چاپ صفحه |  صفحه نخست سامانه |  نویسندگان |  اطلاعات تفضیلی |  دانلود مقاله | دانشگاه علوم پزشکی تبریز |
| نویسنده | نفر چندم مقاله |
|---|---|
| سولماز قنبری همائی | دوم |
| هانیه اصغریان | چهارم |
| منصور رضائی | اول |
| عنوان | متن |
|---|---|
| خلاصه مقاله | Abstract: A 39-year-old G5P3ab1 at 30 weeks of gestation was admitted with epigastric and abdominal pain. Her pain was attributed to uterine contractions and due to IUFD, was admitted to LDR her twins was born by APGAR zero. According to the blood tap and report of abundant free abdominal fluid in the ultrasound and hemoglobin 7.2, the patient was immediately transferred to the operating room. About 4.5 liters of blood and clots were drained from the abdomen and because of diagnosing SAA, splenectomy was done. In the ICU, due to bleeding from the operation site, bradycardia and not responding to the resuscitation, she unfortunately expired. Key words: Splenic artery aneurysm, Pregnancy Introduction: Splenic artery aneurysms (SAA) is defined as pathological dilation of the splenic artery more than 1 cm in diameter (1). SAA are uncommon and often are found incidentally on ultrasound examination or autopsy (2, 3). This condition is more common in women (1) and four times more in multiparous women (4). The reported prevalence of SAA ranges from 0.01% to 10.4%; however, the true incidence is unknown as about 95% of the cases are asymptomatic (5). Pregnancy is an important risk factor for SAA rupture (2). SAA rupture is a catastrophic event associated with high maternal mortality (75%) and fetal mortality (95%) (6) and two third of SAA rupture occurs in the third trimester of pregnancy (3). We report a case of ruptured splenic artery aneurysm during the third trimester of pregnancy with both maternal and fetal mortality. Case Report: This is a case of a 39-year-old woman with a gestational age of 30 weeks and a twin pregnancy, which was her fifth pregnancy (G5P3ab1), referred to hospital with severe epigastric and abdominal pain along with nausea, lethargy and cold sweats in winter 1400. In the examination, blood pressure was 64 /42mmHg, heart rate 42, respiration rate 14, and oxygen saturation 98%. The abdomen was slightly distended and the heartbeat of none of the fetuses was heard. In the gynecological examination, there were no other abnormal points such as vaginal bleeding or discharge, and the cervix was not dilated. The patient mentioned a history of heart palpitations since the fifth month of pregnancy and mitral and tricuspid valve regurgitation. The results of the tests obtained upon arrival were: Hb: 10.1, Hct: 24.9, Cr: 1.33 and HbA1C: 6.1, and no abnormal point was found in the patient's electrocardiography. Her pain was then attributed to uterine contractions and due to IUFD, the patient was admitted to LDR for induction of labor by oxytocin and the twins (a boy and a girl) was born by APGAR zero. Because of suspected symptoms of Covid 19, consultation with an infectious disease specialist was performed and according to his order, the patient was isolated and PCR test was taken, which was positive. In the CT scan of the chest, atelectasis next to the posterior-basal segments of the lungs was evident, and no evidence of corona was found, which of course did not rule it out either. In ultrasound abdominal free fluid, suggesting hemo-peritoneum, was seen with 88x180mm dimention, anterior to the stomach. The next day, due to the drop in hemoglobin to 6.5, a consultation was done with a surgical specialist and two units of PC were transfused and an abdominal fluid tap was performed, which was clear. During the hospitalization, periods of tachycardia up to 120 have been reported for the patient, who was treated with propranolol tablets according to her history of heart palpitations, and according to the cardiologist's opinion, the tachycardia could be related to Covid-19. In ultrasound, the liver Span was 158 mm and was in the maximum normal diameter, and moderate free fluid in the abdomen was seen. On the 5th day of hospitalization, the patient was discharged from the hospital after the hemoglobin was 11, and the general condition was good and the vital signs were stable. According to the statement of the patient's male partner, after returning home, the patient was not in a good general condition and was completely pale. She returns to hospital. During the test, his hemoglobin was 8.7 and she had psychotic movements. She was referred to Al-Zahra Hospital in Tabriz with the possibility of pulmonary embolism. At Al-Zahra Hospital, according to the blood tap under the ultrasound guide and the report of abundant free abdominal fluid in the ultrasound and hemoglobin 7.2, as a result of the emergency test, the patient was immediately transferred to the operating room. After an abdominal incision, about 4 liters of blood and 600 cc of clots were drained from the abdomen, and according to the identification of bleeding in LUQ, under the spleen, the main source was put under compression, and after calling