Case report
Rupture of the spleen or splenic vessels (splenic emergency syndrome) in late pregnancy: A report of two autopsy cases

https://doi.org/10.1016/j.forsciint.2007.06.018Get rights and content

Abstract

Emergencies of splenic origin in pregnancy involving rupture of the splenic artery or hemorrhage are rare events that can present suddenly and unexpectedly. We report two cases of young women, both in the third trimester of gestation, who suffered sudden malaise while at home and were admitted to the ER. On arrival, both were in severe hemorrhagic shock due to gross hemoperitoneum and they died in the operating theatre during emergency surgery. To better clarify the causes and sequence of these mortalities, forensic autopsy was requested in each case. In the first (a 26-year-old primigravida in the 40th week of pregnancy), cadaveric section demonstrated the rupture of an aneurysm of the splenic artery. In the second (a 28-year-old multipara in the 33rd week of pregnancy), the clinical and anatomopathological data suggested splenic hemorrhage. In both cases histology showed a fibrodysplasia of the arterial wall involving the splenic artery in one case and the hilar branches in the other. In agreement with the data in literature, in such cases particular importance must be attributed to examination of the arterial wall. In pregnancy a synergic effect between hemodynamic and endocrine factors can cause degeneration of the arteries resulting in dramatic hemorrhage. From the forensic pathologist's viewpoint, these cases underline the importance of histopathological study of the splenic artery in the interpretation of the pathogenesis of splenic vessel rupture or hemorrhage.

Introduction

Insidious spontaneous rupture of the spleen or splenic vessels in pregnancy is a rare event and the pathogenetic factors are still largely unknown. The event carries a high maternal and fetal mortality rate and the clinical picture has been named “splenic emergency syndrome”, terminology that well describes such cases [1], [2]. In fact, brisk intraperitoneal bleeding often causes an abrupt onset of shock, leading to sudden, unexpected death [3], [4]. These cases therefore come under the observation of the forensic pathologist because the precise cause of death can only be determined by autopsy [1], [5]. The forensic pathologist must evaluate any traumatic cause, even of a mild nature, especially in the context of familial violence. Quite often, medical negligence may be hypothesized, due to failure to diagnose or to inappropriate medical care [6]. We report two cases of death of young women in the third trimester of pregnancy, caused by rupture of an aneurysm of the splenic artery in one case and by splenic hemorrhage in the other. A review of the literature on similar cases emphasizes the morphological changes of the splenic arteries that may be correlated with these events [1], [3], [4], [5], [7], [8], [9].

Section snippets

Clinical summary

A 26-year-old woman, primigravida in the 40.5th week of pregnancy, suffered sudden malaise while at home, without loss of consciousness. Due to rapid, progressive deterioration of her condition, the patient was admitted to the local hospital two hours from the onset of the symptoms. She arrived in a state of hypovolemic shock. Intensive care procedures were performed, blood and plasma substitutes were transfused and ultrasound scans were urgently accomplished. No fetal movements were noted, but

Discussion

The cases we describe demonstrate classic “splenic emergency syndrome” occurring in the third trimester of pregnancy, during labor or postpartum. The events most frequently reported in literature giving rise to this dramatic picture are rupture of a splenic artery aneurysm (SAA) and, more rarely, cases of “spontaneous” rupture of the spleen.

Aneurysm of the splanchnic arteries is an uncommon form of vascular disease but has a considerable clinical importance owing to its tendency to rupture. SAA

Acknowledgments

The authors would like to thank Prof. Mary V.a Pragnell and Janet S. Barber Duval (MSN, RN) for their help in the preparation of the manuscript.

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