O&G Forum

OBSTETRICS & GYNAECOLOGY FORUM 2022 | ISSUE 3 | 28 Case Report A 34-year-old female (gravida 5; para 3; miscarriage 1) at 33 weeks, with dichorionic diamniotic (DCDA) twins was referred from a secondary-level hospital with upper gastrointestinal (GIT) bleeding based on a history of abdominal pain and co ee-grounds vomiting. An upper GIT endoscopy at the referring hospital found esophagitis with no active upper GIT bleeding, which did not explain the patient’s condition. e patient was a citizen from a neighbouring country working on farms near Bloemfontein, Free State. is was the patient’s rst antenatal presentation. At our unit, the patient complained of abdominal pain and vomiting with no history of trauma or bleeding per vagina. She had two previous caesarean sections with no signi cant medical history before the pregnancy. On general examination, the patient had pallor, hypotension (blood pressure (BP) 79/49 mmHg) and tachycardia (pulse rate 123 beats/min). Per-abdominal examination revealed a distended, tense and tender abdomen with a fundal height of 45 cm. Per-vaginal examination showed that the cervix was not dilated with no bleeding. Resuscitation with intravenous (IV) uid, blood products and oxygen was already started at the referring facility and established during admission. e trans-abdominal and vaginal ultrasound scanning revealed an intrauterine twin pregnancy with both foetuses without a heartrate; no retro-placental clot was seen. On investigation, the patient’s haemoglobin (Hb) level was 7.4 g/ dl and platelet count 211.000 per µl. Kidney function test and clotting pro le were normal. Di erential diagnosis of rupture uterus or placenta abruption was made, and operative intervention was done with a midline laparotomy. Per-operative ndings revealed massive hemoperitoneum (2 litres of blood), but the uterus was intact. A lower segment uterine incision was performed, and fresh stillborn twins were delivered, the rst baby was female, and the second baby was male; both were in a transverse lie, amniotic uid was clear, and there were no retroplacental clots. On further abdomen exploration, active bleeding was identi ed from the spleen, and multiple haemostatic stitches were done with the application of Surgical® to achieve good haemostasis. e patient received 2 units of red blood cells and 2 units of fresh frozen plasma intraoperative. e patient received antibiotics postoperatively, and postoperative recovery was uneventful. Introduction Acute abdomen during pregnancy can be caused by various aetiologies - obstetric or non-obstetric, as illustrated in Figure 1. A systematic approach, including detailed patient history, physical examination, and laboratory and radiological investigations, isnecessary foranaccuratediagnosis.Anatomical and physiological changes in pregnancy should be considered as these changes mask the typical presentation of the conditions causing acute abdomen, making interpreting symptoms, signs, and biochemical and radiological investigations challenging. ere is also the fear of foetal exposure to ionizing radiation, causing a delay in using imaging modalities which help to reach prompt diagnosis. 1,2 O&G Forum 2022; 32: 28-31 CASE REPORT Spontaneous Non-Traumatic Splenic Rupture in Twin Pregnancy Shisana M. Baloyi 1 , Samia RM El Ammari 1 1 Department of Obstetrics and Gynaecology, University of the Free State, South Africa Abstract The authors present a case of a 34-year-old woman with twin pregnancy who presented with acute abdomen and haemorrhagic shock due to splenic rupture at 33 weeks and further discuss the difficulties that might ensue when diagnosing acute abdomen is made in a pregnant woman. The occurrence of an acute abdomen in a pregnant woman is always a cause for concern, given the vast differential diagnosis for the problem and the potentially harmful consequences for both the mother and foetus.Acute abdominal pain during pregnancy can be attributed to either obstetric factors or for reasons unrelated to the pregnancy itself. The diagnostic approach to acute abdomen during pregnancy can be challenging due to the differences in the clinical signs and symptoms associated with anatomical and physiological variations related to pregnancy. Certain radiological investigations should be used with caution to prevent unfavourable effects to the foetus. Postponement diagnosing and managing acute abdominal pain in pregnancy can lead to undesirable maternal and foetal outcomes. The aim of this report is to review and discuss the various aetiologies, current concepts of diagnosis, and treatment to develop a strategy for timely diagnosis and management of pregnant women presenting with acute abdomen. Keywords: ectopic pregnancy, rupture uterus, abdominal pain, appendicitis, cholecystitis, acute abdomen, pregnancy Correspondence Shisana Baloyi email: BaloyiSM@ufs.ac.za