A case report of emergency splenectomy following a suspected ruptured ectopic pregnancy

1. OPTIONALLOGO HERE A case report of emergency splenectomy following a suspected ruptured ectopic pregnancy Venkatesh Subramanian, Venkataraman Chandra, Sanjeev Sharma, Krish Gokul, Dmitri ArtioukhSouthport & Ormskirk Hospitals, Ormskirk,, Lancashire, UK Discussion Conclusions Case Report References A 19 year old lady (Gravida 1, Para 0) whose last menstrual period was approximately 8 weeks ago came to the emergency department with lower abdominal pain, left shoulder tip pain and dizziness. There was no history of trauma . She had a past medical history of type two Diabetes Mellitus treated with Metformin. On examination she was tachycardic and there was marked tenderness of the lower abdomen. A urinary pregnancy test done in the department was positive and she was transferred to the gynaecology ward. An immediate trans-vaginal ultrasound scan was performed and free fluid was seen in the pouch of Douglas but no intrauterine pregnancy. The serum β-hcg was 1764 iu/l and haemoglobin was 9.1 g/dl.  A presumed diagnosis of ruptured ectopic was made and she was taken to theatre for urgent exploratory laparotomy with a Pfannenstiel incision. Intra-operatively the ovaries, fallopian tubes and uterus looked macroscopically normal. However a massive haemoperitoneum of 1.5 litres was noted within the abdominal cavity and there was further trickling of blood in the left paracolic gutter. The patient required two units of intraoperative blood transfusion. Due to these findings the assistance of the general surgeons was sought. The incision was extended to a midline laparatomy; however the source of bleeding could not be easily identified. There was no bleeding from the small bowel, large bowel or mesenteries. Fresh oozing was noted from the spleen from a visible large defect in the splenic capsule. The patient underwent subsequent splenectomy. The serum β-hcg rapidly decreased post splenectomy to 68 iu/l and there was no clinical evidence of miscarriage. She was discharged home 8 days later. Histopathological analysis of the spleen revealed a histological normal spleen with partial loss of the splenic capsule of unknown cause. This case highlights two important presentations that all surgeons should be aware of. Firstly spontaneous rupture of the spleen during pregnancy is uncommon but the mortality from missed diagnosis remains high. In patients with suspected ruptured ectopic pregnancies where all pelvic organs intra-operatively look normal, there should be a high index of suspicion for rupture of the spleen. Secondly the true location of an ectopic pregnancy may not be seen either on ultrasound scan or intra-operatively in patients with massive haemoperitoneum. It is vital that these patients are followed up with serial serum β-hcg and ultrasound imaging and that we monitor the outcome of these PULs, which can later present as a persisting ectopic pregnancy and result in fatal maternal outcomes. There are documented cases of spontaneous rupture of the spleen during pregnancy in the literature with some being misdiagnosed as ruptured ectopic pregnancy. Whilst spontaneous rupture of the spleen is a rare phenomenon, misdiagnosis can lead to high rates of mortality. Computed tomography has been used to identify splenic rupture but this is not appropriate in the haemodynamically unstable patient. The pathophysiology of spontaneous rupture of the spleen is still very poorly understood with no clear mechanism described. A literature review revealed there are no case reports thus far of a patient with both spontaneous rupture of the spleen and pregnancy of unknown location (PUL).(1) PUL can be broadly defined as a biochemical indication of pregnancy but no signs of intra or extra uterine pregnancy seen on ultrasound or visualisation of an ectopic during surgery. The incidence of PUL has been reported as between 10-30% of all patients with a positive pregnancy test. The majority of these pregnancies can be managed expectantly with serial serum β-hcg and regular follow up in the early pregnancy unit. However as the patient was haemodynamically unstable urgent surgical exploration was indicated.(2) It is possible to speculate two explanations for the disappearance of the PUL: ·     Primary splenic pregnancy not histologically confirmed. ·     Tubal abortion with spontaneous rupture of the spleen. A primary abdominal pregnancy, where the site of implantation was the spleen, is extremely rare but known. The presentation of splenic pregnancies is very similar with haemodynamic instability secondary to haemorrhage from the spleen and this was the initial working diagnosis post-operatively. As histological analysis showed there was loss of capsule of the spleen it is possible to postulate that this capsular area was the site of a primary splenic pregnancy.(3) Tubal abortion is where a pregnancy is expelled from the tube before rupture. We found two reported cases of massive haemoperitoneum secondary to tubal abortion. However in both cases intra-operatively there was evidence of tubal pregnancy such as bleeding. In this patient both tubes were normal. There is no obvious association between tubal abortion and spontaneous rupture of the spleen in the literature. Albeit being extraordinarily rare for both of these conditions occurring in a single episode it would explain the clinical, histological and biochemical findings. (4) 1. Bljajić D, Ivanišević M, Djelmiš J, Majerović M, Starčević V. Splenic rupture in pregnancy—traumatic or spontaneous event? : Elsevier Scientific Publishers; 2004 [cited 115 1]; 113-4]. 2. Kirk E, Bourne T. Pregnancy of unknown location. 2009;19(3):80-3. 3. Biolchini F, Giunta A, Bigi L, Bertellini C, Pedrazzoli C. Emergency laparoscopic splenectomy for haemoperitoneum because of ruptured primary splenic pregnancy: a case report and review of literature. ANZ Journal of Surgery. 2010;80(1-2):55-7. 4. Tse L, Lau, Lau. Haemoperitoneum due to tubal abortion in a patient with a negative urine pregnancy test - Case report and Literature review. Hong Kong J Gynaecol Obstet Midwifery. 2006;6:45-8. 5. Ribeiro Jorge C., Silva Carlos M., Santos Americo R.. Splenosis: a diagnosis to be considered. Int. braz j urol.  [serial on the Internet]. 2006  Dec [cited  2012  May  05] ;  32(6): 678-680 Splenic Pregnancy 5