Spontaneous rupture of the spleen at full term during pregnancy: a case report

Abstract

Spontaneous rupture of the spleen during pregnancy is a rare, fatal disease. This condition is easily misdiagnosed as uterine rupture, placental abruption, or other obstetric diseases; and if a timely diagnosis is not made and effective treatment instituted, serious sequelae rapidly develop, including hemorrhagic shock and maternal and fetal death. Here, we report a case of spontaneous splenic rupture in a woman in her third trimester of pregnancy. Furthermore, through a literature review, we discuss the possible presentations, symptoms, and causes of splenic rupture during pregnancy, in the hope of facilitating the early diagnosis and treatment of this condition.

Introduction

Spontaneous rupture of the spleen during pregnancy is a rare condition, with few documented cases worldwide. ¹ Failure of a clinician to rapidly recognize this condition and surgically intervene can result in the death of both the mother and baby. ² Obstetricians may be the first group of clinicians to encounter patients with such obstetric emergencies, and therefore it is important that they have a good understanding of such conditions. In this manuscript, we report a case of spontaneous rupture of the spleen during the third trimester of pregnancy that was rapidly followed by the development of hypovolemic shock. Through the study of this case, we hope to improve the ability of obstetricians to rapidly recognize, diagnose, and treat acute abdominal disease in pregnant women.

Case report

We have reported this case according to the CARE guidelines. ³ We obtained the informed consent of the patient for treatment and for the publication of her case. All the details presented have been confirmed by the patient.

A 25-year-old female patient was admitted to the hospital because of the lack of signs of delivery, despite her pregnancy continuing 2 days beyond the expected date of delivery. The patient had a history of thrombocytopenia since childhood and had undergone therapeutic splenic artery embolization 10 years previously. She had undergone regular examinations during her pregnancy, and her platelet count had been between 70 × 10⁹ and 100 × 10⁹/L without specific treatment. The patient was hospitalized at 10:00 that day, without reporting discomfort at that time. However, at approximately 11:00, she developed epigastric pain, in the absence of any obvious uterine contraction on physical examination. Fetal heart rate monitoring showed deceleration of the fetal heart. At 11:24, a bedside B-ultrasound examination revealed that the fetal heart rate was 75 beats/minute, and there was almost no amniotic fluid. At that time, uterine rupture or placental abruption was suspected, and therefore cesarean section was immediately scheduled. However, during the preparation for surgery, the patient experienced a worsening of her abdominal pain and her condition rapidly deteriorated. When she entered the operating room at 11:50, she was very pale, she had cold skin, her consciousness was impaired, she had difficulty responding to her physician’s questions, and she showed other signs of shock. She had a heart rate of 108 beats/minute and a blood pressure of 80/50 mmHg. During surgery, a large amount of blood was found in her abdominal cavity, and a baby girl weighing 2.625 g was delivered by rapid cesarean section. The baby had an Apgar score of 0′-3′-4′/1-5-10′ and was transferred to a neonatal pediatrician for resuscitation. The uterus of the patient was exteriorized for exploration intraoperatively and no local hemorrhage or rupture was identified. Further abdominal exploration revealed a large amount of blood (>3000 mL) in the patient’s abdominal cavity and obvious enlargement of the spleen, which had a 3-cm tear at the splenic pedicle and continued to hemorrhage. Therefore, the surgeon performed a splenectomy, and the surgical procedure was uneventful. The total volume of pre-/intraoperative hemorrhage was 4500 mL; and the patient was administered an infusion of 9 iu red blood cell suspension, 1050 mL plasma, 16 iu cryoprecipitate, 9 iu platelets, 3 g fibrinogen, and 400 iu prothrombin complex. She was transferred to the Intensive Care Unit for further treatment following the surgery, and showed an improvement in her condition over the following 3 days, such that she could be returned to the general ward, and she was stable enough to be discharged a further 8 days later. Postoperative histopathological examination suggested congestive swelling of the spleen caused by thrombocytopenic purpura (Figure 1). A postoperative computed tomography image is shown in Figure 2.

