Rupture of a Splenic Artery Aneurysm During Pregnancy

Excerpt

A 30-year-old woman G2P1 presented to the clinic at term of her second pregnancy for delivery. Suddenly, the patient presented episodes of hypotension with fetal activity monitor showing signs of fetal distress. The patient was taken in emergency to the operating room for cesarean section. A stillborn baby is extracted during the procedure. In the recovery room, the patient was in hemodynamic instability and drainage was hemorrhagic. A pelvic arteriography with a right artery femoral access is performed but failed to identify the origin of the bleeding. A salvage hysterectomy was then decided. After the procedure, the patient, still in hemorrhagic shock, is transferred in the resuscitation unit of a tertiary reference center. At the admission, the patient was in hypothermia with signs of peripheral hypoperfusion, mean arterial blood pressure was 60 mm of mercury (mmHg), and heart rate was 160 beats per minute under vasopressor support with noradrenalin. CT scan showed a hemoperitoneum and a voluminous hematoma in the lesser sac due to the rupture of a splenic artery aneurysm (Figs. 1 and 2). The patient underwent finally a distal pancreatectomy with splenectomy. Postoperative course was complicated with an acute right inferior limb ischemia at postoperative day 5 due to thrombosis of the extern iliac artery and requiring thrombectomy in emergency. After satisfactory evolution, the patient was discharged on postoperative day 25. Final anatomopathological examination of the specimen confirmed the presence of a ruptured splenic aneurysm with hematoma. Splenic artery aneurysms (SAAs) are the most common visceral aneurysm and the third most common intra-abdominal aneurysm after those affecting the aorta and iliac artery. Prevalence in the general population is about 0.78% with a 4:1 female to male predominance. Risk factors of rupture include aneurysm size greater than 2 cm, pregnancy, and cirrhosis with portal hypertension. SAA rupture during pregnancy is most common in the third semester and carries a high mortality with a maternal mortality about 70% and a fetal mortality about 90%. Elevation of female hormone blood levels during pregnancy could explain the association between SAAs and pregnancy. Estrogen and progesterone favorize vasodilatation and increase vessel wall elasticity leading to deformation and rupture.¹ A “double rupture” phenomenon could be clinically observed. In the first stage, the aneurysm ruptures in the lesser sac. The adjacent organs limit the hemorrhage and the symptoms are mild. In the second stage, the hemorrhage extends to the large peritoneal cavity causing hemodynamic instability.²

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