171
Int. J. Gynecol. Obstet.. 1990,31: 171-173 International Federation of Gynecology and Obstetrics
Spontaneous S. Nanda,
splenic rupture in early pregnancy
N. Gulati
and K. Sangwan
Department of Obstetrics and Gynaecology, Medical College and Hospital, Rohtak-124001 (India) (Received August lSth, 1988) (Revised and accepted February 6th, 1989)
Abstract
examination. The present case fulfils all these criteria of a spontaneous rupture.
Spontaneous rupture of a normal spleen is a rare entity. We report a case of spontaneous rupture during early pregnancy. Ruptured ectopic pregnancy was suspected preoperatively, but on exploration a splenic rupture was detected and splenectomy performed. Keywords: Spleen; Pregnancy;
Rupture.
Introduction
Splenic rupture is rare in pregnancy and carries a high mortality rate. The etiologies of splenic rupture in pregnancy include trauma, rupture of a spleen with underlying diseases such as toxemia, malaria, mononucleosis, neoplasm, hemangioma or aneurysm. However spontaneous rupture is reported rarely. Four criteria given by Orloff and Peskin [7] must be fulfilled before a spontaneous rupture is diagnosed. Firstly, no history of trauma can be elicited. Secondly, there is no evidence of any disease that may adversely affect the spleen. Thirdly, no evidence of perisplenic adhesions or scarring of the spleen to suggest previous trauma is present at laparotomy or autopsy. Finally the spleen should be normal macroscopically and on histologic
Case report A 26-year-old third gravida, para two was admitted at 13 weeks gestation with a 12-h history of acute upper abdominal pain. It began suddenly while she was resting in bed. No history of recent trauma, forceful coughing or sneezing or usage of seat belt was elicited on careful direct questioning. There was no past medical history of note. Oral and parenteral analgesics given by the family doctor brought her no relief. Moderate pain persisted, became very severe and spread to whole of abdomen after 12 h, prompting admission to hospital. Symptoms at admission also included nausea, vomiting and syncope. She presented in acute distress. Her pulse was 14O/min and weak. Her BP was 90/ 60 mmHg. Her abdomen was tense and diffusely tender. On pelvic examination, her cervix was tender to palpation, uterus was soft, 12-14 weeks size, lateral fornices were also tender and full without any definite mass and posterior fornix was bulging. Her hemoglobin was 5 g%. Ruptured ectopic pregnancy with hemoperitoneum was suspected. Culdoscentesis revealed dark blood. On laparotomy, hemoCase Report
112
Nanda et al.
peritoneum of about 2 1 of dark blood was removed from the peritoneal cavity. Uterus was 12-14 weeks in size, both fallopian tubes and ovaries were normal. Exploration revealed fresh hemorrhage from the left hypochondrium. The incision was extended exposing a single 3.5 cm long tear on inferomedial surface of a normal appearing spleen. The rupture site was actively bleeding. Prompt splenectomy was performed. The patient was transfused 3 1of blood. The spleen measured 13 x 8 x 5 cm and weighed 240 g. Except for the rupture site and a large subcapsular hematoma, the spleen appeared normal. On microscopic examination, the structure was quite normal and there were no abnormalities in the parenchymous tissue. There was no evidence of any splenic artery aneurysm. Postoperative recovery was uneventful until the tenth day when she complained of a brownish vaginal discharge. Ultrasound revealed a missed abortion and she underwent dilatation and curettage. She was discharged well on the twelveth postoperative day. Discussion
The majority (80%) of splenic ruptures in pregnancy occur during the last trimester [8]. Sparkman [8] and Bucksbaum [2] who had reviewed 37 and 21 cases of splenic rupture in pregnancy, observed only 3 and 4 cases, respectively, of spontaneous rupture in early pregnancy. Recently one case of delayed spontaneous rupture in first trimester of pregnancy has been described, where rapid surgical intervention saved the mother and fetus and the pregnancy reached full term [5]. No historic, operative or microscopic cause for splenic rupture could be found in the present case. Exceedingly minor trauma such as forceful vomiting, bending, coitus has been implicated in splenic rupture during pregnancy and cannot be ruled out here. Undetected local areas of disease or local vascular abnormalities such as intrasplenic
Int J Gynecol Obstet 31
