Canad. Med. Ass. J.
Sept. 28, 1963, vol.89
CASE REPORTS: Rur'ruiu. OF THE SPLEEN IN PREGNANCY
A rare case is presented of total anomalous pul-
monary venous return associated with both great vessels
originating from the right ventricle (partial transposi-
tion). The nature of both malformations is described.
Clinical, hemodynamic and pathologicoanatomic find-
ings are reviewed. It is felt that electrocardiographic
findings, cardiac catheterization and angiocardiography
might be of diagnostic help in establishing the nature
of such combined malformations.
The authors wish to thank Mr. J. Gauthier, photographer,
and Miss J. Dupuis for the illustrations.
1. AUER, J.: Anat. Rec., 101: 581. 1948.
2. NEILL, C. A.: Pediatric8. 18: 880, 1956.
3. EDWARDS, J.E. AND HELMHOLZ, H.
Olin., 31: 151, 1956.
4. BURCHELL, H. B.: Ibid., 31: 161, 1956.
5. WILSON, 3.: Phil.
6. BRODY, H.: Arch. Path.
7. SMITH, 3. C.: Amer. Heart J., 41: 561. 1951.
Tr. Roy. Soc. (London), 1798,
9. IvEMARK, B.: Acta Paediat.
Year Book Publishers,
11. KEITH, J. D. et al.: Amer. J. Med., 18: 23, 1954.
12. SNELLEN, H. A. AND ALBERS, F. H.:
13. ABBOTT, M.
B.S.: Atlas of congenital
American Heart Association,
14. TAusSIG, H.
B.: Congenital malformations
2nd ed., Harvard University Press, Cambridge, Mass.,
15. WITHAM, A. C.: Amer. Heart J., 53:
16. NEUFELD, H. N.. Du SHANE, J. W. AND EDWARDS,
Circulation, 23:603, 1961.
J.T. AND EDWARDS,
(Uppsala), 44(suppi. 104):
S. R.: Diagnosis of congenital heart disease,
Inc., Chicago, 1959.
inc., New York,
of the heart,
Nous avons discut6 un cas d'anomalie de retour vemeux
partielle, l'aorte et l'art.re pulmonaire venant du ventricule
Nous avons pr6sent6 le tableau cinique et h.modynami-
que de ce syndrome complexe ainsi que les faits anato-
mopathologiques. Nous croyons que l'6lectrocardiogramme,
le cath6t6risme cardiaque et l'angiocardiogramxne peuvent
aider . 6tablir
i. une transposition
le diagnostic de ces malformations com-
Spontaneous Rupture of the Spleen in Pregnancy
S. E. O'BRIEN, M.D., F.R.C.S.[C], F.A.C.S., Hamilton, Out.
SPONTANEOUS rupture of the spleen is now
recognized as a rare but definite complication
of pregnancy. A recent case seen in the author's
practice prompted a brief review of this subject.
was admitted to St. Joseph's Hospital, Hamilton, in
the late evening of October 3, 1962.
Her last normal menstrual period occurred on July
3, 1962. During the first weeks of her pregnancy she
had experienced considerable nausea and vomiting, but
these symptoms subsided a month or so before her
admission to hospital.
She stated that she was in her usual state of health
until about 6 p.m. on October 3, when she suddenly
became nauseated and began to retch. Almost immedi-
ately afterwards she experienced severe pain in the
epigastrium and left upper quadrant. The pain was
steady and gradually increased in severity. After about
four or five hours she began to complain of pain in the
left shoulder which was even more severe than the ab-
There had been no vaginal bleeding or spotting since
her last normal period in July. Her bowel movements
had been quite regular and there were no urinary
symptoms. Repeated questioning failed to reveal any
history of even minor trauma.
The patient was a pale, thin young adult woman
who appeared to be in acute distress. Her pulse was
regular at a rate of 105 per minute and her blood
pressure was 110/70 mm. Hg.
Italian woman, para
The abdomen was not grossly distended. There was
generalized tenderness throughout the entire abdomen,
more pronounced in the left upper and lower quadrants.
There was marked voluntary rigidity of the left rectus
abdominis muscle, and rebound tenderness could be
elicited over the entire abdomen. No mass could be
palpated. Theliver and spleen were not palpable.
Bowel sounds were active.
Pelvic examination revealed a parous introitus. The
uterus was enlarged to the size of a two to three
months' pregnancy. There was acute pain on moving
the cervix. Marked tenderness could be demonstrated
in both fornices and there was some fullness in the
left adnexal region.
Laboratory findings included a normal urinalysis, a
hemoglobin level of 72%, and a white blood cell count
of 19,000 per c.mm.
A diagnosis of spontaneous rupture of the spleen
was entertained, but because of its rarity, and because
of the findings on pelvic examination, ruptured ectopic
pregnancy seemed a more likely preoperative diagnosis.
Shortly after admission,
mately 500 c.c. of free blood was found in the pen-
toneal cavity. The uterus was enlarged, soft, and obvi-
ously gravid. Both tubes and ovaries appeared normal.
