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Diagnostic Dilemma: Delayed/Spontaneous Splenic Rupture in Pregnancy
Abstract Number: F3C-7
Abstract Type: Case Report/Case Series
Splenic rupture during pregnancy is exceedingly rare and is commonly misdiagnosed as placental abruption or uterine rupture. It leads to high fetal and maternal mortality if intervention is not expeditious. Prior trauma is the leading cause of spontaneous splenic rupture, although can occurs in splenic artery aneurysm. We present a rare case of splenic rupture in 38 week parturient presented as placental abruption and the successful management of the patient.
A 19 year old female 38 weeks gestation presented with progressive abdominal pain for 2 hours. She was healthy except, 2 weeks prior she was in a motor vehicle accident in which she was a restrained passenger. She only had minor musculoskeletal pain at that time. During current presentation she was hypotensive and tachycardic; not responsive to multiple fluid boluses. On examination, her abdomen was tender and she had left shoulder pain. Fetal heart tracing was category II. Obstetrician made the diagnosis of placental abruption. Emergent C/S started under GA. On incision, about 1L of blood was evacuated from the peritoneum which was not from the uterus. Baby was delivered uneventfully with APGARS 8/9. Continued bleeding noted from the left upper quadrant. Further exploration reveled a 2cm splenic laceration, and splenectomy was done (Fig). Patient received 4 units of PRBCs and 2 units of FFP in the OR. She was taken to the ICU for close monitoring. 6 hours post-op, patient became hemodynamically unstable and was again taken to the OR where another 3L of hemoperitoneum was evacuated. Bleeding was noted from the splenic hilum, specifically splenic arterial bleeding. This was oversewn, the abdomen was packed, and she was transported to ICU. Patient received total of 12 units of PRBCs, 9 units of FFP and 1 unit of platelets. On inspection the following day, hemostasis was noted and the abdomen was closed. Patient and baby had an uneventful hospital course thereafter, and patient had a full recovery. Patient discharged home in stable condition on post-op day 7.
Splenic rupture is extremely rare in pregnant patients. High index of suspicion is needed as its occurrence can be fatal, especially if not managed immediately. Management should be aimed at maintaining hemodynamic stability as placental perfusion can rapidly decline due to exsanguination. Multi-disciplinary team work was instrumental for the successful management of this parturient and her baby.