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Perioperative Management of a Splenic injury and Postpartum Hemorrhage Following an Emergent Cesarean Section in a Patient with Concomitant Influenza A and Chorioamniotis.
Abstract Number: F2C-1
Abstract Type: Case Report/Case Series
Postpartum hemorrhage remains a significant cause of mortality among parturients worldwide(1). Peripartum splenic rupture is a rare and catastrophic cause of post-partum hemorrhage. Due to its vague presentation and, oftentimes, late diagnosis, it is associated with a high maternal and fetal mortality. Though seen mostly with severe preeclampsia, splenic rupture can be spontaneous or a result of various clinical scenarios(2).
A 22 year old G2P1A1 patient with active influenza A presented to our institution for premature rupture of membranes. An emergency cesarean section was performed under general anesthesia for failed induction of labor, moderate intrapartum meconium, chorioamnionitis and respiratory distress secondary to influenza. The surgery was performed with a vertical abdominal incision followed by a low transverse uterine incision. The patient remained intubated post operatively and was transferred to the intensive care unit (ICU) for further management of presumed evolving sepsis. She grew increasingly unstable in the ICU requiring vasopressor support. Marked abdominal distention was soon noted. Laboratory findings revealed a hemoglobin of 4g/dL and significant lactic acidosis. She was taken to the OR for an exploratory laparotomy by trauma surgery. Intraoperative findings included 5L hemoperitoneum, and a grade 2 splenic laceration, necessitating a splenectomy. The uterine incision was hemostatic. The patient was resuscitated appropriately using a massive transfusion protocol. Her post-operative course was uneventful and she was discharged home on post-operative day 10.
Although rare, peri-partum splenic rupture is a potential cause of postpartum hemorrhage and should be considered in all patients with hemodynamic instability. Potential contributing factors include hypervolemia, vascular engorgement of the spleen that changes its position relative to other abdominal organs, and a traumatic cesarean section2.In this case, confounding infections and a presumed diagnosis of sepsis led to a dangerously late diagnosis of hemorrhagic shock.
1. Lockhart E. (2015) Postpartum Hemorrhage: A Continuing Challenge. Hematology. 1 132.137
2. Blajajíc, D., Ivaniśević M., Djelmiš J., Majerovi ć M., Starčević V. (2004) Splenic rupture in pregnancy – traumatic or spontaneous event? European Journaal of Obstetrics and Gynecology and reproductive Biology, 115, 113-114.