatening environment in which to express emotions (see Box 6). Opportunity for staff to defuse and deal with emotions after crucial incidents is lacking in many institutions. Some hospitals have developed stress management programs for their employees. Other strategies described in the literature to reduce stress in the workplace include relaxation or meditation rooms, use of trained peer counselors, group and humor therapy, use of personal reflective critical incident reviews and reorganization of the workplace environment to promote collaboration, communication and empowerment (Maloney, 2012). Critical incident reviews should involve staff at all levels. A critical event can become a growth and learning experience leading to positive changes. A Critical Incident Management Team could be implemented. One tool that could be utilized is team debriefing (Corbett, Hurko, & Vallee, 2012). A team facilitator (a clinical nurse trained in debriefing) leads a structured, brief (15 minutes) session in a blame-free environment during which team members examine the situation (critical incident) and the background information leading to the incident, and then discuss what went right and what needed improvement. Areas for improvement can be structured into the components of communication, resources, systems and equipment. Avenues for improved teamwork could be explored, along with development of improved policies and protocols. Implementation of tools such as obstetric hemorrhage carts, nursing checklists and enhanced simulation drills facilitate process improvement. Collaboration with other department and disciplines, such as the trauma team or emergency room, could also improve obstetric emergency outcomes.

Conclusion Splenic artery aneurysm rupture during pregnancy is a rare, but potentially catastrophic event that requires the utmost skill and vigilance of an interdisciplinary team of health care providers for assessment, diagnosis, rapid response and management of the crisis and sequelae. It is our hope that the lessons learned from the case described here will provide valuable insights for other health care providers. NWH

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Angelini, D. (2003). Obstetric triage revisited: Update on non-obstetric surgical conditions in pregnancy. Journal of Nurse Midwifery, 48(2), 111–118. Angelini, D. (2006). Obstetric triage: State of the practice. Journal of Perinatal Neonatal Nursing, 20(1), 74–75. Blacklock, E. (2012). Interventions following a critical incident: Developing a critical incident stress management team. Archives of Psychiatric Nursing, 26(1), 2–8. doi:10.1016/j.apnu.2011.04.006 Callister, L. C. (2006). Perinatal loss: A family perspective. Journal of Perinatal Neonatal Nursing, 20(4), 227–234.

Corbett, N., Hurko, P., & Vallee, J. (2012). Debriefing as a strategic tool for performance improvement. Journal of Obstetric, Gynecologic & Neonatal Nursing, 41 (4), 572–579. Cressey, D., & Reid, F. (1996) Splenic artery aneurysm rupture in pregnancy. International Journal of Obstetric Anesthesia, 5(2), 103–104. Doe, J. (1991). Tunnel vision. Nursing, 21(10), 54–56. He, M., Zheng, J., Zhang, S., Wang, J., Liu, W., & Zhu, M. (2010). Rupture of splenic artery aneurysm in pregnancy. American Journal of Forensic Medicine/Pathology, 31(1), 92–94. doi:10.1097/ PAF.0b013e3181c65da2 Kersting, A., & Wagner, B. (2012). Complicated grief after perinatal loss. Dialogues in Clinical Neuroscience, 14(2), 187–194. Khurana, J., & Spinello, I. (2012, May 6). Splenic artery aneurysm rupture: A rare but fatal cause for peripartum collapse. Journal of Intensive Care Medicine. [Epub ahead of print.] doi:10.1177/0885066612444257 Lombardo, B., & Eyre, C. (2011). Compassion fatigue: A nurse’s primer. Online Journal of Issues in Nursing, 16(1), 1–7. doi:10.3912/OJIN.Vol16No01Man03 Maloney, C. (2012). Critical incident stress debriefing and pediatric nursing. Pediatric Nursing, 38(2), 110–113.

