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Rupture of the Spleen as a Complication of Pregnancy*
RUPTURE OF THE SPLEEN AS A COMPLICATION OF PREGNANCY* ELIZABETH CONFORTH,
M.D.,
AND JoHN CARANGELO,
M.D.,
LIT'l'LE RocK, ARK.
(From the Departments of Pathology and, Obstetrics, Dni,;ersity of School of Medici-ne)
Arkan.sa.~
rupture of the spleen, although reported in other cases, is a rare com· SPONTAN.EOUS plication of pregnancy. Only twenty-two cases are reported in the literature. Because of the rarity, the difficulty in diagnosis, and the rapidity of death, most cases of rupture of the spleen are not recognized during life and are discovered only at postmortem examination. Early in pregnancy, the diagnosis is most often confused with ruptured ectopic pregnancy, and later with rupture of the uterus or extensive premature separation of the placenta. The following case of rupture of the spleen serves to emphasize the rarity of this condition. Case Hi.sto·ry.-The patient was a Negro woman, aged 30 years, gravida vi, para iii, who entered the hospital complaining of a severe frontal headache. She stated that for the past two months she had had edema of the lower extremities, chronic headache, fainting spells, and blurring of vision. A severe nocturia had been present during this time. The patient was in her thirty-sixth week of pregnancy. The family history was noncontributory. The patient had been followed in the Medical Clinic of the Out-patient Department for the last three years, and had been treated for hypertensive heart disease. She had received antiluetic treatment intermittently for three years. However, for four month~ previous to admission, she did not receive any therapy. She had three children, all delivered spontaneously and without complications. In two sub· sequent pregnancies she was hospitalized with the same complaint as on this admission. Both re~ulted in premature stillbirth deliveries. · Physicc1l Exarninat·ion.-Temperature 99.8" F.; pulse, J 00; respiration, 24; blood pres· sure, 230 systolic, 115 diastolic. On ophthalmoscopic examination, there was marked arterio· venous comp:ression. There were fine moist rales in the bases of both lungs. The maximum impulse was in the fifth interspace in the left anterior axillary line. A soft blowing systolic murmur was heard in the mitral area, transmitted to the axilla; and over the pulmonic re· gion, transmitted to the neck. The rhythm was regular, rate 100. Abdominal examination revealed cephalic presentation with the occiput to the right. The fetal heart tones were heard in the right lower quadrant. The heart rate was 140. The height of the fun.dus was 26 em. There was moderate diastasis recti. On rectal examination, the cervix was thick, uneffaced, and about 1 em. dilated. There was 1 plus pitting edema of the lower extremities. Laboratm·y Exarni-nation,.-Urine showed a trace of albumin on several occasions but no casts. Hemoglobin was 10 gm. per 100 c.c.; white blood count, 17,200; red blood count, 3.45 million. Nonprotein nitrogen, 28 mg. per cent; uric acid, 4.68 mg. per cent; creatinine 1.5Si mg. per cent. Course in Hospital.-The patient was placed on a regime consisting of 20 per cent glucose, and 10 per cent magnesium sulfate intravenously, sodium luminal for sedation, and strict bed rest. Under this routine the patient improved considerably. The edema of the extremities and the rales in the lungs disappeared. The blood pressure progressively decreased from 250 systolic to 140, and from 115 diastolic to 110. After one week, the patient's condition was greatly improved and she was permitted to sit up in a chair. Approximately seventeen days after admission to the hospital the patient awakened at 5:00 A.M. screaming with pain. Exami'nation at this time revealed moderate tenderness of the epigastrium but no spasm or rigidity. The blood pressure could not be obtained. The pulse was rapid and thready. Fetal heart tones were inaudible. The patient was given •Research paper .•581, Journal Series. University of Arkansas.
429
430
.·\J\1ERICA?\ ,JOURNAL 01<' OBSTETRICS AND G\:NECOLOG\
intravenous :fluids, caffeine, and whole blood transfusions. 'f1he lJlood pn~~sur . . : rost: tu ~'tl systolic and 70 diastolic. Approximately one !lOur ttfter onset of tlw aeutP pain; tlwt<' was some distention of thP upper abdomen and a ,Jf:'tinite fluid wuw. and ~hifting·
could he elicited. A diagnosis of internal abdominal hemonhag·e was made, and tht> pati<•nt wa8 jJl'Pf'!ll'<"d for operation. However, before surgery could he pt'rformed. ,Jeatlt or·rmTPrl. ~PVPn ],.,\n~ following the onset of the ~ewre abdominal pain. Al
The heart weighe•l 4HO grams. The wall of the left vent.ri..le measured :\ em. and the right 4 mm. in thickness. The margin of the mitral valw waR slightly thickened, and nodular and the chor.dae tendinae \Vere slightly Bhortet· than IHl!'niaL ThP right -ve-ntriele was moderately dilated. The kidneys were normal grossly. 'l'he basement membrane in a few of the glomeruli was slightly thickener]. Only one arteriole was foun1l with an ahnonnally tlt.iek waH.
