Managing Ruptured Splenic Ectopic Pregnancy Without Splenectomy: Case Report and Literature Review

Abstract

Splenic ectopic pregnancy is extremely rare but carries a high risk of uncontrollable life-threatening bleeding. Our aim is to try to diagnose those cases earlier and to include splenic preservation as good alternative for selected cases. Extensive review of the literature has been performed. Thirty-one case reports were identified, of which 4 have been excluded because they were not written in English. A 36-year-old woman presented to the Emergency Department with haemorrhagic shock. Despite the levonorgestrel intrauterine system (LNG-IUS) being in situ for 4 months, urinary and serum tests were both positive for pregnancy, and an ultrasound scan revealed haemoperitoneum suggestive of a ruptured ectopic pregnancy. An emergency Pfannenstiel laparotomy was performed and a diagnosis of spontaneous tubal abortion was made and the abdomen was subsequently closed. Following a period of cardiovascular instability on the Intensive Care Unit postoperatively, an urgent CT scan was performed which revealed bleeding from the spleen. A midline laparotomy was performed by the general surgeon, which involved resection of the gestational sac and splenorrhaphy. Twenty-seven cases were reviewed, and 73% of them presented as an emergency and 21 cases (81%) had been managed with splenectomy. CT scan had been used in eight of the previous case reports of splenic ectopic pregnancy with 100% diagnostic accuracy rate. Non-tubal ectopic pregnancies are very rare. Splenorrhaphy is a safe alternative to splenectomy in cases of splenic ectopic pregnancy. CT abdomen and pelvis with intravenous contrast can be very helpful in relatively stable patients with a vaginal ultrasound demonstrating an empty uterus, no clear adnexal masses or free fluid.

Minimally Invasive Management and Diagnosis of Ectopic Splenic Pregnancy

“…Risk factors associated with abdominal pregnancy align with those of other ectopic pregnancies and include a history of previous ectopic pregnancies, pelvic inflammatory disease, the presence of an intrauterine device (IUD), endometriosis, in vitro fertilization and prior tubal surgeries, smoking, and infertility [ 10 , 11 , 13 ]. Patients with a history of one prior ectopic pregnancy have a 10% risk of subsequent ectopic pregnancy recurrence.…”

“…The pain may become more generalized when the tube ruptures and the hemoperitoneum develops. Other possible symptoms include diarrhea or pain during bowel movements, vomiting, presyncope, syncope, shoulder pain, lower urinary tract symptoms, rectal pressure, and vaginal bleeding [ 13 , 14 ].…”

“…The clinical presentation of splenic ectopic pregnancy is associated with many symptoms and can lead to misdiagnosis. Splenic pregnancies present earlier than other abdominal extrauterine pregnancies, mainly manifesting as an acute abdomen and hemoperitoneum occurring at 6–8 weeks after gestation [ 13 ]. Therefore, in any female of reproductive age presenting with atypical abdominal pain, the possibility of an ectopic abdominal pregnancy must be considered [ 13 ].…”

“…β-hCG during pregnancy can be detected as early as eight days after ovulation [ 13 ]. Although the β-hCG level is 1500 IU/L or higher, ectopic pregnancy should be suspected in patients whose intrauterine gestational sac cannot be seen on TVUS.…”

Abdominal pregnancy: a case report

“…The ectopic pregnancy rate is estimated 11 per 1000 pregnancies, and the maternal mortality is about 0.2 per 1000 ectopic pregnancies. The ectopic pregnancies outside the fallopian tubes are rare, but they may be seriously life-threatening 1 , 2 .…”