The incision was then extended upward almost to the
left costal margin. Several large clots were found in
the region of the hilum of the spleen. The spleen
seemed slightly enlarged and there was a recent linear
tear approximately 3 cm.
surface. Splenectomy was carried out and the patient
made an uneventful recovery. She was discharged from
hospital on her tenth postoperative day. Her pregnancy
operation was performed
in length on
668 CASE REPORTS:RUPTURE OF THE SPLEEN IN PREGNANCYCanad. Med. Ass. J.
Sept. 28, 1963, vol.89
The pathological specimen consisted of a spleen
weighing 224 g. with a laceration 3 cm. in length and
1 cm. in depth on its visceral surface. Microscopic ex-
amination revealed recent hemorrhage in the region
of the laceration, but there was no specific lesion to
account for the spontaneous rupture. Subsequent blood
smears, heterophil antibody tests, and serological tests
for syphilis were normal.
At least 50 cases of rupture of the spleen in
pregnancy have been reported and doubtless many
more have occurred. From a review of the literature
it would appear that the majority of these were
cases of spontaneous rupture of the normal spleen.
Spontaneous rupture of the normal spleen has
always remained a surgical enigma. Indeed there
are many authorities who truly doubt that the con-
dition exists, and feel that most cases represent
delayed rupture following minimal or forgotten
trauma. When one considers the frequency of de-
layed rupture of the spleen following trauma, such
a view seems justified.
However, in many of the cases reported, thorough
questioning failed to reveal any evidence of even
minor trauma, andthese have therefore been
classified as cases of spontaneous rupture.
Sparkman,7 in an excellent review of 44 cases of
rupture of the spleen in pregnancy, categorized the
etiology of the condition in this series as follows:
(1) traumatic rupture-seven definite, seven ques-
tionable cases; (2) rupture of diseased spleens-
five cases; (3) toxemia-four cases; (4) spontane-
ous rupture-21 cases.
The diseased spleens included three with malaria
and one with Banti's disease, one with an old
splenic abscess, and one with thrombosis of the
splenic vein. Other writers have indicated that in-
fectious mononucleosis also predisposes to spon-
taneous rupture of the spleen. Four cases of splenic
rupture occurred in patients with toxemia of preg-
nancy in which hypertension, thrombosis and dif-
fuse angiitis are said to predispose to vascular
Suggested etiological factors in cases of true spon-
taneous rupture include internal trauma, as pro-
posed by Barnett
vomiting, coitus in the latter stages of pregnancy
and the bearing-down efforts of the second stage
of labour). In the case described in this report
vomiting may well have been the initiating factor.
Many writers have suggested that the enlarge-
ment of the spleen that occurs in pregnancy may
predispose to rupture from trivial trauma, but it
has never been proved that the spleen actually does
enlarge at any stage in pregnancy. On the other
hand, it has been well proved that the blood volume
increases as much as 45% in the last trimester of
possible factor in splenic rupture.
Another widely held theory is that rupture of
a small intrasplenic aneurysm may occur, with
(i.e. occasioned by coughing,
this has been considered
the hemorrhage, thus preventing its discovery by
the pathologist. Certainly larger aneurysms of the
splenic artery are more prone to rupture during
pregnancy, and even spontaneous rupture of the
splenic vein has been reported.
Finally, disturbance of the normal position of the
spleen by the gravid uterus, particularly where the
splenic pedicle is short, has been cited as a possible
causative factor in this condition.
Spontaneous rupture of the spleen is most fre-
quently encountered in the last trimester of preg-
nancy, though cases have been reported during
the early months as well as during labour and in
the puerperium. The signs and symptoms are identi-
cal to those in cases of traumatic rupture of the
spleen in non-pregnant patients and will not be
discussed in detail in this report.
A correct preoperative diagnosis of spontaneous
rupture of the spleen is rarely made. In the first
ectopic pregnancy. In the last trimester abruptio
placentae and rupture of the uterus are the two
most likely differential diagnoses. However, in the
case of rupture of the spleen the uterus
tender or hard, and fetal heart sounds can usually
be heard. The presence of referred pain in the left
shoulder area should always alert the examiner to
the possibility of splenic pathology.
Once the diagnosis of rupture of the spleen has
been made, the only effective treatment is restora-
tion of blood loss and immediate splenectomy. In
the latter stages of pregnancy a preliminary Ces-
arean section is necessary to empty the uterus and
provide access to the spleen. Without splenectomy
the prognosis is almost always fatal. In Sparkman's
series, all cases in which splenectomy was not per-
formed terminated fatally. These included four pa-
tients who underwent laparotomy but in whom the
source of the bleeding was not found.
of the aneurysm being destroyed by
it is usually confused with ruptured
A case of spontaneous rupture of the normal spleen
complicating pregnancy is described. The various etio-
logical factors have been reviewed and the differential
diagnosis and treatment have been indicated. Although
the condition is rare, it is lethal and should always
be considered in the differential diagnosis of every
pregnant woman who develops an acute abdominal
catastrophe, particularly if there is evidence of internal
The author wishes to express
his thanks to Dr. Paul
1. BARNETT, T.: J. Ob8tet. Gynec. Brit. Emp., 59: 795, 1952.
2. HUNTER, R. M. AND SHOEMAKER, W. c.: Amer.,!. Obstet.
(tynec., 73: 1326, 1957.
3. GeRMAN, A. J. AND ROWE, D. H.: Ibid., 62: 1361, 1951.
4. MOORE, D. W.: Western,!. Burg., 64: 306, 1956.
5. SHANNON, W. F.: Amer.
6. SMITH, A. H. D., MORRISON, W.
Lancet, 1: 694, 1933.
7. SPARKMAN, R. S.: Amer. 3. Obstet. Gynec., 76: 587, 1958.
.7. Obstet. Gynec., 40: 323, 1940.
3. AND SLADDEN, A.