E.S. Mikhailin 1 , L.A. Ivanova 1 , A.G. Savitsky 1,2 , S.G. Curly 1.3 , R.A. Krasnolobov 4 , P.Yu. Krasnolobova 1
1 SPbGBUZ “Maternity Hospital No. 10”, St. Petersburg, Russia;
2 SBEE HPE “North-Western State Medical University named after I.I. Mechnikov”, St. Petersburg, Russia;
3 Federal State Budgetary Institution “Research Institute of Obstetrics and Gynecology named after D.O. Ott”, Northwestern Branch of the Russian Academy of Medical Sciences, St. Petersburg, Russia;
4 St. Petersburg City Clinical Hospital No. 15, St. Petersburg, Russia.
Summary: The article presents its own observation of a case of spontaneous rupture of the spleen at 33/34 weeks of gestation. The patient underwent active-expectant tactics, taking into account premature rupture of amniotic fluid at a period of 33 weeks. Suddenly, against the background of complete well-being, clinical signs of massive intra-abdominal bleeding appeared. During the revision of the abdominal organs, a rupture of the spleen capsule was found. A caesarean section and splenectomy were performed. The postoperative period was uneventful, discharged home with the child.
Key words: spleen, spontaneous rupture of the spleen, rupture of the spleen during pregnancy.
Introduction. Splenic rupture is a rare and potentially fatal condition that causes acute abdominal syndrome and hemodynamic compromise and requires urgent surgical treatment. Rupture of the spleen is divided into traumatic and atraumatic or spontaneous. Traumatic rupture of the spleen is well studied, the frequency of detection of this condition during operations for blunt abdominal trauma is about 30% [7,8]. Data from a review of 845 cases of ruptured spleen from 1980 to 2008.  demonstrate a much rarer incidence of spontaneous rupture (about 7%) compared to traumatic rupture of the spleen (more than 93% of cases).
In connection with the above, our observation is of particular interest.
Patient D.A.V., 40 years old, was admitted to St. Petersburg State Budgetary Health Institution “Maternity Hospital No. 10” at a gestational age of 33 1/7 weeks with an indication of premature rupture of amniotic fluid from 11:30 on November 18, 2013.
History of SARS, childhood infections, fracture of the left fibula in childhood. Suffers from chronic anemia (minimum hemoglobin levels before pregnancy – 47 g / l). She was examined by a therapist, the causes of anemia were not identified. Periods from the age of 14, 6 days after 30, regular, moderate, painless. Sexual life since 22 years. Of the gynecological diseases, she notes ectopia of the cervix, for which diathermocoagulation was performed in 2007. This is the second pregnancy. The first pregnancy ended in an urgent delivery in 1999, a boy was born weighing 3070 grams, 51 cm tall. He has been registered in the antenatal clinic since 7 weeks. From the beginning of pregnancy, she notes the appearance of pulling, aching pains in the left hypochondrium, left epigastric region. Suffering from chronic constipation. Total weight gain 6 kg. BP 120/80 – 125/90 mm Hg Urinalysis is normal. In the early stages of pregnancy, she was diagnosed with iron deficiency anemia of the 2nd degree (she took sorbifer, totem), the usual values of hemoglobin during pregnancy were 81-88 g/l. In sowing urine and sowing from the cervical canal, microflora was not detected. Sexually transmitted infections have not been identified. There were no hospitalizations during pregnancy. Ultrasound examination of the fetus – within the normal range.
