Author Information
Puri J*, Thakur H**, Gupta AS***.
(* Third year resident, ** Assistant Professor, *** Professor and
Unit Head.
Department of Obstetrics and Gynecology, KEM Hospital, Parel, Mumbai,
India.)
Abstract
A
successful outcome of pregnancy with accessory spleen torsion at 14
weeks of gestation that required an exploratory laparotomy in the
antenatal period is being presented. Pregnancy was carried till 37
weeks of gestation and an elective LSCS was done as the
patient
had undergone previous two LSCS.
Introduction
Accessory
spleen is a rare cause of acute abdomen. Accessory spleen was found
in 10-15% of autopsy series accidentally.[1] Most of the accessory
spleen are asymptomatic, and become problematic only if they get
infected, undergo torsion, or necrosis. Most of them present in
children. No records were found indicating their presentation and
diagnosis in pregnancy on a pubmed,
medline
and google
search. Accessory splenic torsion that occurred at 14 weeks of
gestation was treated by exploratory laparotomy and excision of the
gangrenous spleen. The pregnancy was continued till term
successfully.
Case
Report
A
26-year-old G3P2L2, patient with previous two LSCS was posted for
elective LSCS and tubectomy at 37 weeks of gestation. Patient
delivered a male baby of 2.688 kg, appropriate for gestational age
with Apgar score of 9/10.
The
patient presented to the emergency room at 14 weeks of gestation with
the complaints of acute onset pain in abdomen with pain originating
in the left lumbar region and radiating to the back. The pain
episode was preceded by one
episode of vomiting.
The patient had come with an ultrasonography scan (USG) from a
private practitioner, suggestive of left psoas abscess. On
examination, general and systemic examination was within normal
limits. On abdominal examination, uterus of 16 weeks size was
palpable; tenderness in left iliac fossa with minimal guarding was
elicited. There was no rigidity. Ill-defined fullness was present in
the left iliac fossa. On speculum examination, creamy, purulent,
non-foul smelling, profuse discharge was seen. Cervix was high up. No
fistulous tract or opening was seen in any of the fornices. Sterile
swabs were collected and sent for smear and culture. On
bimanual pelvic examination, uterus was soft, about 14 weeks in size,
deviated to right, os was closed, but cervix was short. No cervical
motion tenderness could be elicited. No mass/ cyst was felt in the
left fornix. Vagina was not warm. On rectal examination, no mass or
collection was felt. Patient underwent a repeat USG
scan that was suggestive of a hemorrhagic left ovarian cyst of 9.6 x
6.8 cm, without any vascularity. Due to discrepancy of clinical
examination and imaging studies, a magnetic
resonance
imaging
(MRI) for the mass was done. The MRI report was suggestive of a
well-defined homogeneous, intraperitoneal mass of size 9.3 x 5.6 x
6.1 cm in the left lumbar region, which was isointense with the
spleen. The lesion had a pedicle arising from its lateral aspect just
beneath the parietal wall. The pedicle showed fat stranding, up to
the splenic vein. Vascular pedicle appeared twisted. MRA (Magnetic
Resonance Arteriogram) and MRV (Magnetic Resonance Venogram) revealed
no flow in the pedicle, which was suggestive of accessory splenic
torsion. Smear
did not grow any AFB, bacteria or candida. The
patient underwent
exploratory laparotomy under general anesthesia.
The anesthetist took adequate care regarding adequate oxygenation and
vigilant intraoperative monitoring was done. Intra-operatively
findings showed an
accessory
spleen in the left lumbar region
with
flimsy adhesions to
the
small bowel loops and the
omentum.
There was torsion of its
pedicle,
whose
blood supply originated
from the
splenic
artery. There was another native spleen, normal in position and blood
supply. Remaining
abdominal
and pelvic structures were normal.
Uterus and adnexae were not handled during the surgery. Patient had
an
uneventful
post-operative stay in the hospital and was discharged on day 5 of
the
surgery.
Figure
1. MRI showing the torsion of the accessory spleen
Figure
2.
Excised gangrenous accessory spleen.
Patient
had a regular ANC follow up
and care. Progesterone
support was given in the form of weekly intramuscular
injection
of 500 mg of Hydroxyprogesterone, till 37 weeks of gestation. The
patient had threatened preterm labor at 33 and 35 weeks of gestation,
and she
was admitted. Injection Dexamethasone 6mg 12 hourly for 4 doses were
given during the first episode. Tocolysis was given with oral
Nifedipine 20 mg followed by Nifedipine sustained release 10 mg 12
hourly for 7 days. Urine routine microscopy was within normal limits,
urine culture report showed no growth, high cervical swab showed no
growth. Patient was conservatively managed and then discharged after
48 hours of observation both the times. Patient underwent an elective
LSCS with tubal ligation for previous two LSCS, at 37 completed weeks
of gestation. Antibiotics
were administered perioperatively as per hospital infection policy.
