Aust. N.Z.J. Obstet. Gynaec. (1979) 19: 116
Spontaneous Rupture of the Spleen in Late Pregnancy P. R. Henderson' and J . D. Keeping
Depurtnient of Obstetrics untl Gynuecology, Royul Bris bane Hospital, HerJton and Depurtnient of Obstetrics unrl Gynaecology, Mater Misericorrliue Hospirul, South Brisbane
Surnmury: Two cases of spontaneous rupture of the spleen are described. The first patient presented with fetal distress in the second stage of labour; the second with hypovolaemic shock. Both mothers and babies survived.
Haemoperitoneum is a rare but important cause of collapse in late pregnancy, and is associated with an appreciable maternal and fetal mortality. Hodgkinson et al. (1950) reviewed 75 cases of uteroovarian vein rupture in which the maternal mortality was 49%. In Macfarlane and Thorbjarnarson's (1966) series of 61 cases of ruptured splenic artery aneurism, the maternal mortality was 72%. A maternal mortality of 45% was reported by Sparkman (1958) in 44 patients with splenic rupture. In recent years, cases have appeared in which both mother and baby survived (Roxburgh, 1975; Brass, 1977). Tn the 2 cases described here the mothers and babies also survived, although one infant is severely retarded. Case 1
The patient, aged 26, was in her fourth pregnancy. There was' no significant past medical, surgical or obstetrical history. The course of her current pregnancy was smooth and she went into spontaneous labour at 41 weeks of gestation. The first stage lasted 8 hours and was uneventful, except that the descent of the head was delayed until the last hour. 1 . Temporary Clinical Lecturer.
Tn the second stage, the head descended to the ischial spines with several pushes. The fetal heart then became irregular and developed a baseline bradycardia of 90 beats/minute with loss of baseline variability (Fig. 1). Vaginal examination revealed the head to be 3 cm below the ischial spines and in a transverse position. Kielland's forceps rotation was performed, resulting in the delivery of a male weighing 3,505 g. The baby was apnoeic, deeply cyanosed, and had a heart rate of 90/minute. Intubation was performed at 2 minutes and assisted ventilation continued for 24 minutes, when spontaneous respiration was established. Thereafter, apart from initial irritability, the progress of the baby has been normal to 1 year. lmmediately after delivery the mother was found to be hypotensive, semiconscious, and to have a tachycardia of 110 beats/minute. Her pulse and blood pressure had previously been normal. She denied any symptoms; in particular, she had no abdominal pain or dyspnoea. She was not cyanosed. The third stage was completed without incident and an intravenous infusion commenced. Examination of chest, abdomen and central nervous system was normal, as was a chest radiograph. At this point the patient complained of shoulder tip pain. A provi-
P. R . HENDERSON AND J . D. KEEPING
Iu HEWLETT-PACKARD
9270-0484
MEDICAL PRODUCTS GROUP
117
7b $0
Figure 1.
sional diagnosis of intraperitoneal bleeding was made and laparotomy arranged. At operation, a haemoperitoneum of 1,500 ml was present. The bleeding was coming from a 2.5 cm tear in the splenic capsule near the hilum. Splenectomy was performed. After resuscitation with 2 litres of whole blood, 2 litres of S.P.P.S.,and 3 litres of Hartmann’s solution, the patient made an excellent recovery. Histological examination of the spleen showed no abnormality apart from the rupture. Case 2
The second patient was aged 23 years, in her third pregnancy. Her previous history was uneventful and the present pregnancy had been normal up to the day of admission. At 37 weeks of gestation, after vomiting for 2 to 3 hours at home, the patient “felt something give” on her left side, and felt progressively weaker. On arrival at hospital by ambulance she was shocked, with a thready pulse of 100 per minute, a systolic blood pressure of 60 mm Hg, and some abdominal discomfort. The fetal heart rate was thought to be 70 per minute, and the abdominal flanks were slightly distended. A diagnosis of intraperitoneal bleeding was made, and resuscitation started with 2 intravenous infusions of Hartmann’s solution and oxygen by face mask. On arrival in theatre the patient was moribund, with an unrecordable blood pressure and a pulse too thready to record.