hemangiomas or aneurysms are possible, but careful histopathology makes them unlikely. Various explanations have been proposed for the predisposition of spleen to spontaneous rupture during pregnancy. These include changes in organ position caused by the growing uterus rendering the spleen and its vascular pedicle more vulnerable and hypervolemia during pregnancy [4]. Since these changes are more pronounced during the last trimester, a higher incidence of rupture is expected during late pregnancy. However, after excluding traumatically and pathologically changed spleens, no date have demonstrated that rupture occurs more frequently in early as opposed to late pregnancy [3]. Splenic artery aneurysm may develop during pregnancy and rupture, the reasons for which are not known [ 11. The features of intraperitoneal hemorrhage, shoulder pain and generalised abdominal pain aggravated by movement or deep breathing appearing almost 12 h after the first phase of pain suggest splenic rupture. Typically three phases are noted, i.e. an initial acute phase of pain without shock, a latent period followed by another phase of severe pain with shock. As in the present case, correct preoperative diagnosis is often not made in pregnancy. Depending on gestational age, the most common preoperative diagnosis are ruptured ectopic pregnancy, ruptured uterus or abruption. Without diagnosis and proper treatment, maternal mortality is 100% while with treatment it is only 5-30% [4]. Early diagnosis and prompt surgical intervention can improve the maternal and fetal salvage. Splenectomy remains the treatment of choice, although successful splenic salvage with splenic artery ligation for splenic artery aneurysm rupture has recently been reported [6]. References 1 Buchet C, Simon P, Bertrand J, Lansac J: Rupture spontanee dun anevrysme de I’artere splenique en tours de
Spontaneous splenic rupture in early pregnancy
2
3
4
5
grossesse. A propos d’un nouveau cas. J Gynecol Obstet Biol Reprod (Paris) 13(2): 157, 1984. Bucksbaum HJ: Splenic rupture in pregnancy. Report of a case and review of literature. Obstet Gynecol Surv 22: 381, 1967. de Graff J, Pijpers PM: Spontaneous rupture of the spleen in third trimester of pregnancy. Report of a case and review of literature. Eur J Obstet Gynecol Reprod Biol 25: 243, 1987. Hoffman RL: Rupture of the spleen. A review and report of a case following abdominal hysterectomy. Am J Obstet Gynecol113: 524, 1972. Krasnodebski J, Olearczyk-Nycz U: Przypadek Opoznionego pekniecia Sledziony u ciezarnej. Ginekol Pol 55(7): 531, 1984.
6
7 8
113
Mehrotra D, diBenedetto R, Theriot E, Mehta P: Spontaneous rupture of splenic artery aneurysm: Sixth instance of both maternal and fetal survival. Obstet Gynecol62: 6651983. Orloff MJ, Peskin GW: Spontaneous rupture of the normal spleen-a surgical enigma. Int Abst Surg 106: 1, 1958. Sparkman RS: Rupture of spleen in pregnancy. Am. J. Obstet Gynecol 76: 587, 1958.
Address for reprints: S. Nanda 25150 Subhash Nagar (Behind Raj) Rohtnk-124001 India
Case Report
Int. J. Gynecol. Obstet.. 1990,31: 171-173 International Federation of Gynecology and Obstetrics
Spontaneous S. Nanda,
splenic rupture in early pregnancy
N. Gulati
and K. Sangwan
Department of Obstetrics and Gynaecology, Medical College and Hospital, Rohtak-124001 (India) (Received August lSth, 1988) (Revised and accepted February 6th, 1989)
Abstract
examination. The present case fulfils all these criteria of a spontaneous rupture.
Spontaneous rupture of a normal spleen is a rare entity. We report a case of spontaneous rupture during early pregnancy. Ruptured ectopic pregnancy was suspected preoperatively, but on exploration a splenic rupture was detected and splenectomy performed. Keywords: Spleen; Pregnancy;
Rupture.
Introduction
Splenic rupture is rare in pregnancy and carries a high mortality rate. The etiologies of splenic rupture in pregnancy include trauma, rupture of a spleen with underlying diseases such as toxemia, malaria, mononucleosis, neoplasm, hemangioma or aneurysm. However spontaneous rupture is reported rarely. Four criteria given by Orloff and Peskin [7] must be fulfilled before a spontaneous rupture is diagnosed. Firstly, no history of trauma can be elicited. Secondly, there is no evidence of any disease that may adversely affect the spleen. Thirdly, no evidence of perisplenic adhesions or scarring of the spleen to suggest previous trauma is present at laparotomy or autopsy. Finally the spleen should be normal macroscopically and on histologic
Case report A 26-year-old third gravida, para two was admitted at 13 weeks gestation with a 12-h history of acute upper abdominal pain. It began suddenly while she was resting in bed. No history of recent trauma, forceful coughing or sneezing or usage of seat belt was elicited on careful direct questioning. There was no past medical history of note. Oral and parenteral analgesics given by the family doctor brought her no relief. Moderate pain persisted, became very severe and spread to whole of abdomen after 12 h, prompting admission to hospital. Symptoms at admission also included nausea, vomiting and syncope. She presented in acute distress. Her pulse was 14O/min and weak. Her BP was 90/ 60 mmHg. Her abdomen was tense and diffusely tender. On pelvic examination, her cervix was tender to palpation, uterus was soft, 12-14 weeks size, lateral fornices were also tender and full without any definite mass and posterior fornix was bulging. Her hemoglobin was 5 g%. Ruptured ectopic pregnancy with hemoperitoneum was suspected. Culdoscentesis revealed dark blood. On laparotomy, hemoCase Report
112
Nanda et al.
