Conservative Management of a Splenic Injury in Second Trimester of Pregnancy

Introduction

Trauma of the abdomen is the commonest nonobstetric cause of fetal death. The estimate of trauma among pregnant women in developed countries is ∼6%–7%. ¹ The most common organ involved is the spleen. Spleen blunt trauma management has changed during recent decades, from operative to nonoperative management. Conservative management has certain advantages, such as low hospital costs, avoidance of nontherapeutic laparotomies, fewer complications, low rates of blood transfusions, and low mortality rates.^2,3 This article, hereby, reports on a case of successful conservative management of a pregnant woman with a splenic trauma following a blunt trauma to her abdomen.

Case

A 23-years-old, gravida 3, para 3, live 2, woman presented at 17 weeks +5 days of gestation with a complaint of pain in her abdomen. She reported that, on the previous day, she had slipped on her floor while doing household chores. She had pain, mainly in the lower abdomen (a pain score of 8/10 on a visual analogue scale), which was noncolicky and nonradiating. She was able to eat and pass stools. There was no complaint of any bleeding or leaking from her vagina. On physical examination, she was conscious, oriented (GCS [Glasgow Coma Scale/Score: 15/15) and afebrile. Her pulse rate was 110 beats per minute; her blood pressure (BP) was 80/40 mmHg; and her respiratory rate was 24 breaths per minute. On room air, her SpO₂ was 97%, and moderate pallor was present.

Her abdominal examination revealed mild abdominal distension with slight tenderness and guarding. On palpation, a uterus of 18 weeks' size with contour maintained was felt. Ultrasound (US) revealed a moderate hemoperitoneum with internal echoes and thin septation in some places. A 7.1 × 1.7–cm subcapsular splenic hematoma on the costal surface was seen (suggestive of a grade 1 splenic injury according to the AAST [American Association for the Surgery of Trauma] organ injury scale for the spleen). Her other abdominal organs were normal. Uterine contour was maintained with a single live intrauterine gestation of ∼17 weeks of gestation. The amount of amniotic fluid was found to be adequate, and no retroplacental clot was detected.

Initial laboratory tests revealed: hemoglobin of 6.5 g%; platelets: 1.5 LAC/mm³, total leucocyte count: 12,300; differential leucocyte count: N₈₈L₈M₂E₂; and international normalized ratio: 1.14. Other biochemical tests such as serum electrolytes, and renal and liver function tests yielded normal results. Blood gas analyses results were normal (pH = 7.37; pO₂/pCO₂ = 141/27.3; SpO₂ = 98.3%; HCO₃ = 15.7; and lactate = 1.7, base excess: −7.4).

As she was in class 2 shock, initial resuscitation was started with intravenous fluid; her BP rose to 100/60 mm Hg. She also received 2 units of packed red blood cells and was kept nil per oral for 24 hours. Hourly monitoring of vitals was performed along with abdominal girth charting. She remained stable. She was started on a soft diet the next day; and passed stools and flatus. A repeat hemoglobin level, taken after 24 hours, was 7.5 g%.

Results

This patient was discharged in satisfactory condition after 4 days. After her discharge, she visited the hospital twice. The remainder of her antenatal follow-up was with her local doctor. At 39 weeks of gestation, she vaginally delivered a baby girl weighing 3000 g.

Discussion

Over the past 3 decades, management of blunt splenic trauma in adults has slowly evolved from mandatory laparotomy and splenectomy to a conservative approach. A successful outcome of conservative treatment depends on the patients' age, grade of splenic injury, hemoperitoneum volume, computed tomography findings, injury severity score, and hemodynamic stability.^4–6

Idiopathic spontaneous rupture of the spleen in pregnancy is a very rare complication. It has been proposed that the growing uterus changes the position of the spleen, making the spleen and its vascular pedicle more vulnerable, and that hypervolemia during pregnancy can lead to spontaneous splenic rupture during pregnancy. ⁷

There have been case reports of traumatic splenic rupture, spontaneous rupture, or a ruptured splenic artery aneurysm in pregnancy. Most of these conditions require urgent splenectomy and rigorous monitoring postoperatively in an intensive care unit. Sheela et al., reported a case of second gravida patient at a 29-week pregnancy with blunt trauma to the abdomen, who was in class 2 shock. US revealed that there was mild-to-moderate hemoperitoneum with a splenic laceration or contusion. The fetus was alive. The surgeons performed a splenectomy, and their patient delivered later at 39 of gestation weeks. ⁸ However, the current patient was also in class 2 shock but responded well to initial resuscitation. This enabled saving her spleen. Aubrey-Bassler and Sowers performed a systematic review of 613 cases of splenic rupture. All cases were without any risk factors or previously diagnosed diseases in the patients' spleens. Of these cases, 38 occurred in pregnant patients. The authors concluded that splenic rupture can be the first manifestation of underlying disease. Hence, the emergency physician should be aware that rupture of the spleen can occur in the absence of any major trauma or previously diagnosed splenic disease. ⁹

There is literature that has supported conservative management of spleen injury in nonpregnant patients. However, there are very few reports this occurring in pregnant patients. Jordan et al. reported a case of a pregnant patient, who presented with delayed splenic hemorrhage from a subcapsular hematoma at 28 weeks of gestation. That patient was managed conservatively and delivered vaginally at 40 weeks of gestation. ¹⁰

The current case highlights that conservative management is an option for hemodynamically stable pregnant patients with splenic injuries. This will not only prevent a surgical intervention and also long vaccination prophylaxis. However, as the need for a delayed splenectomy might arise, such patients should be kept under close observation for at least 10–14 days.

Conclusions

Conservative management is an option for hemodynamically stable pregnant women with splenic injuries.