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.

Keywords: Abdominal pregnancy; Ectopic pregnancy; Splenic pregnancy; Splenorrhaphy.

Fig. 1

CT scan showed active bleeding with linear contrast extravasation from the small oval low density “defect” at the posterior side of the spleen with haemoperitoneum in the parasplenic space

Fig. 2

3 × 3-cm ruptured gestational sac is visible on the posterior surface of the spleen. Hypermobile spleen is retracted towards the right to see the posterior surface

Fig. 3

Microscopic histological section shows a splenic tissue (top right), which infiltrated by trophoblastic tissue (left bottom)

Fig. 4

HCG trend before and after the operation