At laparotomy, by midline vertical incision, the abdomen contained approximately 3 litres of blood. The baby was delivered rapidly through the lower uterine segment, and the abdominal incision extended up to the xiphisternum. The lateral border of the spleen contained a 3 cm tear and splenectomy was performed. The free blood was removed, the lower uterine segment repaired, and the abdomen closed. The patient was transfused with a total of 2 litres of Hartmann’s solution, 1,300 ml of plasma, and 3.3 litres of blood, the first litre being uncrossmatched. The central venous pressure was monitored during the period of rapid intravenous fluid replacement, and after operation the patient was wrapped in a heated water blanket to raise her temperature, which had fallen to 35°C. Her postoperative course was uneventful. The baby, a male weighing 2,800 g, was stillborn but was actively resuscitated, and scored 3 on the Apgar scale at 10 minutes. The baby’s development was abnormal from the start. At 3 months signs of quadraplegic spasticity were present, and neurological development was that of a 3-week old baby. Apart from the tear, the spleen was again macroscopically and histologically normal. DISCUSSION
A total of 57 cases of rupture of the spleen have been reported in the English literature (Sparkman, 1958; Embrey and Painter, 1962; Gudgeon, 1967).
118
AUST. AND N.Z. JOURNALOF OBSTETRICS A N D GYNAECOLOGY
The aetiology is largely conjectural: Sparkman (1958) looked at 3 suggested factors - trauma, antecedent disease of the spleen, and pre-eclampsia. In only 16 of the 44 cases he reviewed were any of these present, leaving a majority with no apparent cause. The part played by trauma has been further obscured by large series in the non-obstetric literature of “delayed rupture” - the interval between trauma and rupture being anything up to several weeks (McIndoe, 1932; Zabinski and Harkins, 1943; Fultz and Actemeier, 1955). Because of the rarity of spontaneous rupture of the spleen, it is impossible to establish whether it is more prevalent in the pregnant or nonpregnant patient. The majority of cases (67%) occur in the last trimester of pregnancy, and it had been suggested that splenic enlargement and increase in blood volume which occur in pregnancy may be implicated in the pathogenesis (Sparkman, 1958; Gudgeon, 1967). In the 2 cases described ‘in the present report there was no obvious cause for the rupture. One patient had been vomiting prior to the rupture, but the other had gone through a normal labour; neither of these incidents would normally be expected to lead to such a catastrophe.
Both babies were affected by the maternal hypovolaemia. In Case 1, in retrospect, the first sign of the maternal catastrophe was sudden fetal bradycardia in a previously normal tracing. These cases illustrate the importance of intraperitoneal haemorrhage as a cause of collapse in pregnancy. The presence of a pregnancy should not delay adequate resuscitation and early laparotomy.
Ref erencex Brass, P. (1977), Amer. J . Obstet. Gynec., 128: 228 42: 575. Embrey, M. P., and Painter, N. S. (1962), Brit. J . Srirg., Fultz, C . T., and Altemeier, W. A. (1955), Surgery, 38: 414. Gudgeon, C. W. (19671, Aust. N.Z. J . Obstct. Gynacc., 7: 99. Hodgkinson, C. P., and Christensen, R. C. (19501, Amer. J . Obstct. Gynec., 59: 112. Macfarlane, J. R., and Thorbjarnarson, B. (1966), Amer. J . Obstet. Gynec., 95: 1025. McIndoe, A. H. (1932), Brit. J . Surg., 20: 249. Roxburgh, D. R. (1975), Aiist. N.Z. J . Obstet. Gynacc., 15: 234. Sparkman, R. S. (1958), Amcr. J . Obstet. Gynec., 76: 587. Zabinski, E. J., and Harkins, H. N. (1943), Arch. Surg., 46: 186.