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Miller, S., & Alpert, P. (2006). Assessment and differential diagnosis of abdominal pain. Nurse Practitioner, 31(7), 38–47. Pacheco, L., Saade, G., Gei, A., & Hankins, G. (2011). Cutting edge advances in the medical management of obstetrical hemorrhage. American Journal of Obstetrics and Gynecology, 205(6), 526–532. doi:10.1016/j.ajog.2011.06.009 Richardson, A. J., Bahlool, S., & Knight, J. (2006). Ruptured splenic artery aneurysm in pregnancy presenting in a manner similar to pulmonary embolus. Anesthesia, 61(2), 187–189. Rowland, A., & Goodnight, W. (2009). Fetal loss: Addressing the evaluation and supporting the emotional needs of parents. Journal of Midwifery and Woman’s Health, 54(3), 241–248. doi:10.1016/j.jmwh.2009.02.011 Sadat, U., Dar, O., Walsh, S., & Varty, K. (2008). Splenic artery aneurysms in pregnancy: A systematic review. International Journal of Surgery, 6, 262–265. Santoso, J., Saunders, B., & Grosshart, K. (2005). Massive blood loss and transfusion in obstetrics and gynecology. Obstetrical and Gynecological Survey, 60(12), 827–837. Sihler, K., & Napolitano, L. (2009). Massive transfusion: New insights. Chest, 136(6), 1654–1667. doi:10.1378/chest.09-0251 Simpson, K. R. (1995). Rupture of a splenic artery aneurysm in pregnancy. Critical Care Nurse, 15(3), 25–29, 31–32. Walsh, F. (2007). Traumatic loss and major disasters: Strengthening family and community resilience. Family Process, 46(2), 207–227. Weiss, L., Frischner, L., & Richman, J. (1989). Parental adjustment to intrapartum and delivery room loss: The role of a hospital based program. Clinics in Perinatology, 16(4), 1009–1019. Wright, J. (1997). Seven abdominal signs every emergency room nurse should know. Journal of Emergency Nursing, 23(5), 446– 450.

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Cappell, M., & Friedel, D. (2003). Abdominal pain during pregnancy. Gastroenterology Clinics of North America, 32(1), 1–58.

McGahan, J., Lamba, R., & Coakley, F. (2010). Imaging non-obstetrical causes of abdominal pain in the pregnant patient. Applied Radiology, 39(11), 10–25.

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References

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Post-Test Questions Instructions: To receive contact hours for this learning activity, please complete the online post-test and participant feedback form at http://JournalsCNE.awhonn.org. CNE for this activity is available online only; written tests submitted to AWHONN will not be accepted.

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1.

Approximately how many pregnancies are complicated by a nonobstetric surgical abdomen condition? a. 1 in 500 b. 1 in 1,000 c. 1 in 5,000

6.

Which of the following is a sign of splenic artery aneurysm rupture? a. Increased blood pressure b. Left upper abdominal quadrant pain c. Right costovertebral angle tenderness

2.

Which of the following is contraindicated when triaging a pregnant woman with abdominal pain? a. Assessment over the phone b. Lab testing c. Physical exam

7.

When during pregnancy is splenic artery aneurysm rupture most likely to occur? a. First trimester b. Second trimester c. Third trimester

3.

Which of the following is a benign cause of abdominal pain during pregnancy? a. Hydronephrosis b. Round ligament pain c. Vaginal bleeding

8.

4.

Approximately what proportion of splenic artery aneurysm ruptures reported in the literature occurred during pregnancy? a. One-tenth b. One-third c. One-quarter

A “double rupture” in which there is a first hemorrhage followed by a second hemorrhage occurs in approximately what percentage of patients? a. 10 percent b. 25 percent c. 50 percent

9.

Which of the following is a nursing consideration during management of acute hemorrhage? a. First call a surgeon b. Keep the patient warm c. Measure voided urine

5.

518

Which of the following is a reason for the increased risk for splenic artery aneurysm rupture during pregnancy? a. As pregnancy progresses, many women become more sedentary, which produces changes in arterial walls. b. Blood volume contraction can stress the walls of the splenic artery. c. Hormonal changes can lead to dilation and increased elasticity in the arterial walls.

Nursing for Women’s Health

10. What is a consideration for nursing care of a grieving family? a. Focusing on physical health, rather than emotions b. Giving the family space by leaving them alone c. Listening may be better than talking

Volume 17

Issue 6

Splenic artery aneurysm rupture during pregnancy.

Abdominal pain is commonly reported by women seeking care in obstetric triage, and although it it is often benign, careful assessment is warranted. A ...
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