Discussion Shannon,r in 1940, collected from the literature twenty·one eases of spontaneous rupture of the spleen complicating pregnancy and a1lded one of his own. Over 50 per cent of these cases have a history of trauma. There were six cases of rupture of an aneurysm of the splenic artery. No cases of splenic rupture have been reported since 1940. Thrombosis of the splenic vein has not been reported in any of the twenty-two ca~es of rupture of the spleen. Thrombosis of the splenic vein is comparatively uncommon, except ciated with cirrhosis of the liver. Inflammatory lesions, such as ulcers pancreatitis, compression py tumors, twist of the pedicle of the spleen, etiological processes associated with 8plenic thrombosis. Xone of these this patient.
when it is assoof the stomach, are some of the was observed in
~4..n increase in the volume of the spleen is kno1Yn to follo\V periods of rest. lt has been shown by several investigators2-4 that sodium amytal, pentobarbital sodium, and pentothal sodium may produce enlargement of the spleen whi.eh persists for several hours after the administration of the drugs. The systolic blood pre-ssure of the patient l?eing discussed decreased from 230 to 140 under therapy. The reduction of blootl pressure and the stasis resulting from barbiturates would favor thrombosis of the -splenic vein. The pressure of the uterus upward would tend also to aid the process of congestion. Although the patient was serologically posi~:ve, there was no histolngic. evidence of syphilis, and syphilis is not believed to have played any part· in the pathology found. The findings in this ease suggest that stasis may have (oontributed to thrombosis of the splenic vein. Brines,5 in a review of cases of rupture of the Rpleen in nonpregnant individuals, cites a case reported by Pringle in' the Irish Journal of Medical Sr.i,ence in which antemortem thrombosis of the splenic artery and tuberculous splenitis were found.
CO.\'FORTH AND CARANGELO:
RUPTURE OF SPLEEN COMPLICATING PREGNANCY
431
Summary A case of thrombosis of the splenic vessels with rupture of the spleen occurring during late pregnancy is reported. Only twenty-two other cases of splenic rupture occurring as a complication of pregnancy have been reported. The pathogenesis of this lesion is briefly discussed.
References 1. Shannon, \Y. F.: A~r. J. OBST. & GY:fEC. 40: 323, 1940. 2. Hahn, P. F., Bale, W. F., and Bonner, J. F., Jr.: Am. J. Physiol. 138: 415, 1942. :l. Hausner, E., Essex, II. E., and Mann, F. C.: Am. J. Physiol. 121: 387, 1938, 4. Davis, J. E.: Proc. Soc. Exper. Bioi. & Med. 36: 71, 19:37. 5. Brines, 0. A.: Arch. Path. 36: 16il, 194:l.
M.D.,
AND JoHN CARANGELO,
M.D.,
LIT'l'LE RocK, ARK.
(From the Departments of Pathology and, Obstetrics, Dni,;ersity of School of Medici-ne)
Arkan.sa.~
rupture of the spleen, although reported in other cases, is a rare com· SPONTAN.EOUS plication of pregnancy. Only twenty-two cases are reported in the literature. Because of the rarity, the difficulty in diagnosis, and the rapidity of death, most cases of rupture of the spleen are not recognized during life and are discovered only at postmortem examination. Early in pregnancy, the diagnosis is most often confused with ruptured ectopic pregnancy, and later with rupture of the uterus or extensive premature separation of the placenta. The following case of rupture of the spleen serves to emphasize the rarity of this condition. Case Hi.sto·ry.-The patient was a Negro woman, aged 30 years, gravida vi, para iii, who entered the hospital complaining of a severe frontal headache. She stated that for the past two months she had had edema of the lower extremities, chronic headache, fainting spells, and blurring of vision. A severe nocturia had been present during this time. The patient was in her thirty-sixth week of pregnancy. The family history was noncontributory. The patient had been followed in the Medical Clinic of the Out-patient Department for the last three years, and had been treated for hypertensive heart disease. She had received antiluetic treatment intermittently for three years. However, for four month~ previous to admission, she did not receive any therapy. She had three children, all delivered spontaneously and without complications. In two sub· sequent pregnancies she was hospitalized with the same complaint as on this admission. Both re~ulted in premature stillbirth deliveries. · Physicc1l Exarninat·ion.-Temperature 99.8" F.; pulse, J 00; respiration, 24; blood pres· sure, 230 systolic, 115 diastolic. On ophthalmoscopic examination, there was marked arterio· venous comp:ression. There were fine moist rales in the bases of both lungs. The maximum impulse was in the fifth interspace in the left anterior axillary line. A soft blowing systolic murmur was heard in the mitral area, transmitted to the axilla; and over the pulmonic re· gion, transmitted to the neck. The rhythm was regular, rate 100. Abdominal examination revealed cephalic presentation with the occiput to the right. The fetal heart tones were heard in the right lower quadrant. The heart rate was 140. The height of the fun.dus was 26 em. There was moderate diastasis recti. On rectal examination, the cervix was thick, uneffaced, and about 1 em. dilated. There was 1 plus pitting edema of the lower extremities. Laboratm·y Exarni-nation,.-Urine showed a trace of albumin on several occasions but no casts. Hemoglobin was 10 gm. per 100 c.c.; white blood count, 17,200; red blood count, 3.45 million. Nonprotein nitrogen, 28 mg. per cent; uric acid, 4.68 mg. per cent; creatinine 1.5Si mg. per cent. Course in Hospital.-The patient was placed on a regime consisting of 20 per cent glucose, and 10 per cent magnesium sulfate intravenously, sodium luminal for sedation, and strict bed rest. Under this routine the patient improved considerably. The edema of the extremities and the rales in the lungs disappeared. The blood pressure progressively decreased from 250 systolic to 140, and from 115 diastolic to 110. After one week, the patient's condition was greatly improved and she was permitted to sit up in a chair. Approximately seventeen days after admission to the hospital the patient awakened at 5:00 A.M. screaming with pain. Exami'nation at this time revealed moderate tenderness of the epigastrium but no spasm or rigidity. The blood pressure could not be obtained. The pulse was rapid and thready. Fetal heart tones were inaudible. The patient was given •Research paper .•581, Journal Series. University of Arkansas.
