Splenic Artery Aneurysm in A Primigravida

Abstract: Splenic artery aneurysm is the third most common true aneurysm occurring in the abdomen after aortic and iliac artery aneurysms. Splenic artery aneurysms are more common in women, with a female to male ratio of 4:1. It is most common in the sixth decade of life as 80 percent occurring in patients >50 years of age. The exact pathophysiology of an aneurysm formation is increased blood flow in turn leading to case irreversible damage to the tunica media, predisposing to aneurysm formation followed by muscle atrophy and calcification. Mortality in case of rupture is 25% and 75% among pregnant women, with fetal mortality of 95%. Case Presentation: 22-year-old female primigravida 26 weeks of gestation presented to the emergency department with sudden severe right upper quadrant (RUQ) pain. On examination upon general inspection the patient was irritated however, she was conscious and alert to place, person and time. Her heart rate was 110 beats per minute otherwise she was vitally stable. Abdominal examination revealed a gravid uterus with a fundal height matching gestational age. Proper abdominal examination was not performed as patient was agitated, and her pain increased in severity when lying supine however, there was tenderness upon palpation in the RUQ with no rebound tenderness or peritoneal signs. Baseline investigations, Electrocardiogram (ECG), and obstetric ultrasound were all normal. Ultrasound abdomen revealed splenic artery aneurysm 2 cm in size with no evidence of leaking or free fluid in abdominal quadrants. Her Hb dropped from 11 to 8 g/dl she received 2 PRBC and her Hb improved to 10 but again dropped to 8.6 g/dl. Her blood pressure was 98/65 and her pulse: 117 beats per minute. The patient was shifted to operating theater and exploratory laparotomy was done. Intraoperatively ruptured splenic artery noted with hemoperitoneum approximately around 1.5 litters and splenectomy done. The patient received 4 pints of PRBC and 4 pints of FFP intraoperatively. Ultrasound was repeated postoperatively by the obstetrician and revealed a single viable fetus with good biophysical profile (BPP) with a score of 8/8. During her hospital stay the patient was managed by a multidisciplinary team (MDT) involving the obstetricians, vascular surgeon, general surgeon and hematologist. Patient was discharge from the hospital on baby aspirin 81 mg po OD and prophylactic dose of enoxaparin according to her weight, which was 0.8 ml S/C once daily. She was commenced on prophylactic penicillin V to cover encapsulated organisms and to reduce her risk of developing Overwhelming post-splenectomy infection (OPSI). The patient was informed about the need to get post splenectomy vaccinations which were the polyvalent pneumococcal, meningococcus, and Hemophilus influenza vaccines. Despite being properly counselled regarding the benefits and risks, she refused to take any of them believing it will harm her unborn fetus. Furthermore, she was followed up routinely in the antenatal clinic according to hospital protocol. Her antenatal follow up was uneventful. Patient was admitted when she was 41 weeks, admitted for induction of labor (IOL) However, due to failure to progress, emergency caesarean section done with good outcome. She was discharged on aspirin 81 mg po od and enoxaparin s/c bd for 6 weeks. She was given a follow-up appointment with hematology outpatient clinic after six weeks from delivery. Six weeks after delivery she was seen in the outpatient clinic of both vascular, hematology and obstetrics and gynecology. Her hemoglobin level was 13.9 and her platelets were 899. A decision was made to stop enoxaparin and to continue aspirin 81 mg po od due to thrombocytosis post splenectomy. Discussion: Always approach the patient in a systematic way not forgetting non-obstetrical causes of the patient presentation. Multidisciplinary team is necessary (MDT) in the management of such cases.