Spontaneous rupture of splenic artery aneurysm in pregnancy: is splenectomy always necessary?

Abstract

Sir, We wish to call attention to the case of a 39-year-old woman, pluripara, in her 35 weeks’ gestation who presented acute abdominal pain with vomiting. The past clinical and obstetric history was unremarkable. The pain was dull and gradually increasing, mainly located to the epigastric and left upper quadrant. Blood pressure and heart rate were normal. Ultrasound examination was performed showing normal fetal heart rate and biometry and a considerable collection of free-fluid and blood clot in the pouch of Douglas. The patient developed severe hypotension, acute anemia and syncope. An emergency cesarean section was performed and a massive hemoperitoneum confirmed. The uterus was intact and there was no visible bleeding from any other pelvic organ. A live fetus (Apgar score 4–8) was delivered and was transferred to the Neonatal Intensive Care Center. The placenta did not show evidence of abruption. Exploration of the abdomen with a general surgeon in attendance showed a ruptured splenic artery aneurysm located in the distal segment of the vessel. The aneurysmal sac was conservatively treated by surgical ligature of the splenic artery. Bleeding was controlled with prompt recovery of the blood pressure. Careful inspection of the spleen was undertaken and no signs of ischemic areas were noted and it was decided to avoid splenectomy meantime. A postoperative total body computed tomography scan was done to confirm possible residual bleeding and/or ischemic areas in the spleen, but both were negative. The patient received three units of red blood cells and was discharged home with her baby 10 days after surgery. Splenic artery aneurysm is the most common visceral artery aneurysm (1–3). It occurs more frequently in younger females. Up to 95% of cases take place during pregnancy, particularly in third-trimester multiparous women, considered to be related to endocrine and mechanical causes (3). Most are asymptomatic until rupture. A recent review reports 32 cases showing a mean maternal and gestational age of 27.9 years and 34.5 weeks, respectively (3). In our case the distal part of the splenic artery was involved, which is rare (3). Splenic artery rupture in pregnancy is rare and can be catastrophic, with high maternal and fetal mortality (1–3). Splenectomy is usually performed in addition to resection and/or ligation of the aneurysm (2) but may sometimes be avoided because of multiple peripancreatic and perisplenic collateral vessels that enable perfusion even after splenic artery ligation. The development of such a vascular variant was demonstrated by magnetic resonance imaging six months after surgery. Obstetricians should consider possible rupture of a splenic artery aneurysm as a cause of acute abdominal hemoperitoneum in the third trimester of pregnancy.