Successful management of postpartum venous thrombosis following splenectomy for traumatic splenic rupture: a case report

Abstract

Traumatic splenic rupture is rare in pregnant women; and multiple venous thromboses of the portal vein system, inferior vena cava and ovarian vein after caesarean section and splenectomy for splenic rupture has not been previously reported. This case report describes a case of multiple venous thromboses after caesarean section and splenectomy for traumatic splenic rupture in late pregnancy. A 34-year-old G3P1 female presented with abdominal trauma at 33⁺¹ weeks of gestation. After diagnosis of splenic rupture, she underwent an emergency caesarean section and splenectomy. Multiple venous thromboses developed during the recovery period. The patient eventually recovered after anticoagulation therapy with low-molecular-weight heparin and warfarin. These findings suggest that in patients that have had a caesarean section and a splenectomy, which together might further increase the risk of venous thrombosis, any abdominal pain should be thoroughly investigated and thrombosis should be ruled out, including the possibility of multiple venous thromboses. Anticoagulant therapy could be extended after the surgery.

Introduction

The spleen is the most vulnerable substantive organ in closed abdominal injury. Over 30% of patients with multiple injuries also have abdominal injuries, among which splenic injuries account for approximately 16%. ¹ This suggests that splenic injury accounts for half of abdominal injuries and splenectomy is often the primary treatment for traumatic splenic rupture. However, there are common complications after splenectomy such as infection and thrombosis,^2–4 among which thrombosis is primarily observed in the portal vein system (including the main portal vein and its branches, superior mesenteric vein, inferior mesenteric vein and splenic vein). As pregnant women are more cautious and less likely to suffer trauma during pregnancy, few studies have been conducted on traumatic splenectomy during pregnancy, and the occurrence of multiple venous thromboses in the portal vein system, inferior vena cava and ovarian vein after this has not yet been reported. This current case report describes a case of multiple venous thromboses after an emergency caesarean section and splenectomy due to traumatic splenic rupture in late pregnancy.

Case report

In December 2020, a 34-year-old G3P1 female complaining of ‘abdominal pain for 5 h after a fall’ was admitted to the Department of Obstetrics and Gynaecology, Affiliated Xiaoshan Hospital, Hangzhou Normal University, Hangzhou, Zhejiang Province, China. In 2014, she underwent curettage due to a missed abortion. In 2015, she delivered by caesarean section due to fetal macrosomia. Her menstrual cycle was regular. At 33⁺¹ weeks of pregnancy, the patient landed on the left side of her body after an inadvertent fall. As the abdominal pain was not obvious at that time, she returned home. However, later she came to the hospital because the abdominal pain had worsened. She was admitted with a pulse of 98 beats/min and a blood pressure of 106/70 mmHg. Her height was 154 cm, her weight was 81 kg and her body mass index (BMI) was 34.1 kg/m². Physical examination revealed left abdominal tenderness, soft uterus texture and normal fetal heartbeat. Her haemoglobin level was 107 g/l and the platelet count was 192 × 10⁹/l. Doppler ultrasound showed a continuous muscle layer at the original incision in the lower segment of the uterus, no significant abnormal echoes in the liver and spleen, and 5.2 cm and 6.0 cm free-liquid dark areas in the left and right abdomen, respectively. After obtaining the patient’s consent, an abdominal computed tomography (CT) scan revealed the possibility of abdominal and pelvic haemoperitoneum and increased density of the spleen margin, and splenic rupture was considered. Following these examinations, traumatic splenic rupture with massive haemorrhage was diagnosed. As the pregnancy was 33⁺¹ weeks and her abdominal pain was progressively increasing, an emergency caesarean section and exploratory haemostasis were performed under general anaesthesia by tracheal intubation. Intraoperatively, a large amount of intraperitoneal blood and clot accumulation were observed (approximately 1800 ml). The uterus was intact and a male newborn with a birthweight of 2240 g and an Apgar score of 5 (1 min)/6 (5 min)/9 (10 min) was delivered by caesarean section. Further exploration of the lower pole of the spleen showed a laceration of approximately 2 cm with bleeding, and finally, a splenectomy was performed. The operation lasted 3 h and 1030 ml autologous blood transfusion was performed. Postoperative treatment such as rehydration and 2 g cefoperazone/sulbactam intravenous every 8 h for 3 days were administered. The patient went to the intensive care unit for postoperative care and her newborn to the neonatal intensive care unit.