During
the LSCS, the scar of the previous LSCS was thinned out, no evidence
of dehiscence or rupture was seen. The uterus was a bicornuate
uterus. Bilateral adnexa were normal. Bilateral kidneys were
palpated. They were normal. The upper abdomen was normal. LSCS
surgery
was
uneventful, and patient tolerated the procedure and anesthesia well.
Post-operative stay in the hospital was uneventful. Patient was
discharged on Day 5 of surgery. Delayed suture removal was done on
day 14.
Suture line was healthy.
Figure
3.
Bicornuate
uterus seen during
LSCS
Figure 4. Normal Upper Abdomen during LSCS
Discussion
Accessory
spleen is usually an incidental finding. Accessory spleen develops
from dorsal mesogastrium during the embryological development. It is
an inert structure, usually does not cause any problems and remains
undiagnosed in the lifetime of a person. Accessory spleen was found
in 10-30% of autopsies.[1] Torsion of an accessory spleen is a rare
clinical event seen in around 0.2-0.3% of splenectomies.[2] Twenty
six cases of torsion of accessory spleen have been reported till
date.[3] None of these 26 patients was a pregnant woman. The most
common locations of accessory spleen
(about
22%)
are posteromedial to the native spleen.[2]
The next most common locations are
near the
upper
pole of the
left
kidney and around the
pancreatic tail.
The
most common symptom of torsion of accessory spleen is presentation
with acute abdomen, severe abdominal pain originating in the left
lumbar region, radiating to the back. The cause of the pain is the
necrosis of the splenic tissue. The patient had come with an outside
ultrasonography suggestive of left psoas abscess with acute abdomen.
A repeat ultrasound was done, which was suggestive of left ovarian
cyst, without any vascular supply. Due to unsatisfactory report of
ultrasound examination and discrepancy in clinical examination and
ultrasound findings, an MRI was done which was suggestive of a 9.3 x
5.6 x 6.1 cm sized accessory spleen with torsion. The patient had
undergone an exploratory laparotomy and the devitalized splenic
tissue was resected. Preoperative diagnosis of splenic torsion is
usually missed and this is detected intraoperatively.[4,
5]
However in our patient due to good clinical acumen the ultrasonic
diagnosis of psoas abscess and ovarian cyst were disregarded due to
mismatch with the abdominal and bimanual pelvic examination and a MRI
was obtained which clinched
the diagnosis.
We feel clinical correlation is essential in such cases and
appropriate imaging modalities can reach the final diagnosis
preoperatively. Either way in pregnancy the enlarging gravid uterus
changes the intra peritoneal dynamics and detection of benign pelvic
masses in pregnancy and an acute or sub acute abdomen is always a
challenge.
The
gold standard for the diagnosis of accessory spleen is MRI. It is
better at diagnosing the site of origin, clinical position of
accessory splenic tissue, and diagnosing signs of inflammation. CT
scan can
also be done but it
is not advisable in pregnancy. Angiography and nuclear Technetium
scans are useful in diagnosing accessory splenic torsion but are
useless when there is complete occlusion of arterial supply due to
torsion.[4] Angiography is not advised during pregnancy because of
fetal irradiation, while Technetium 99m scans can be done when the
whole fetal exposure of 0.5 rad is not
exceeded.[7]
The
differential diagnoses of acute left sided abdominal pain in early
pregnancy include genitourinary causes like adnexal torsion; torsion
of left ovarian cyst, ureteral calculus. Conditions associated with
pregnancy that cause acute abdominal symptoms include torsion of
gravid uterus, acute urinary retention due to retroverted uterus,
acute red degeneration of a uterine fibroid, and uterine rupture.
Vascular causes mimicking acute abdomen include sickle cell crisis,
acute splenic artery aneurysm, abdominal trauma, and splenic rupture.
Gastrointestinal causes like, acute pancreatitis, peptic ulcer,
gastroenteritis, pancreatic pseudocyst, and bowel obstruction. The
most common surgical cause of acute abdomen in pregnancy is
appendicitis,[7]
while
the most common gynecologic cause of acute abdomen is ectopic
pregnancy.[8]
Exploratory
laparotomy or laparoscopy is safe in pregnancy in all trimesters
though there is a slight increased risk of preterm labor.[9,10]
Patients
undergoing exploratory laparotomy for surgical management of acute
abdomen was studied in a study conducted by Unal et al. [11]
Patients tolerated the procedure well. Our
patient probably had threatened labor due to the bicornuate uterus
rather than due to the emergency laparotomy that was performed at the
start of the 2nd
trimester. Prompt diagnosis and management of acute abdomen is the
corner stone for optimum maternal and fetal outcome as was seen in
our case.
Acknowledgments
We thank Dr. Gwalani
and his team. Department
of Surgery, Seth GS Medical College and KEM Hospital for performing the operation.
References
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