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Splenic artery aneurysm rupture in pregnancy
YAJEM-56357; No of Pages 4 American Journal of Emergency Medicine xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Splenic artery aneurysm rupture in pregnancy Joshua Jacobson, DO ⁎, Chad Gorbatkin, MD, Stacey Good, DO, Scott Sullivan, MD Department of Emergency Medicine, Madigan Army Medical Center, 9040 Jackson Ave., Tacoma, WA 98431, USA
a r t i c l e
i n f o
Article history: Received 12 December 2016 Accepted 13 December 2016 Available online xxxx Keywords: Ultrasound Vascular Obstetrics/gynecology
a b s t r a c t Case presentation: A pregnant woman at 22 + 5/7 weeks gestation presented to the emergency department (ED) from an outpatient clinic, hypotensive after experiencing a syncopal episode. On arrival to the ER she was tachycardic, tachypneic and complaining of abdominal pain. A bedside FAST was performed and noted free fluid in the abdomen. Subsequent CT obtained noted the rare but life-threatening diagnosis of ruptured splenic artery aneurysm that resulted in emergent transfer to the operating room with OB/GYN and general surgery. The patient underwent emergent splenectomy and endovascular repair with vascular surgery, as well as massive transfusion and was transferred to the ICU post-operatively. The patient made a complete recovery and was discharged home on day four of her hospital stay. She underwent an uncomplicated cesarean section at 37 + 1 weeks (Figs. 1–4). Discussion: Rare but baring a high mortality rate, splenic artery aneurysm should be on the differential of any pregnant woman with abdominal pain, especially in the setting of hemodynamic instability. Prompt recognition, early involvement of OB/GYN and vascular surgery as well as rapid surgical intervention is needed for stabilization. These patients may require large amounts of blood for transfusion and it is important to acquire labs including a type and cross to avoid delays in resuscitation. Over 100 cases of SAA in pregnancy have been reported, but a minority reported both maternal and fetal survival. Published by Elsevier Inc.
1. Summary A 30 year-old pregnant woman at 22 weeks and 5 days gestation with a history of preeclampsia, gestational diabetes and two prior cesarean sections presented to the emergency department from an outpatient clinic after experiencing a syncopal episode. She had been transferred to the ED because was hypotensive on evaluation and appeared in distress. When she arrived to the ER she was anxious appearing, tachycardic, tachypneic and complaining of abdominal pain. A bedside FAST was performed and noted free fluid in the abdomen. Subsequent CT obtained noted a rare but life-threatening diagnosis that resulted in emergent transfer to the operating room with OB/ GYN for immediate management and stabilization. This report is to increase awareness of this serious and often fatal condition. 2. Background Splenic Artery Aneurysm (SAA) is relatively rare and usually asymptomatic. It is the most common splanchnic vessel aneurysm with a reported incidence is 0.16–0.18% based upon unselected autopsy cases [1]. Risk factors for rupture include pregnancy, pancreatitis, portal hypertension, liver transplantation, rapid growth, and size N2 cm [1]. ⁎ Corresponding author at: Madigan Army Medical Center, 9040 Jackson Ave., Tacoma, WA 98431, USA. E-mail address: [email protected] (J. Jacobson).
The risk of rupture increases in pregnancy due to hormonal changes (estrogen, progesterone, relaxin) and mechanical changes (increased plasma volume and cardiac output, and potral hypertension). Rupture carries a general mortality of 25%. Maternal mortality reaches as high as 75%, and fetal mortality to 95% [1,2]. We report a case of a ruptured SAA in a 30 year-old female at 22 weeks gestation. Our goal is to increase awareness of this life threatening complication.
3. Case presentation A 30 year-old G6P2 female at 22 + 5/7 weeks gestation presented to the emergency department (ED) with nausea, vomiting, LUQ abdominal pain, and syncope beginning several hours prior to presentation. Initially she was seen at her outpatient clinic, but was referred to the ED after a reading of low blood pressure. In the ED the patient appeared anxious and tachypneic, but was awake and alert. She complained of nausea, abdominal pain, and lightheadedness. Her past medical history was significant for preeclampsia, two cesarean sections, gestational diabetes and cholelithiasis. Her vital signs upon arrival to the ED were heart rate 124, blood pressure 103/64, respiratory rate 28, SpO2 100% on 12 l by facemask and afebrile. Her exam noted an obese, gravid female lying on the stretcher, able to speak in full sentences and alert and oriented. Her exam was significant for diffuse abdominal tenderness on palpation, a gravid uterus with the fundus
http://dx.doi.org/10.1016/j.ajem.2016.12.035 0735-6757/Published by Elsevier Inc.