Figure 1.

Histological section through the spleen of the patient, stained with hematoxylin and eosin, showing hyperemia, consistent with thrombocytopenic purpura. Magnification ×40.

Figure 2.

Postoperative computed tomography image of the abdomen.

The condition of the newborn improved and she was discharged after 10 days of treatment in the neonatal intensive care unit. No sequelae have been reported at the time of writing.

Discussion

Spontaneous rupture of the spleen, also known as the spontaneous pathological rupture of the spleen, is a relatively rare event that generally occurs secondary to an underlying condition. ⁴ Any rupture of the spleen is caused by the application of an external force; bending over, leaning over, or even turning over when asleep may lead to local rupture of the splenic capsule, owing to excessive tension. ⁵ The patient reported herein had a history of thrombocytopenia since childhood. Moreover, she had previously undergone therapeutic splenic artery embolization that induced obvious pathological changes in her spleen, and this was considered to be a significant contributor to her splenic rupture. In addition, there might have been structural changes in the spleen, secondary to hemodynamic changes resulting from the increases in circulating blood volume and estrogen and progesterone concentrations that characterize the third trimester of pregnancy. Furthermore, the risk of splenic rupture during pregnancy may be increased by the reduction in abdominal space, uterine contraction during pregnancy, and gestational hypertension.^6,7 The patient walked and bent over to organize her personal belongings on the day of admission, which may have contributed to the cause of the rupture.

Sudden-onset abdominal pain has been reported to be a principal symptom of patients who experience a rupture of the spleen during the third trimester of pregnancy. ⁸ The affected patients may report pain in their left upper abdomen, back, left subscapular area, or left hypochondriac region; and in addition may show myotonia of the abdominal musculature, hemorrhagic shock, and other signs; but generally do not report obstetric symptoms, such as vaginal bleeding and fluid flow. Furthermore, the large uterus may restrict the blood flow to the parietal peritoneum, leading to minor signs of peritoneal irritation during the early stage of the disease; and the diagnosis may be missed because abdominal pain owing to splenic rupture may be confused with labor pains. In addition, it is difficult to detect a decrease in blood pressure because the blood volume of a woman increases by 30% to 50% during the third trimester of pregnancy. ⁹ During such a physiologic hypervolemic state, hypovolemia only develops when the 30% to 50% of the blood volume of a pregnant woman has been lost. In the present case, the initial symptom to develop was epigastric pain, the cause of which could be easily confused with labor. However, further physical examination revealed no obvious uterine contraction. In addition, the fetus was in distress because of intrauterine fetal ischemia and hypoxia owing to blood loss, accompanied by a decrease in fetal heart rate and the finding of almost no amniotic fluid on B-ultrasonography. Indeed, the patient showed a rapid onset of symptoms and rapid deterioration, with the appearance of symptoms of shock during the half-hour period of preparation for surgery. This was accounted for by substantial hemorrhage into her abdominal cavity.

Fortunately, the patient described herein was already waiting for her delivery in the hospital when she developed her first symptom, which enabled successful emergency surgery to be performed immediately after her condition deteriorated. She was transferred to the operating room, where effective anti-shock treatment could be administered by an anesthesiologist, which gained time and stabilized her condition for the subsequent surgery, meaning that she survived without serious sequelae. However, we overlooked the possibility of splenic rupture during pregnancy, which should be considered in pregnant women with a history of thrombocytopenia or splenic disease. In such patients, ultrasonography of the spleen during pregnancy may be helpful in assessing their condition, and excessive movements that could induce splenic rupture should be minimized during the third trimester of pregnancy. Furthermore, in most instances, obstetricians are the first clinicians to come into contact with patients when obstetric emergencies and or spontaneous rupture of the liver or spleen develop. Therefore, it is critical to perform a comprehensive examination of pregnant women with abdominal pain, and it is important for obstetricians to know the objectives of treatment and the methods of monitoring indicators of shock. ¹⁰