On postoperative day (POD) 1, the white blood cell (WBC) count was 26.03 × 10⁹/l and the haemoglobin level was 100 g/l. On POD 2, the haemoglobin level reduced to 82 g/l, so two units of concentrated red blood cells were transfused to correct anaemia. Referring to the Queensland Clinical Guidelines for Venous thromboembolism (VTE) prophylaxis in pregnancy and the puerperium, ⁵ her high risk was ‘any surgery (pregnancy or postpartum)’ and her postpartum weight was 75 kg (BMI, 31.6 kg/m²). Therefore, the patient was administered low-molecular-weight heparin (LMWH) for standard prophylaxis while in hospital (40 mg enoxaparin subcutaneous once a day for 11 days). In subsequent routine blood tests, the platelet count gradually increased. On POD 8, the platelet count was 640 × 10⁹/l, so 0.1 g aspirin oral once a day was administered until discharge. The patient was discharged on POD 11 and the pathological examination after splenectomy did not reveal any pathological diseases. After discharge, enoxaparin was stopped, while aspirin was continued at the same dosage.

On POD 18, the patient presented to the Department of Obstetrics and Gynaecology, Affiliated Xiaoshan Hospital, Hangzhou Normal University with epigastric pain for 7 h. The patient’s WBC count was 9.07 × 10⁹/l, the haemoglobin level was 115 g/l, the platelet count was 1030 × 10⁹/l and the D-dimer level was 2.08 mg/l (normal range, 0–0.243 mg/l). An abdominal CT scan revealed a patchy soft tissue shadow in the spleen area. The next day, an abdominal CT enhancement scan showed embolism of the right branch of the portal vein, splenic vein, superior mesenteric vein, inferior vena cava and bilateral ovarian vein (Figure 1). Multiple thromboses were diagnosed, so 60 mg enoxaparin subcutaneous every 12 h was administered for 1 week and 0.1 g aspirin oral once a day was continued. At follow-up, the platelet counts began to decline. On POD 24, the anticoagulant was switched from enoxaparin to 3 mg warfarin oral once a day for 5 days, then adjusted to 2.25 mg warfarin oral once a day until discharge. On POD 32, she was discharged and continued to be anticoagulated with 2.25 mg warfarin oral once a day and 0.1 g aspirin oral once a day for 3 months. A CT scan at the local hospital 4 months after surgery revealed that the thromboses had disappeared. The study was approved by the Ethical Committee of Affiliated Xiaoshan Hospital, Hangzhou Normal University (no. 2023025) and written informed consent for treatment and publication of the case report was obtained from the patient. The reporting of this study conforms to CARE guidelines. ⁶

Figure 1.

Computed tomography images of a 34-year-old G3P1 pregnant female who initially presented with ‘abdominal pain for 5 h after a fall’ at 33⁺¹ weeks of pregnancy and subsequently underwent a splenectomy. Images taken on postoperative day 19 showed multiple venous thromboses (arrows): (a) right branch of the portal vein; (b) splenic vein thrombosis; (c) superior mesenteric vein thrombosis; (d) inferior vena cava thrombosis; (e) right ovarian vein thrombosis and (f) left ovarian vein thrombosis.

Discussion

To the best of our knowledge, this is the first report of multiple thromboses of the portal vein system, inferior vena cava and ovarian veins after caesarean section and splenectomy for traumatic splenic rupture during pregnancy. Based on a review of the pertinent literature, traumatic splenectomy during pregnancy is rarely reported. ⁷

The spleen is a substantial organ with a thin envelope and poor tensile resistance, which is easily ruptured during trauma. In late pregnancy, increased blood volume, increased splenic volume and decreased abdominal volume may increase the risk of splenic rupture. ⁸ Trauma is less common in women during pregnancy; therefore, splenic rupture is even rarer but needs to be clinically differentiated from uterine rupture and placental abruption, relying mainly on ultrasound or CT to confirm the diagnosis. ⁹ In this current case, the splenic rupture was diagnosed by a CT scan.

The spleen is the largest lymphoid and immune organ of the human body; and it plays an important role in immune function, anti-infection and tumour suppression.^10,11 Complications such as dangerous infection, coronary arteriosclerosis, secondary pulmonary hypertension, coronary heart disease and tumours have also been reported after splenectomy.^12,13 Therefore, nonsurgical options can be considered for patients with minor splenic injury, no other organ injuries and stable haemodynamics. Changes in vital signs and haemoglobin need to be closely monitored during follow-up. However, this current patient was pregnant and her abdominal pain was progressively increasing, so the presence of active bleeding was considered likely and surgery was selected after communicating with the patient.