Please cite this article as: Jacobson J, et al, Splenic artery aneurysm rupture in pregnancy, American Journal of Emergency Medicine (2016), http:// dx.doi.org/10.1016/j.ajem.2016.12.035
2
J. Jacobson et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx
Fig. 1. RUQ Fast showing the presence of free fluid.
palpable above the umbilicus, and no vaginal bleeding present. She was tachycardic and tachypneic and had 1+ distal pulses bilaterally. OB/GYN was consulted early for evaluation and assistance in management. A bedside FAST was completed due to patient's abdominal pain and concerning vital signs and noted free fluid present. The patient was resuscitated and when deemed stable was transported for a CT abdomen/pelvis with IV contrast was obtained, which noted a ruptured splenic artery aneurysm measuring 16 mm by 16 mm.
4. Treatment The patient underwent emergent splenectomy and endovascular repair with vascular surgery. She also underwent massive transfusion and was subsequently transferred to the ICU post-operatively.
5. Outcome Following successful repair of the aneurysm, the patient made a complete recovery and was discharged home on day four of her hospital stay. She underwent an uncomplicated cesarean section at 37 + 1 weeks.
6. Discussion Rare but baring a high mortality rate, splenic artery aneurysm should be on the differential of any presentation of a pregnant woman with abdominal pain, especially in the setting of hemodynamic instability being present. Prompt recognition, early involvement of OB/GYN and vascular surgery as well as rapid surgical intervention is needed for stabilization. These patients may require large amounts of blood for
Fig. 2. Measure of fetal heart rate, confirming fetal viability.
Please cite this article as: Jacobson J, et al, Splenic artery aneurysm rupture in pregnancy, American Journal of Emergency Medicine (2016), http:// dx.doi.org/10.1016/j.ajem.2016.12.035
J. Jacobson et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx
3
Fig. 4. Transverse and Sagital CT slices demonstrating the ruptured SAA.
Fig. 3. Coronal CT Slices showing the ruptured SAA and abdominal free fluid in this gravid patient.
transfusion and it is important to acquire labs including hematocrit and a type and cross on to avoid delays in adequate resuscitation. Over 100 cases of SAA in pregnancy have been reported, but a minority reported both maternal and fetal survival [3].
Fig. 3. (continued)
Other important diagnoses to consider are placental abruption, uterine rupture, heterotopic pregnancy, a wide array of gastrointestinal processes including appendicitis, pancreatitis, bowel obstruction (especially with a history of prior abdominal surgeries), cholecystitis and perforated or symptomatic peptic ulcer. When working up these pregnant patients can prove difficult especially when considering exposing the mother and the fetus to high doses of radiation by
Fig. 4. (continued)
Please cite this article as: Jacobson J, et al, Splenic artery aneurysm rupture in pregnancy, American Journal of Emergency Medicine (2016), http:// dx.doi.org/10.1016/j.ajem.2016.12.035
4
J. Jacobson et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx
performing abdominal and/or pelvic CT scans. The ultrasound can be a helpful tool to rapidly assess for an acute abdominal catastrophe and MRI can also be considered when there is concern for an acute process in an otherwise stable patient. SAA rupture can occur at any time during pregnancy, and this includes the recent postpartum period. The majority of reported cases have occurred during the third trimester. Incidental finding of an SAA should prompt a referral to vascular surgery for consideration for endovascular repair.
References [1] Ducasse, Fourcade. Rupture of splenic artery aneurysm during early pregnancy. Am J Emerg Med 2009;27:898.e5–6. [2] Nanez, et al. Ruptured splenic artery aneurysms are exceedingly rare in pregnant women. J Vasc Surg 2014;60:1520–3. [3] Garey, et al. Ruptured splenic artery aneurysm in pregnancy: a case series. Air Med J 2014;33(5):214–7.