Upon admission, the general condition is satisfactory. Height 160 cm, weight 77.2 kg. The skin and visible mucous membranes are clean, pale. Heart rate 90 min. BP 105/70 mmHg Heart sounds are clear, rhythmic. Respiration is vesicular. Respiration rate 18 per minute. The tongue is moist and clean. The abdomen is enlarged due to pregnancy, in places accessible to palpation it is soft, not tense, painless, moderately swollen along the transverse colon. The liver is not enlarged. Tapping in the region of the kidneys is painless. The chair is regular, urination is not disturbed, painless. The uterus is enlarged up to 32 weeks of pregnancy, in normal tone, not excitable on palpation. The fetal head is movable above the entrance to the small pelvis. The fetal heartbeat is clear, rhythmic, 136 per minute. Light amniotic fluid leaks from the genital tract. On vaginal examination, the cervix is “immature”. General clinical analyzes – without features. According to ultrasound data, there is one live fetus in the uterus, corresponds to 33 1/7 weeks, the estimated weight of the fetus is 1988 grams, amniotic fluid – oligohydramnios (premature rupture of amniotic fluid), placenta along the anterior wall of the uterus with the transition to the bottom, 1 degree of maturity according to Grannum. Dopplerometry in the mother-placenta-fetus system showed no hemodynamic disturbances. Cardiotocography – no violations of the functional state of the fetus were detected.
Taking into account the gestational age, the satisfactory condition of the pregnant woman and the fetus, the absence of signs of inflammatory changes, it was decided to start an active-expectant tactics. Prevention of fetal distress syndrome was carried out, antibiotic therapy was started, prevention of fetal hypoxia with antioxidants and antihypoxants. During dynamic observation, the results of smears from the genital organs, thermometry, clinical blood analysis, data on the assessment of the functional state of the fetus were within the normal range.
At a period of 33 4/7 weeks, with an anhydrous period of 96 hours, given the presence of an “immature” cervix, preparation for childbirth with mifepristone (200 mg orally twice every 24 hours) was started against the background of infusion of beta-agonists.
November 23, 2014 at 23.00, with an anhydrous period of 23 hours 30 minutes, notes the appearance of dull pain in the left hypochondrium and epigastric region after straining during defecation. Injury, fall denies. At 23.15 – a single vomiting of food, severe weakness appeared. Moderate condition. The skin is pale, wet, cold. Pulse 94 beats per minute, rhythmic, weak filling. BP 80/60 mmHg The abdomen is soft, swollen, painful on palpation in the epigastric region and left hypochondrium. Symptoms of peritoneal irritation are positive. The uterus is in normal tone, painless on palpation. The fetal heartbeat is muffled, 100 beats per minute. There are no pathological discharges from the genital tract. The patient’s condition is progressively deteriorating. At 23.20 pulse 110 beats per minute, rhythmic, weak filling. BP 70/40 mmHg Dry tongue. The abdomen is swollen, palpation is difficult, the uterus is poorly palpated. The fetal heartbeat is deaf, 70 beats per minute. Given the suspicion of uterine rupture, delivery by caesarean section is indicated on an emergency basis. It was decided to clarify the volume of the operation during the operation. At 5 minutes from the start of the operation, a live premature baby boy was removed, weighing 1970 grams, 45 cm tall, with an Apgar score of 5/8 points. Amniotic fluid is light. The walls of the uterus are intact. In the abdominal cavity, liquid blood with clots in the amount of about 1.5 liters. An audit of the abdominal organs was performed. The source of bleeding is a defect in the capsule of the lower pole of the spleen with a diameter of 1 cm. The spleen is fixed in the bed. Performed splenectomy with stitching legs of the spleen. Produced drainage of the abdominal cavity. The total blood loss was 2800 ml. Washed erythrocytes were re-infused with a Cell-Saver apparatus. The course of the postoperative period without complications. Healing by primary intention. Blood test (PCR) for parvovirus B19, Epstein-Barr virus, cytomegalovirus – negative. Discharged on the 17th day with a child.
Histopathological examination: Spleen 11×9×4.5 cm. In the area of the gate gap 4×2.5 cm. The surface is smooth, gray-pink. The tissue of the spleen of the usual histological structure, at the site of rupture, hemorrhagic impregnation of tissues.
Histological examination of the placenta: chronic subcompensated placental insufficiency.
