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Peripartum Hemorrhage: Splenic Artery Aneurysm Rupture
Abstract Number: T 43
Abstract Type: Case Report/Case Series
Peripartum hemorrhage (PPH) is one of the leading causes of maternal mortality, accounting for nearly 25% of fatalities.(1) One rare cause of PPH is splenic artery aneurysm (SAA) rupture. We present a case of PPH associated with SAA rupture and subsequent successful resuscitation.
A 32 year-old female, G2P1001 at 34 weeks gestation, presented to labor and delivery with increasing abdominal pain and vaginal spotting. She was found to be tachycardic and hypotensive. Fetal bradycardia was identified, and an emergency cesarean section was called. Our initial assessment of the patient in the operating room (OR) revealed a pale, lethargic, ~60kg pregnant female. Her history and physical exam were otherwise unremarkable. Standard ASA monitors were placed and a rapid sequence induction was performed using etomidate and succinylcholine. A radial arterial line and second 18G PIV were placed. The institution’s massive transfusion protocol was initiated.
The neonate was delivered 4 minutes after the patient entered the OR. Apgar scores at 1, 5, and 10 minutes were 0, 3, and 6. No pathology was identified in the placenta or uterus.
The patient remained stable initially, but intractable bleeding continued from an unidentified source. The trauma surgery service was emergently consulted. During exploration, the patient became unstable. Two 16G PIV’s were placed and a Belmont rapid infuser and cell scavenging device were employed.
The trauma surgeons identified the source of bleeding as a ruptured SAA. A splenectomy and partial pancreatectomy was performed, and the patient was stabilized. Her resuscitation included 41 units of packed red blood cells, 2.3L of scavenged cells, 20 units of fresh frozen plasma, 4 platelet concentrate packs, 4 units of crypoprecipitate, 8L of crystalloid, and 1L of albumin.
Postoperatively the patient was taken to the surgical intensive care unit intubated, but stable. On postoperative day (POD) 3 she was extubated without evidence of adverse sequelae. The infant remained stable and was extubated on POD 1 without apparent sequelae.
Ruptured SAA during pregnancy is a rare event with potentially catastrophic consequences. SAA rupture presents with a constellation of signs and symptoms that may be mistaken for other pathology, and it has an identified maternal mortality of nearly 22% and fetal mortality of 15%.(2) While rare, SAA rupture should be considered in the differential diagnosis when other causes of peripartum hemorrhage have been excluded. Anesthetic concerns in this case consist of 1) accurate diagnosis of source of massive hemorrhage 2) obtaining timely adequate intravenous access and 3) administration of blood products appropriate to maintain adequate coagulation and hemodynamic stability.
1)Caillouette JC, et al. Ruptured SAA in pregnancy. Am J Obstet Gynecol.1993 Jun:1810-1.
2)Ha JF, et al. SAA rupture in pregnancy. Eur J Obstet Gynecol Reprod Biol.2009 Oct:133-7.