Spontaneous Rupture of the Spleen in Late Pregnancy P. R. Henderson' and J . D. Keeping
Depurtnient of Obstetrics untl Gynuecology, Royul Bris bane Hospital, HerJton and Depurtnient of Obstetrics unrl Gynaecology, Mater Misericorrliue Hospirul, South Brisbane
Surnmury: Two cases of spontaneous rupture of the spleen are described. The first patient presented with fetal distress in the second stage of labour; the second with hypovolaemic shock. Both mothers and babies survived.
Haemoperitoneum is a rare but important cause of collapse in late pregnancy, and is associated with an appreciable maternal and fetal mortality. Hodgkinson et al. (1950) reviewed 75 cases of uteroovarian vein rupture in which the maternal mortality was 49%. In Macfarlane and Thorbjarnarson's (1966) series of 61 cases of ruptured splenic artery aneurism, the maternal mortality was 72%. A maternal mortality of 45% was reported by Sparkman (1958) in 44 patients with splenic rupture. In recent years, cases have appeared in which both mother and baby survived (Roxburgh, 1975; Brass, 1977). Tn the 2 cases described here the mothers and babies also survived, although one infant is severely retarded. Case 1
The patient, aged 26, was in her fourth pregnancy. There was' no significant past medical, surgical or obstetrical history. The course of her current pregnancy was smooth and she went into spontaneous labour at 41 weeks of gestation. The first stage lasted 8 hours and was uneventful, except that the descent of the head was delayed until the last hour. 1 . Temporary Clinical Lecturer.
Tn the second stage, the head descended to the ischial spines with several pushes. The fetal heart then became irregular and developed a baseline bradycardia of 90 beats/minute with loss of baseline variability (Fig. 1). Vaginal examination revealed the head to be 3 cm below the ischial spines and in a transverse position. Kielland's forceps rotation was performed, resulting in the delivery of a male weighing 3,505 g. The baby was apnoeic, deeply cyanosed, and had a heart rate of 90/minute. Intubation was performed at 2 minutes and assisted ventilation continued for 24 minutes, when spontaneous respiration was established. Thereafter, apart from initial irritability, the progress of the baby has been normal to 1 year. lmmediately after delivery the mother was found to be hypotensive, semiconscious, and to have a tachycardia of 110 beats/minute. Her pulse and blood pressure had previously been normal. She denied any symptoms; in particular, she had no abdominal pain or dyspnoea. She was not cyanosed. The third stage was completed without incident and an intravenous infusion commenced. Examination of chest, abdomen and central nervous system was normal, as was a chest radiograph. At this point the patient complained of shoulder tip pain. A provi-
P. R . HENDERSON AND J . D. KEEPING
Iu HEWLETT-PACKARD
9270-0484
MEDICAL PRODUCTS GROUP
117
7b $0
Figure 1.
sional diagnosis of intraperitoneal bleeding was made and laparotomy arranged. At operation, a haemoperitoneum of 1,500 ml was present. The bleeding was coming from a 2.5 cm tear in the splenic capsule near the hilum. Splenectomy was performed. After resuscitation with 2 litres of whole blood, 2 litres of S.P.P.S.,and 3 litres of Hartmann’s solution, the patient made an excellent recovery. Histological examination of the spleen showed no abnormality apart from the rupture. Case 2
The second patient was aged 23 years, in her third pregnancy. Her previous history was uneventful and the present pregnancy had been normal up to the day of admission. At 37 weeks of gestation, after vomiting for 2 to 3 hours at home, the patient “felt something give” on her left side, and felt progressively weaker. On arrival at hospital by ambulance she was shocked, with a thready pulse of 100 per minute, a systolic blood pressure of 60 mm Hg, and some abdominal discomfort. The fetal heart rate was thought to be 70 per minute, and the abdominal flanks were slightly distended. A diagnosis of intraperitoneal bleeding was made, and resuscitation started with 2 intravenous infusions of Hartmann’s solution and oxygen by face mask. On arrival in theatre the patient was moribund, with an unrecordable blood pressure and a pulse too thready to record.