Discussion. Spontaneous rupture of the spleen is a rare clinical condition and, in the absence of trauma, diagnosis and treatment of this potentially fatal complication is often delayed . The most common cause of spontaneous rupture of the spleen is an infectious or neoplastic process with damage to the reticuloendothelial system [4,7]. Non-traumatic rupture of the affected spleen is usually associated with various infectious, neoplastic, hematological, metabolic, inflammatory and local splenic diseases (Table 1) [1,3,5,6,10-12].
Table 1. Causes of pathological rupture of the spleen
|infectious causes||Neoplastic and hematological causes|
|Clostridium sp.||multiple myeloma|
|Actinomycosis||Malignant tumors of the spleen|
|Salmonella sp.||Hepatocellular adenocarcinoma|
|Enterobacter sp.||Lungs’ cancer|
|Haemophilus sp.||Protein S deficiency|
|legionellosis||Therapy with anticoagulants|
|Viral||Local splenic causes|
|Infectious mononucleosis||spleen cyst|
|Rubella||Thrombosis of the splenic vein|
|Hepatitis A||Splenic purpura|
|Dengue fever||Diffuse angiomatosis of the spleen|
|Varicella-Zoster virus||Various kinds of reasons|
|Other reasons||Wilson’s disease – Konovalov|
|Echinoccocus sp.||Polyarteritis nodose|
|typhus||Systemic lupus erythematosus|
|Q fever||Rheumatoid arthritis|
|Recurrent fever||Wegener’s granulomatosis|
The possibility of spontaneous rupture of a histologically normal spleen is questioned by many [2,13], the authors point out that almost always a thorough history taking and examination reveal injuries or pathology of the spleen. Orloff and Peskin (1958)  proposed 4 diagnostic criteria necessary for the diagnosis of true spontaneous idiopathic splenic rupture, Crate and Payne (1991)  added a fifth criterion: no history of trauma or unusual physical effort; the absence of diseases in which the spleen is involved; absence of perisplenic adhesions or scarring of the spleen at surgery, suggesting previous trauma or rupture; the spleen should be normal on general examination and histological examination; the absence of an increase in the titer of antiviral antibodies associated with pathogens that cause diseases associated with the involvement of the spleen.
In our patient, with a careful history taking, there were no indications of even minimal trauma. Unfortunately, we did not have the opportunity to examine the patient for all possible pathogens leading to splenomegaly with neoplastic or infectious lesions of the reticuloendothelial system, however, the size and appearance of the spleen, as well as its histological structure, were normal, which may indicate an idiopathic rupture. . It can be assumed that a sharp excessive straining during constipation (as well as during coughing in the work of Toubia et al. ), which led to a sudden increase in intra-abdominal pressure, contributed to the occurrence of tearing of the spleen capsule with the subsequent clinic of intra-abdominal bleeding, however, the possibility of such a mechanism in the absence of splenomegaly and the presence of a histologically unchanged spleen is doubtful. In conclusion, it should be noted that when conducting a differential diagnosis of the causes of intra-abdominal bleeding during pregnancy, this rare formidable complication should be remembered, which, if left unrecognized, can lead to life-threatening conditions.
1. Ballardini P., Incasa E., Del Noce A., Cavazzini L., Martoni A., Piana E. Spontaneous splenic rupture after the start of lung cancer chemotherapy. A case report. Tumouri. 2004; 90(1): 144-146.
2. Crate ID, Payne MJ Is the diagnosis of spontaneous rupture of a normal spleen valid? JR Army Medical Corps. 1991; 137:50-51.
3. Debnath D., Valerio D. Atraumatic rupture of the spleen in adults. JR Coll Surg Edinb. 2002; 47:437-445.
4. Imbert P, Rapp C, Buffet PA: Pathological rupture of the spleen in malaria: analysis of 55 cases (1958-2008). Travel Med Infect Dis. 2009; 7:147-159.
5. Kyriacou A., Arulraj N., Varia H. Acute abdomen due to spontaneous splenic rupture as the first presentation of lung malignancy: a case report. Journal of Medical Case Reports. 2011; 5:444.