429
430
.·\J\1ERICA?\ ,JOURNAL 01<' OBSTETRICS AND G\:NECOLOG\
intravenous :fluids, caffeine, and whole blood transfusions. 'f1he lJlood pn~~sur . . : rost: tu ~'tl systolic and 70 diastolic. Approximately one !lOur ttfter onset of tlw aeutP pain; tlwt<' was some distention of thP upper abdomen and a ,Jf:'tinite fluid wuw. and ~hifting·
could he elicited. A diagnosis of internal abdominal hemonhag·e was made, and tht> pati<•nt wa8 jJl'Pf'!ll'<"d for operation. However, before surgery could he pt'rformed. ,Jeatlt or·rmTPrl. ~PVPn ],.,\n~ following the onset of the ~ewre abdominal pain. Al
The heart weighe•l 4HO grams. The wall of the left vent.ri..le measured :\ em. and the right 4 mm. in thickness. The margin of the mitral valw waR slightly thickened, and nodular and the chor.dae tendinae \Vere slightly Bhortet· than IHl!'niaL ThP right -ve-ntriele was moderately dilated. The kidneys were normal grossly. 'l'he basement membrane in a few of the glomeruli was slightly thickener]. Only one arteriole was foun1l with an ahnonnally tlt.iek waH.
Discussion Shannon,r in 1940, collected from the literature twenty·one eases of spontaneous rupture of the spleen complicating pregnancy and a1lded one of his own. Over 50 per cent of these cases have a history of trauma. There were six cases of rupture of an aneurysm of the splenic artery. No cases of splenic rupture have been reported since 1940. Thrombosis of the splenic vein has not been reported in any of the twenty-two ca~es of rupture of the spleen. Thrombosis of the splenic vein is comparatively uncommon, except ciated with cirrhosis of the liver. Inflammatory lesions, such as ulcers pancreatitis, compression py tumors, twist of the pedicle of the spleen, etiological processes associated with 8plenic thrombosis. Xone of these this patient.
when it is assoof the stomach, are some of the was observed in
~4..n increase in the volume of the spleen is kno1Yn to follo\V periods of rest. lt has been shown by several investigators2-4 that sodium amytal, pentobarbital sodium, and pentothal sodium may produce enlargement of the spleen whi.eh persists for several hours after the administration of the drugs. The systolic blood pre-ssure of the patient l?eing discussed decreased from 230 to 140 under therapy. The reduction of blootl pressure and the stasis resulting from barbiturates would favor thrombosis of the -splenic vein. The pressure of the uterus upward would tend also to aid the process of congestion. Although the patient was serologically posi~:ve, there was no histolngic. evidence of syphilis, and syphilis is not believed to have played any part· in the pathology found. The findings in this ease suggest that stasis may have (oontributed to thrombosis of the splenic vein. Brines,5 in a review of cases of rupture of the Rpleen in nonpregnant individuals, cites a case reported by Pringle in' the Irish Journal of Medical Sr.i,ence in which antemortem thrombosis of the splenic artery and tuberculous splenitis were found.
CO.\'FORTH AND CARANGELO:
RUPTURE OF SPLEEN COMPLICATING PREGNANCY
431
Summary A case of thrombosis of the splenic vessels with rupture of the spleen occurring during late pregnancy is reported. Only twenty-two other cases of splenic rupture occurring as a complication of pregnancy have been reported. The pathogenesis of this lesion is briefly discussed.
References 1. Shannon, \Y. F.: A~r. J. OBST. & GY:fEC. 40: 323, 1940. 2. Hahn, P. F., Bale, W. F., and Bonner, J. F., Jr.: Am. J. Physiol. 138: 415, 1942. :l. Hausner, E., Essex, II. E., and Mann, F. C.: Am. J. Physiol. 121: 387, 1938, 4. Davis, J. E.: Proc. Soc. Exper. Bioi. & Med. 36: 71, 19:37. 5. Brines, 0. A.: Arch. Path. 36: 16il, 194:l.