Abstract
This is the case of a 38 year-old Lebanese woman G2P1, history of previous cesarean section, presenting at 30+5 weeks of gestation with acute left-sided flank pain and a two-day history of chills and dysuria. In light of the clinical presentation, the patient was initially diagnosed with pyelonephritis and managed accordingly; however, her clinical status deteriorated with worsening hypotension and lethargy despite resuscitative measures and a normal abdominal ultrasound. Failure to revive the patient eventually led to a cardiac arrest for which a peri-mortem cesarean section was performed at bedside. Upon abdominal entry, an actively-bleeding ruptured splenic artery aneurysm (SAA) was identified, for which massive transfusion protocol was activated, and the patient was transferred to the operating room. The patient had a complicated postoperative course, the fetus was stillborn, and she was discharged home after 6 months of hospital stay. In view of the high mortality and morbidity associated with ruptured SAA in pregnancy, early recognition and prompt intervention are crucial for maternal and fetal benefit.
Highlights
A wise man once said “For an understanding of the future, look to the past” [1]
splenic artery aneurysm (SAA) was first reported by Beaussier in 1770, and another case was reported by Parker in 1844; these two cases were for many years omitted from the literature not to mention erroneously credited to another author [2]
Of importance is the significant difference in mortality between pregnant and non-pregnant patients: mortality outside of pregnancy ranges from 10–25%, whereas in pregnancy, maternal mortality increases up to 75%, and fetal mortality increases to as high as 95% [16]
Summary
A wise man once said “For an understanding of the future, look to the past” [1]. Outside of pregnancy, SAA was first reported by Beaussier in 1770, and another case was reported by Parker in 1844; these two cases were for many years omitted from the literature not to mention erroneously credited to another author [2]. The majority of splenic artery aneurysms are diagnosed at the time of laparotomy; in the setting of a high clinical suspicion, radiological investigations are helpful in making the diagnosis in both emergency and elective settings; the diagnostic utility of radiologic studies, in pregnancy remains questionable [24]. They should not delay the immediate resuscitation and control of the hemorrhage by emergency surgery [24]. Because of the high mortality rate and common misdiagnosis, splenic artery aneurysm should be on the differential of any pregnant woman with abdominal pain, especially in the setting of hemodynamic instability [20]
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