6. Lieberman M., Levitt A. Spontaneous rupture of the spleen. Am J Emerge Med. 1989; 7:28-31.
7. Orloff MJ, Peskin GW Spontaneous rupture of the normal spleen – a surgical enigma. Int Abstr Surg. 1958; 106:1-11.
8. Renzulli P., Hostettler A., Schepfer A., Gloor B., Candinas D. Systematic review of atraumatic splenic rupture. BrJ Surg. 2009; 96(10): 1114-1121.
9. Rice J., Sutter C. Spontaneous splenic rupture in an active duty Marine upon return from Iraq: a case report. Journal of Medical Case Reports. 2010; 4:353.
10. Schmidt BJ, Smith SL Isolated splenic metastasis with primary lung adenocarcinoma. South Med J. 2004; 97(3): 298-300.
11. Smith WM, Lucas JG, Frankel WL Splenic rupture: a rare presentation of pancreatic carcinoma. Arch Pathol Lab Med. 2004; 128(10): 1146-1150.
12. Sugahara K., Togashi H., Aoki M., Mitsuhashi H., Matsuo T., Watanabe H., Abe T., Ohno S., Saito K., Saito T., Shinzawa H., Tanida H., Ito M., Takahashi T. Spontaneous splenic rupture in a patient with large hepatocellular carcinoma. Am J Gastroenterol. 1999; 94(1): 276-278.
13. Toubia NT, Tawk MM, Potts RM, Kinasewitz GT Cough and spontaneous rupture of a normal spleen. Chest. 2005; 128: 1884-1886.
- Ballardini P., Incasa E., Del Noce A., Cavazzini L., Martoni A., Piana E. Spontaneous splenic rupture after the start of lung cancer chemotherapy. A case report. Tumouri. 2004; 90(1): 144-146.
- Crate ID, Payne MJ Is the diagnosis of spontaneous rupture of a normal spleen valid? JR Army Medical Corps. 1991; 137:50-51.
- Debnath D., Valerio D. Atraumatic rupture of the spleen in adults. JR Coll Surg Edinb. 2002; 47:437-445.
- Imbert P, Rapp C, Buffet PA: Pathological rupture of the spleen in malaria: analysis of 55 cases (1958-2008). Travel Med Infect Dis. 2009; 7:147-159.
- Kyriacou A., Arulraj N., Varia H. Acute abdomen due to spontaneous splenic rupture as the first presentation of lung malignancy: a case report. Journal of Medical Case Reports. 2011; 5:444.
- Lieberman M., Levitt A. Spontaneous rupture of the spleen. Am J Emerge Med. 1989; 7:28-31.
- Orloff MJ, Peskin GW Spontaneous rupture of the normal spleen–a surgical enigma. Int Abstr Surg. 1958; 106:1-11.
- Renzulli P., Hostettler A., Schepfer A., Gloor B., Candinas D. Systematic review of atraumatic splenic rupture. BrJ Surg. 2009; 96(10): 1114-1121.
- Rice J., Sutter C. Spontaneous splenic rupture in an active duty Marine upon return from Iraq: a case report. Journal of Medical Case Reports. 2010; 4:353.
- Schmidt BJ, Smith SL Isolated splenic metastasis with primary lung adenocarcinoma. South Med J. 2004; 97(3): 298-300.
- Smith WM, Lucas JG, Frankel WL Splenic rupture: a rare presentation of pancreatic carcinoma. Arch Pathol Lab Med. 2004; 128(10): 1146-1150.
- Sugahara K., Togashi H., Aoki M., Mitsuhashi H., Matsuo T., Watanabe H., Abe T., Ohno S., Saito K., Saito T., Shinzawa H., Tanida H., Ito M ., Takahashi T. Spontaneous splenic rupture in a patient with large hepatocellular carcinoma. Am J Gastroenterol. 1999; 94(1): 276-278.
- Toubia NT, Tawk MM, Potts RM, Kinasewitz GT Cough and spontaneous rupture of a normal spleen. Chest. 2005; 128: 1884-1886.