Please cite this article as: Jacobson J, et al, Splenic artery aneurysm rupture in pregnancy, American Journal of Emergency Medicine (2016), http:// dx.doi.org/10.1016/j.ajem.2016.12.035
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Splenic artery aneurysm rupture in pregnancy Joshua Jacobson, DO ⁎, Chad Gorbatkin, MD, Stacey Good, DO, Scott Sullivan, MD Department of Emergency Medicine, Madigan Army Medical Center, 9040 Jackson Ave., Tacoma, WA 98431, USA
a r t i c l e
i n f o
Article history: Received 12 December 2016 Accepted 13 December 2016 Available online xxxx Keywords: Ultrasound Vascular Obstetrics/gynecology
a b s t r a c t Case presentation: A pregnant woman at 22 + 5/7 weeks gestation presented to the emergency department (ED) from an outpatient clinic, hypotensive after experiencing a syncopal episode. On arrival to the ER she was tachycardic, tachypneic and complaining of abdominal pain. A bedside FAST was performed and noted free fluid in the abdomen. Subsequent CT obtained noted the rare but life-threatening diagnosis of ruptured splenic artery aneurysm that resulted in emergent transfer to the operating room with OB/GYN and general surgery. The patient underwent emergent splenectomy and endovascular repair with vascular surgery, as well as massive transfusion and was transferred to the ICU post-operatively. The patient made a complete recovery and was discharged home on day four of her hospital stay. She underwent an uncomplicated cesarean section at 37 + 1 weeks (Figs. 1–4). Discussion: Rare but baring a high mortality rate, splenic artery aneurysm should be on the differential of any pregnant woman with abdominal pain, especially in the setting of hemodynamic instability. Prompt recognition, early involvement of OB/GYN and vascular surgery as well as rapid surgical intervention is needed for stabilization. These patients may require large amounts of blood for transfusion and it is important to acquire labs including a type and cross to avoid delays in resuscitation. Over 100 cases of SAA in pregnancy have been reported, but a minority reported both maternal and fetal survival. Published by Elsevier Inc.
1. Summary A 30 year-old pregnant woman at 22 weeks and 5 days gestation with a history of preeclampsia, gestational diabetes and two prior cesarean sections presented to the emergency department from an outpatient clinic after experiencing a syncopal episode. She had been transferred to the ED because was hypotensive on evaluation and appeared in distress. When she arrived to the ER she was anxious appearing, tachycardic, tachypneic and complaining of abdominal pain. A bedside FAST was performed and noted free fluid in the abdomen. Subsequent CT obtained noted a rare but life-threatening diagnosis that resulted in emergent transfer to the operating room with OB/ GYN for immediate management and stabilization. This report is to increase awareness of this serious and often fatal condition. 2. Background Splenic Artery Aneurysm (SAA) is relatively rare and usually asymptomatic. It is the most common splanchnic vessel aneurysm with a reported incidence is 0.16–0.18% based upon unselected autopsy cases [1]. Risk factors for rupture include pregnancy, pancreatitis, portal hypertension, liver transplantation, rapid growth, and size N2 cm [1]. ⁎ Corresponding author at: Madigan Army Medical Center, 9040 Jackson Ave., Tacoma, WA 98431, USA. E-mail address: [email protected] (J. Jacobson).
The risk of rupture increases in pregnancy due to hormonal changes (estrogen, progesterone, relaxin) and mechanical changes (increased plasma volume and cardiac output, and potral hypertension). Rupture carries a general mortality of 25%. Maternal mortality reaches as high as 75%, and fetal mortality to 95% [1,2]. We report a case of a ruptured SAA in a 30 year-old female at 22 weeks gestation. Our goal is to increase awareness of this life threatening complication.
3. Case presentation A 30 year-old G6P2 female at 22 + 5/7 weeks gestation presented to the emergency department (ED) with nausea, vomiting, LUQ abdominal pain, and syncope beginning several hours prior to presentation. Initially she was seen at her outpatient clinic, but was referred to the ED after a reading of low blood pressure. In the ED the patient appeared anxious and tachypneic, but was awake and alert. She complained of nausea, abdominal pain, and lightheadedness. Her past medical history was significant for preeclampsia, two cesarean sections, gestational diabetes and cholelithiasis. Her vital signs upon arrival to the ED were heart rate 124, blood pressure 103/64, respiratory rate 28, SpO2 100% on 12 l by facemask and afebrile. Her exam noted an obese, gravid female lying on the stretcher, able to speak in full sentences and alert and oriented. Her exam was significant for diffuse abdominal tenderness on palpation, a gravid uterus with the fundus
http://dx.doi.org/10.1016/j.ajem.2016.12.035 0735-6757/Published by Elsevier Inc.