At laparotomy, by midline vertical incision, the abdomen contained approximately 3 litres of blood. The baby was delivered rapidly through the lower uterine segment, and the abdominal incision extended up to the xiphisternum. The lateral border of the spleen contained a 3 cm tear and splenectomy was performed. The free blood was removed, the lower uterine segment repaired, and the abdomen closed. The patient was transfused with a total of 2 litres of Hartmann’s solution, 1,300 ml of plasma, and 3.3 litres of blood, the first litre being uncrossmatched. The central venous pressure was monitored during the period of rapid intravenous fluid replacement, and after operation the patient was wrapped in a heated water blanket to raise her temperature, which had fallen to 35°C. Her postoperative course was uneventful. The baby, a male weighing 2,800 g, was stillborn but was actively resuscitated, and scored 3 on the Apgar scale at 10 minutes. The baby’s development was abnormal from the start. At 3 months signs of quadraplegic spasticity were present, and neurological development was that of a 3-week old baby. Apart from the tear, the spleen was again macroscopically and histologically normal. DISCUSSION
A total of 57 cases of rupture of the spleen have been reported in the English literature (Sparkman, 1958; Embrey and Painter, 1962; Gudgeon, 1967).
118
AUST. AND N.Z. JOURNALOF OBSTETRICS A N D GYNAECOLOGY
The aetiology is largely conjectural: Sparkman (1958) looked at 3 suggested factors - trauma, antecedent disease of the spleen, and pre-eclampsia. In only 16 of the 44 cases he reviewed were any of these present, leaving a majority with no apparent cause. The part played by trauma has been further obscured by large series in the non-obstetric literature of “delayed rupture” - the interval between trauma and rupture being anything up to several weeks (McIndoe, 1932; Zabinski and Harkins, 1943; Fultz and Actemeier, 1955). Because of the rarity of spontaneous rupture of the spleen, it is impossible to establish whether it is more prevalent in the pregnant or nonpregnant patient. The majority of cases (67%) occur in the last trimester of pregnancy, and it had been suggested that splenic enlargement and increase in blood volume which occur in pregnancy may be implicated in the pathogenesis (Sparkman, 1958; Gudgeon, 1967). In the 2 cases described ‘in the present report there was no obvious cause for the rupture. One patient had been vomiting prior to the rupture, but the other had gone through a normal labour; neither of these incidents would normally be expected to lead to such a catastrophe.
Both babies were affected by the maternal hypovolaemia. In Case 1, in retrospect, the first sign of the maternal catastrophe was sudden fetal bradycardia in a previously normal tracing. These cases illustrate the importance of intraperitoneal haemorrhage as a cause of collapse in pregnancy. The presence of a pregnancy should not delay adequate resuscitation and early laparotomy.
Ref erencex Brass, P. (1977), Amer. J . Obstet. Gynec., 128: 228 42: 575. Embrey, M. P., and Painter, N. S. (1962), Brit. J . Srirg., Fultz, C . T., and Altemeier, W. A. (1955), Surgery, 38: 414. Gudgeon, C. W. (19671, Aust. N.Z. J . Obstct. Gynacc., 7: 99. Hodgkinson, C. P., and Christensen, R. C. (19501, Amer. J . Obstct. Gynec., 59: 112. Macfarlane, J. R., and Thorbjarnarson, B. (1966), Amer. J . Obstet. Gynec., 95: 1025. McIndoe, A. H. (1932), Brit. J . Surg., 20: 249. Roxburgh, D. R. (1975), Aiist. N.Z. J . Obstet. Gynacc., 15: 234. Sparkman, R. S. (1958), Amcr. J . Obstet. Gynec., 76: 587. Zabinski, E. J., and Harkins, H. N. (1943), Arch. Surg., 46: 186.