the senior surgical resident and his presence in the operating room, because of diagnosing SAA, splenectomy was done. The splenic artery and vein were ligated and hemostasis was checked at the splenectomy site and the abdominal wall was sutured after ensuring the absence of bleeding. During the operation, the patient receives four units of Packed Cell, four units of FFP and three units of platelets. In the ICU, the patient was bleeding from the corrugate drain site, and due to bradycardia, resuscitation and cardiac massage were started for the patient, and in order to investigate the source of the bleeding, he was transferred to the operating room while breathing support, in the abdominal cavity there were two liters of bright blood. It was suctioned. The abdomen was examined and the bleeding vessels were ligated and the bleeding site were compressed, but the next day, he had bleeding again from the operation site and suffered bradycardia again, she did not respond to the resuscitation and unfortunately expired. Discussion: We presented a case where that because of the lack of timely diagnosis due to relating the patient's symptoms to corona, labor pain and underlying heart palpitations, unfortunately witnessed the maternal death. SAA is the rare non-obstetric (0.23%) conditions specific to pregnancy where timely diagnosis could be lifesaving (7). Symptoms vary widely and include diffuse abdominal pain, especially in the left upper quadrant, syncope, shortness of breath, or nausea and vomiting. This is known to occur most frequently in the third trimester (8). The fetal distress and mortality usually results from hypovolemia, shock and their resulting consequences (9). The recent guideline for the management of visceral artery aneurysm suggests that splenic artery aneurysm in pregnancy should be treated regardless of its size because of the high mortality rate of both the mother and fetus in case of rupture (10). Approximately, 95% of SAA rupture occurs during pregnancy, most commonly during the third trimester (11). Spontaneous hemorrhage from splenic artery aneurysm (SAA) rupture is a rare and fatal complication during pregnancy. It seems parity influences the incidence of SAA in women, being four times more common in multiparous women (9). Physiological changes during pregnancy also enhance the stress on the arterial wall. These include enhanced cardiac output, increased blood volume and portal hypertension (12). Rupture of SAA is usually a rapid process; however, in about 25% of cases, it can occur in two stages. The initial stage may last for a few hours to days presenting with mild to moderate pain. Prompt diagnosis and treatment at this stage are associated with better maternal and fetal outcomes. The second stage of rupture is associated with bleeding into the abdominal cavity and is catastrophic (1). The clinical features result from aneurysm rupture usually which is characterized consistently with sharp abdominal pain, either in the epigastrium or more often localized in the left hypochondrial area with associated pain in the tip of the left shoulder (Kehrs sign). This is associated with nausea, vomiting and sudden collapse (13) It seems that high degree of suspicion is required to make diagnosis of SAA rupture in pregnant females having sudden collapse or sharp abdominal pain, as rapid diagnosis is essential in view of hypovolemic shock and aggressive volume replacement and prompt surgical intervention are favorable (14). In pregnant women, it might be misdiagnosed as uterine rupture (in 70% of cases), abruptio placenta, amniotic fluid embolism, or other surgical emergencies such as perforated peptic ulcer disease (1, 6). Angiography is the gold standard for diagnosis, and in pregnant women, ultrasound with pulsed Doppler is the preferred imaging modality (1). When splenic aneurysm was diagnosed in pregnancy, ccaesarean section helps in hemodynamic stability and has shown to improve maternal and fetal survival (15). Conclusion: In conclusion, SAA rupture in pregnancy is a rare but life-threatening obstetrical complication and is often associated with a high rate of maternal and fetal morbidity and mortality. Early consideration of ruptured SAA diagnosis significantly increases the chances of survival for both the mother and the fetus. Earlier awareness of SAA rupture during pregnancy, even with a vague presentation, may further contribute to maternal and fetal survival based on successful multidisciplinary team efforts. Conflict of Interest The authors declare no potential conflict of interest. Acknowledgment: The Authors would like to thanks Clinical Research Development Unit, Taleghani Hospital, Tabriz University of Medical Sciences, Tabriz, Iran for kind supports. |
| کلمات کلیدی | Splenic artery aneurysm, Pregnancy |
| نام فایل | تاریخ درج فایل | اندازه فایل | دانلود |
|---|---|---|---|
| rezaee.pdf | 1402/05/09 | 298108 | دانلود |
| A maternal and fetal death due to ruptured splenic artery aneurysms.docx | 1402/05/11 | 31075 | دانلود |
