What is the emergency management of a pregnant woman with a spontaneous splenic rupture and no history of trauma?

Emergency Management of Spontaneous Splenic Rupture in Pregnancy

Immediate Resuscitation and Diagnosis

In a pregnant woman presenting with spontaneous splenic rupture without trauma, immediate aggressive resuscitation with massive transfusion protocol and emergency surgical intervention (splenectomy with or without endovascular repair) is life-saving, as maternal mortality reaches 70-95% and fetal mortality exceeds 90% without rapid intervention. 1, 2

Recognition and Initial Assessment

• Suspect spontaneous splenic artery aneurysm (SAA) rupture in any pregnant woman presenting with abdominal pain, syncope, and hemodynamic instability 1, 3
• The classic presentation includes sudden abdominal pain with syncope and hemorrhagic shock 2
• Approximately 25% present with "double rupture phenomenon"—an initial small herald bleed with warning symptoms, followed by catastrophic hemorrhage 1
• Risk is highest in the third trimester when hyperdynamic circulation maximizes splenic blood flow, though rupture can occur in any trimester 1, 4

Diagnostic Approach

• Perform bedside FAST examination immediately to identify hemoperitoneum 3
• If hemodynamically unstable, proceed directly to operating room without delay for imaging 3, 5
• CT angiography can confirm diagnosis in stable patients but should not delay intervention in unstable patients 2

Emergency Treatment Algorithm

For Hemodynamically Unstable Patients (Most Common Presentation)

1. Activate massive transfusion protocol immediately 3

   • Obtain type and cross without delaying resuscitation 3
   • Correct coagulopathy and transfuse platelets as needed 1

2. Assemble multidisciplinary team urgently: OB/GYN, general surgery, vascular surgery, and anesthesia 3, 5

3. Proceed to emergency laparotomy with splenectomy 1, 6, 3

   • Surgical arterial ligation and splenectomy are required for failed endovascular therapy or when endovascular approach is not rapidly available 1
   • Combined approach with endovascular repair may be utilized if vascular surgery is immediately available 3

4. Perform cesarean delivery if fetus is viable (typically ≥24 weeks) 5

   • Delivery decision should be made intraoperatively based on gestational age and fetal status 5

For Hemodynamically Stable Patients (Rare)

• Trans-catheter embolization is the mainstay of treatment if patient remains stable 1, 2
• Technical success rates range from 67-100% 2
• Coil embolization should be preferred over temporary agents 1
• Surgical backup must be immediately available as patients can deteriorate rapidly 1

Critical Pitfalls to Avoid

Diagnostic Delays

• Do not delay intervention for extensive imaging workup in unstable patients—the diagnosis should be suspected clinically and confirmed at laparotomy 3, 5
• SAA rupture is often not considered in the differential diagnosis of pregnant women with abdominal pain, leading to fatal delays 6, 3

Size Misconceptions

• Up to 50% of SAAs that rupture during pregnancy are <2 cm in diameter, making size-based risk stratification unreliable in this population 2, 7
• This differs from non-pregnant patients where 2 cm is the standard threshold for intervention 2

Underestimating Blood Loss

• These patients require massive transfusion—early activation of transfusion protocols is essential 3
• The "double rupture" pattern can mislead clinicians into underestimating severity after initial stabilization 1

Special Considerations

Underlying Risk Factors

• Cirrhosis with portal hypertension and severe splenomegaly increases SAA risk 1
• Multiparous women are at higher risk 2
• Most SAAs are asymptomatic until rupture, so prior diagnosis is uncommon 2, 6

Post-Operative Management

• Transfer to ICU for close monitoring post-operatively 3
• Monitor for complications including abdominal pain and fever 2
• Neonatal outcomes depend heavily on rapidity of maternal stabilization and delivery timing 5

Prognosis

• Maternal survival requires recognition within minutes to hours—delays are uniformly fatal 1, 3
• Even with optimal intervention, fetal neurologic impairment may occur due to hypoperfusion 5
• Successful maternal and fetal survival has been reported but remains the minority of cases 3