Please cite this article as: Jacobson J, et al, Splenic artery aneurysm rupture in pregnancy, American Journal of Emergency Medicine (2016), http:// dx.doi.org/10.1016/j.ajem.2016.12.035
2
J. Jacobson et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx
Fig. 1. RUQ Fast showing the presence of free fluid.
palpable above the umbilicus, and no vaginal bleeding present. She was tachycardic and tachypneic and had 1+ distal pulses bilaterally. OB/GYN was consulted early for evaluation and assistance in management. A bedside FAST was completed due to patient's abdominal pain and concerning vital signs and noted free fluid present. The patient was resuscitated and when deemed stable was transported for a CT abdomen/pelvis with IV contrast was obtained, which noted a ruptured splenic artery aneurysm measuring 16 mm by 16 mm.
4. Treatment The patient underwent emergent splenectomy and endovascular repair with vascular surgery. She also underwent massive transfusion and was subsequently transferred to the ICU post-operatively.
5. Outcome Following successful repair of the aneurysm, the patient made a complete recovery and was discharged home on day four of her hospital stay. She underwent an uncomplicated cesarean section at 37 + 1 weeks.
6. Discussion Rare but baring a high mortality rate, splenic artery aneurysm should be on the differential of any presentation of a pregnant woman with abdominal pain, especially in the setting of hemodynamic instability being present. Prompt recognition, early involvement of OB/GYN and vascular surgery as well as rapid surgical intervention is needed for stabilization. These patients may require large amounts of blood for
Fig. 2. Measure of fetal heart rate, confirming fetal viability.
Please cite this article as: Jacobson J, et al, Splenic artery aneurysm rupture in pregnancy, American Journal of Emergency Medicine (2016), http:// dx.doi.org/10.1016/j.ajem.2016.12.035
J. Jacobson et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx
3
Fig. 4. Transverse and Sagital CT slices demonstrating the ruptured SAA.
Fig. 3. Coronal CT Slices showing the ruptured SAA and abdominal free fluid in this gravid patient.
transfusion and it is important to acquire labs including hematocrit and a type and cross on to avoid delays in adequate resuscitation. Over 100 cases of SAA in pregnancy have been reported, but a minority reported both maternal and fetal survival [3].
Fig. 3. (continued)
Other important diagnoses to consider are placental abruption, uterine rupture, heterotopic pregnancy, a wide array of gastrointestinal processes including appendicitis, pancreatitis, bowel obstruction (especially with a history of prior abdominal surgeries), cholecystitis and perforated or symptomatic peptic ulcer. When working up these pregnant patients can prove difficult especially when considering exposing the mother and the fetus to high doses of radiation by
Fig. 4. (continued)
Please cite this article as: Jacobson J, et al, Splenic artery aneurysm rupture in pregnancy, American Journal of Emergency Medicine (2016), http:// dx.doi.org/10.1016/j.ajem.2016.12.035
4
J. Jacobson et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx
performing abdominal and/or pelvic CT scans. The ultrasound can be a helpful tool to rapidly assess for an acute abdominal catastrophe and MRI can also be considered when there is concern for an acute process in an otherwise stable patient. SAA rupture can occur at any time during pregnancy, and this includes the recent postpartum period. The majority of reported cases have occurred during the third trimester. Incidental finding of an SAA should prompt a referral to vascular surgery for consideration for endovascular repair.
References [1] Ducasse, Fourcade. Rupture of splenic artery aneurysm during early pregnancy. Am J Emerg Med 2009;27:898.e5–6. [2] Nanez, et al. Ruptured splenic artery aneurysms are exceedingly rare in pregnant women. J Vasc Surg 2014;60:1520–3. [3] Garey, et al. Ruptured splenic artery aneurysm in pregnancy: a case series. Air Med J 2014;33(5):214–7.
Please cite this article as: Jacobson J, et al, Splenic artery aneurysm rupture in pregnancy, American Journal of Emergency Medicine (2016), http:// dx.doi.org/10.1016/j.ajem.2016.12.035