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Splenic artery rupture in an obstetric patient mimicking concealed placental abruption.
Abstract Number: F3D-1
Abstract Type: Case Report/Case Series
Introduction: Splenic artery aneurysm rupture is exceptionally rare in pregnant women, however, it carries a mortality of 75% and 95% for the mother and foetus respectively.1 We present a case of a pregnant woman with unrecognised splenic artery aneurism who suffered a cardiac arrest and survived.
Case Report: A 31 year old primiparous women at 29 weeks gestation attended the maternal assessment unit with sudden generalised abdominal pain and no bleeding. Positive findings included, hypotension, tachycardia, abdominal guarding; foetal ultrasonography demonstrated bradycardia. She underwent an emergency cesarean delivery under general anaesthesia for a suspected concealed placental abruption. The foetus was delivered, no placental abruption was found, however, there was a large volume of free blood within the abdominal cavity. During this time, despite aggressive resuscitation with intravenous fluids and blood products she suffered a hypovolaemic cardiac arrest for 20 minutes. The incision was extended to a full midline laparotomy by a general surgeon, no source was identified and the abdomen was packed. Ongoing abdominal distension, hypotension, deteriorating pH (7.17) and lactate (14.9) warranted an immediate second laparotomy to ligate a short gastric branch of the splenic artery.
The estimated blood loss was 15 litres, requiring a massive transfusion of 26 packed red cell units, 19 plasma units, 9 cryoprecipitate units and 4 pools of platelets, as well as recombinant factor VIIa. The lowest Hb recorded was 73 g/l. She was transferred to Intensive care for 7 days and had one failed trial of extubation, secondary to developing the classical picture of TRALI after 72 hours.
She went on to make a full recovery and was discharged home at 21 days. The foetus was delivered alive, but despite aggressive resuscitation and immediate transfer to a specialist local tertiary centre, treatment was withdrawn 14 days later.
Discussion: Although rare, a splenic artery aneurysm has an estimated probability of rupturing during pregnancy of between 20-50%, associated with a mortality of 75% for the mother and 95% for the foetus.1 The presentation of abdominal pain and shock is often misdiagnosed as a concealed placental abruption, however, the best management involves simultaneous obstetric and general or vascular surgical input.1 Awareness of splenic artery aneurysm rupture in pregnancy by all front line staff is important in achieving the correct management and best outcome.1 An early multi disciplinary team approach may be facilitated through detection of free fluid within the abdomen prior to surgery by ultrasound or computed tomography.2
1. Gent L, Blackie P, The Spleen, BJA Educ. 2017; 17 (6): 214-220.
2. Hope J, Diaconu S, Maluso P, Ruptured Splenic Artery Aneurysms and the Use of an Adapted Fast Protocol in Reproductive Age Women with Hemodynamic Collapse: Case Series. Case Reports in Emergency Medicine. 2014; Article ID 454923, 5 pages.