O&G Forum

OBSTETRICS & GYNAECOLOGY FORUM 2022 | ISSUE 3 | 30 A ruptured uterus should be considered in patients with previous uterine surgery, such as a myomectomy, hysterotomy and caesarean section, who complain of abdominal pain with signs of internal haemorrhage. e foetus is usually a ected by foetal distress or loss in the case of late diagnosis. An ultrasound can con rm foetal heart abnormality and intra- peritoneal free uid; in some cases, the foetus will be visible outside the uterine cavity. Severe preeclampsia presents with severe epigastric or right upper quadrant pain due to oedema and stretching of the liver capsule and is usually associated with other symptoms and signs of imminent eclampsia, such as severe headache, blurred vision and vomiting. Diagnosis is usually suspected in a patient with elevated blood pressure in conjunction with these symptoms. Laboratory investigations might show proteinuria, renal and liver impairment, haemolysis, and a low platelet count. An ultrasound nding might show intrauterine growth restriction or foetal loss, while a subscapular haematoma could be visible. Acute fatty liver has a similar presentation of severe preeclampsia in addition to jaundice, which is more common in acute fatty liver in pregnancy. e patient’s condition worsens to hepatic failure and disseminated intravascular coagulopathy. In gynaecological causes, adnexal masses complicate 2% of all pregnancies. Although 65% of patients show no symptoms, torsion and rupture might complicate these masses, causing severe abdominal pain. An ultrasound, in the case of ovarian torsion, shows the ovarian mass with twisted vascular pedicle and pelvic free uid.1,3 e colour Doppler nding is reduced or absent in the arterial ow. A leiomyoma is the most common gynaecological tumour during pregnancy due to an increase in oestrogen levels and is mainly seen in the rst trimester. 14,15 Red degeneration is a complication of leiomyoma during pregnancy when the tumour outgrows its blood supply leading to haemorrhage. 3 e patients usually have a history of leiomyoma present with abdominal pain. In such cases, ultrasound is the diagnostic tool of choice. Among non–obstetrical causes, acute appendicitis is most common, followed by cholecystitis and pancreatitis. 16,17 In the case of appendicitis, the classical presentation is usually masked due to the displaced appendix from gravid uterus. In non-pregnant patients, the classical presentation starts as periumbilical pain, which later shi s and localizes to the right lower quadrant with maximal tenderness at McBurney’s point. On examination, rebound tenderness (Rovsing’s sign) in pregnant patients may not be as noticeable as in non-pregnant patients, and the presence of leukocytosis may not be reliable for the diagnosis due to the physiological changes. 6 Ultrasonography has a reported sensitivity of 67–100% and speci city of 83–96% for appendicitis in pregnancy, while an MRI has been recommended by e American College of Radiology as the second line of imaging in the case of inconclusive ultrasound ndings. 18,19 Gall bladder stonedisease is the secondmost common indication for surgical intervention during pregnancy, as pregnancy is a risk factor for cholesterol cholelithiasis, causing acute cholecystitis. 6,20 Patients present with nausea, vomiting and mild to severe colicky right upper quadrant or epigastrium pain radiating to the right shoulder. On examination, there is maximal tenderness on the right upper abdomen, and on investigation, ultrasound is crucial. 21 In acute pancreatitis, patients present similarly to non-pregnant patients with sudden-onset nausea, vomiting and mild to severe upper abdominal pain radiating to the back with elevated serum amylase and lipase levels. 6 In urolithiasis, patients present with nausea, vomiting and severe colicky ank pain, but in the absence of peritoneal signs. In the case of di cult visualisation due to gravid uterus, an intravenous pyelogram can be done with a de nitive diagnosis by ultrasonography of the ureters. Intestinal obstruction, peptic ulcer and splenic rupture are rare causes of acute abdomen in pregnancy. 6 Spontaneous splenic rupture is a life-threatening condition as the spleen is a vascular organ where even minor trauma could cause signi cant bleeding. e cause could be traumatic or atraumatic, usually associated with a pre-existing spleen pathology. Spontaneous splenic rupture in pregnancy is generally associated with a delayed diagnosis due to an absent history of trauma. In 1803, the rst case of splenic rupture in pregnancy was described by Saxtorph. 22 Patient presentation usually mimicked rupture uterus or abruption placenta, and most cases were taken to theatre based on these two di erential diagnoses. e aim of this report is to enhance awareness of this rare, life- threatening condition and to emphasize the interpretation of clinical signs to indicate further investigations. Discussion Non-traumatic rupture of the spleen is o en associated with systemic diseases that a ect the spleen directly or indirectly, for example, infectious mononucleosis, malaria, leukaemia, sarcoidosis and amyloidosis, which in our case were excluded. 23 e initial consultation at the referral hospital missed the occult haemorrhagic shock secondary to splenic rupture, a very uncommon phenomenon. Splenic rupture in pregnancy is attributed to a hypervolemic state related to increased maternal plasma volume resulting in splenic enlargement, diminished peritoneal cavity volume due to an enlarged gravid uterus and muscular contractions during pregnancy. In addition, increased circulating hormones such as oestrogen and progesterone cause structural changes to the spleen resulting in an increased risk of splenic rupture during pregnancy, even a er minor trauma. 24 Spontaneous rupture of the spleen in pregnancy without systemic disease is a rare condition and associated with a maternal mortality of up to 45%, and foetal mortality of up to 82% due to delayed diagnosis, which is usuallymistaken for ectopic pregnancy in early pregnancy or placenta abruption and rupture uterus in late pregnancy. 25,26 In our patient, splenic rupture occurred at 33 weeks of pregnancy. It is more common in the third trimester, but post- partum spontaneous splenic rupture has also been reported. 27,28,29 Elghanmi et al. 30 reported a case of spontaneous splenic rupture in the third trimester. eir patient presented with acute abdomen and hypovolemic shock and was taken for an emergency laparotomy and caesarean delivery. Active bleeding was present at the splenic hilum, which is consistent with splenic rupture. In our case, the patient presentation was uncommon since co ee-ground vomit is reported as an unusual presentation of rupture of the spleen. 31 Our patient also complained of acute abdomen; therefore, all obstetric and non-obstetric causes of acute abdomen should be considered in such cases. About 0.5–2% of surgical intervention secondary to acute abdomen in pregnancy is due to non-obstetric acute abdomen. 32 O&G Forum 2022; 32: 28-31 CASE REPORT