peritoneum of about 2 1 of dark blood was removed from the peritoneal cavity. Uterus was 12-14 weeks in size, both fallopian tubes and ovaries were normal. Exploration revealed fresh hemorrhage from the left hypochondrium. The incision was extended exposing a single 3.5 cm long tear on inferomedial surface of a normal appearing spleen. The rupture site was actively bleeding. Prompt splenectomy was performed. The patient was transfused 3 1of blood. The spleen measured 13 x 8 x 5 cm and weighed 240 g. Except for the rupture site and a large subcapsular hematoma, the spleen appeared normal. On microscopic examination, the structure was quite normal and there were no abnormalities in the parenchymous tissue. There was no evidence of any splenic artery aneurysm. Postoperative recovery was uneventful until the tenth day when she complained of a brownish vaginal discharge. Ultrasound revealed a missed abortion and she underwent dilatation and curettage. She was discharged well on the twelveth postoperative day. Discussion
The majority (80%) of splenic ruptures in pregnancy occur during the last trimester [8]. Sparkman [8] and Bucksbaum [2] who had reviewed 37 and 21 cases of splenic rupture in pregnancy, observed only 3 and 4 cases, respectively, of spontaneous rupture in early pregnancy. Recently one case of delayed spontaneous rupture in first trimester of pregnancy has been described, where rapid surgical intervention saved the mother and fetus and the pregnancy reached full term [5]. No historic, operative or microscopic cause for splenic rupture could be found in the present case. Exceedingly minor trauma such as forceful vomiting, bending, coitus has been implicated in splenic rupture during pregnancy and cannot be ruled out here. Undetected local areas of disease or local vascular abnormalities such as intrasplenic
Int J Gynecol Obstet 31
hemangiomas or aneurysms are possible, but careful histopathology makes them unlikely. Various explanations have been proposed for the predisposition of spleen to spontaneous rupture during pregnancy. These include changes in organ position caused by the growing uterus rendering the spleen and its vascular pedicle more vulnerable and hypervolemia during pregnancy [4]. Since these changes are more pronounced during the last trimester, a higher incidence of rupture is expected during late pregnancy. However, after excluding traumatically and pathologically changed spleens, no date have demonstrated that rupture occurs more frequently in early as opposed to late pregnancy [3]. Splenic artery aneurysm may develop during pregnancy and rupture, the reasons for which are not known [ 11. The features of intraperitoneal hemorrhage, shoulder pain and generalised abdominal pain aggravated by movement or deep breathing appearing almost 12 h after the first phase of pain suggest splenic rupture. Typically three phases are noted, i.e. an initial acute phase of pain without shock, a latent period followed by another phase of severe pain with shock. As in the present case, correct preoperative diagnosis is often not made in pregnancy. Depending on gestational age, the most common preoperative diagnosis are ruptured ectopic pregnancy, ruptured uterus or abruption. Without diagnosis and proper treatment, maternal mortality is 100% while with treatment it is only 5-30% [4]. Early diagnosis and prompt surgical intervention can improve the maternal and fetal salvage. Splenectomy remains the treatment of choice, although successful splenic salvage with splenic artery ligation for splenic artery aneurysm rupture has recently been reported [6]. References 1 Buchet C, Simon P, Bertrand J, Lansac J: Rupture spontanee dun anevrysme de I’artere splenique en tours de
Spontaneous splenic rupture in early pregnancy
2
3
4
5
grossesse. A propos d’un nouveau cas. J Gynecol Obstet Biol Reprod (Paris) 13(2): 157, 1984. Bucksbaum HJ: Splenic rupture in pregnancy. Report of a case and review of literature. Obstet Gynecol Surv 22: 381, 1967. de Graff J, Pijpers PM: Spontaneous rupture of the spleen in third trimester of pregnancy. Report of a case and review of literature. Eur J Obstet Gynecol Reprod Biol 25: 243, 1987. Hoffman RL: Rupture of the spleen. A review and report of a case following abdominal hysterectomy. Am J Obstet Gynecol113: 524, 1972. Krasnodebski J, Olearczyk-Nycz U: Przypadek Opoznionego pekniecia Sledziony u ciezarnej. Ginekol Pol 55(7): 531, 1984.
6
7 8
113
Mehrotra D, diBenedetto R, Theriot E, Mehta P: Spontaneous rupture of splenic artery aneurysm: Sixth instance of both maternal and fetal survival. Obstet Gynecol62: 6651983. Orloff MJ, Peskin GW: Spontaneous rupture of the normal spleen-a surgical enigma. Int Abst Surg 106: 1, 1958. Sparkman RS: Rupture of spleen in pregnancy. Am. J. Obstet Gynecol 76: 587, 1958.
Address for reprints: S. Nanda 25150 Subhash Nagar (Behind Raj) Rohtnk-124001 India
Case Report