There have been numerous reports of thrombosis after splenectomy, especially in the portal vein system.^3,14 A large cohort study of over 8000 patients also confirmed an increased risk of deep vein thrombosis and pulmonary embolism after splenectomy. ¹⁵ In another study, the factors associated with thrombotic complications after splenectomy involved hypercoagulability, platelet activation, endothelial alteration and altered lipid profiles, as well as haemodynamic alterations of the portal flow. ¹⁶

Due to the loss of the removal of retained platelets after splenectomy, platelets tend to increase rapidly in circulation in the short term. In this current case, the platelets also increased significantly after splenectomy, reaching a maximum of 1030 × 10⁹/l within 3 weeks after surgery. However, the relationship between increased platelet count and thrombosis after splenectomy remains contentious. Increased platelet count after splenectomy has been identified as a high-risk factor for thrombosis.^17,18 However, other reports have found that increased platelet count is not significantly associated with the occurrence of VTE after splenectomy.^3,14 Another study reported that primary thrombocytosis was found to be a high-risk factor for VTE, while secondary thrombocytosis was not significantly associated with VTE, ¹⁹ which concluded that secondary thrombocytosis after splenectomy does not imply a higher risk of VTE.

The risk of VTE (especially portal system thrombosis) in patients after splenectomy has also been reported to be associated with the indication for surgery and the patient’s underlying condition, with patients after traumatic splenectomy less likely to result in thrombosis, while patients with cirrhosis, myeloproliferative disease and splenomegaly at a higher risk of thrombosis after splenectomy.^9,20 In this current case, although it was a traumatic splenectomy, it was special because of the combination of pregnancy. Hypercoagulability is usually present in patients after splenectomy. ²¹ Pregnant and puerperal women are also in a hypercoagulable state, and compared with non-pregnant women, the incidence of VTE during pregnancy and the puerperal period increases by 4–5 times. ²² In addition, BMI ≥30 kg/m² has been recognized as an independent risk factor for the development of VTE after splenectomy. ²³ Obesity itself is also considered to be a risk factor for VTE. ²⁴ As stated earlier, the BMI of this patient was 34.1 kg/m² upon admission. These factors may have contributed to the multiple thromboses observed in this patient. The patient had no history of smoking and no family history of thromboembolic disease. She turned down genetic tests such as Factor V Leiden mutation and prothrombin gene mutation for financial reasons.

Pharmacological prophylactic anticoagulation after splenectomy has been reported to reduce the risk of VTE.^25,26 A meta-analysis reported that LMWH after splenectomy could reduce the occurrence of portal vein thrombosis without increasing the risk of postoperative bleeding. ²⁷ Another study of 297 post-splenectomy cases concluded that the rate of thrombosis was significantly lower in patients who received extended prophylactic anticoagulation with LMWH (2–4 weeks) after discharge, whereas the rate of antiplatelet administration did not differ between patients with and without thrombosis. ³ Whether the thrombotic event in the current patient could have been prevented had LMWH anticoagulation been administered after discharge remains unknown. However, this treatment approach needs to be validated by more clinical studies.

As for the treatment after thrombosis, the American Association for the Study of Liver Diseases recommended a transition from early LMWH to warfarin. ²⁸ A meta-analysis showed that initial anticoagulation with heparin followed by warfarin for 3–6 months resulted in complete resolution of the thrombus in 67% of patients and partial remission in 13%. ²⁹ A previous study also recommended warfarin anticoagulation for 3–6 months for patients with portal or inferior vena cava thrombosis. ² In this current case, LMWH anticoagulation was also initially given after thrombosis and then the patient was transferred to warfarin anticoagulation gradually 1 week later. A CT scan 4 months later showed that the thromboses had disappeared.

In conclusion, although traumatic splenic rupture is rare in pregnant women, the possibility of organ rupture should be considered when a pregnant woman has abdominal trauma accompanied by abdominal effusion, especially the spleen, which is an intra-abdominal organ more likely to rupture. Splenectomy combined with pregnancy may aggravate the risk of thrombosis. In the case of persistent abdominal pain and even fever after splenectomy, the possibility of thrombosis should be considered, especially portal vein thrombosis. Prophylactic anticoagulation after splenectomy can reduce the risk of thrombosis. For similar patients, the course of anticoagulation therapy may be extended to reduce the risk of thrombosis, but more clinical studies are required to confirm this. In the future, the screening and follow-up of thrombotic disease should be strengthened for such patients after surgery.

Supplemental Material

sj-pdf-1-imr-10.1177_03000605241255507 - Supplemental material for Successful management of postpartum venous thrombosis following splenectomy for traumatic splenic rupture: a case report

Supplemental material, sj-pdf-1-imr-10.1177_03000605241255507 for Successful management of postpartum venous thrombosis following splenectomy for traumatic splenic rupture: a case report by Hongdan Zhu, Xia Sang, Heli Wu, Wei Shen, Yanli Wang, Liling Yu, Mengjia Li and Tao Zhou in Journal of International Medical Research