ABSTRACT
Objective Ruptured splenic artery aneurysms (SAAs) in pregnancy are a rare but significant cause of maternal and foetal mortality. We describe an unusual presentation of SAA rupture at term with predominantly chest symptoms to encourage clinicians to consider this rare differential diagnosis in the obstetric setting, especially in context of the COVID-19 pandemic. Case report A 36-year-old pregnant female (G1P0) presented at 38 + 4 weeks with lower left-sided chest pain and a history of coryzal symptoms. She was hypotensive and tachycardic with oxygen desaturation at presentation. Chest and abdominal examinations were unremarkable. Intravenous fluids and antibiotics were commenced on the suspicion of septic shock from a chest infection. However, new-onset left shoulder-tip pain and a pathological cardiotocogram prompted an emergency Caesarean section. A female infant (APGARs 2,7) was delivered and admitted to NICU for respiratory distress. Significant haemoperitoneum was noted upon abdominal entry, which was localised to the left upper quadrant. Subsequent exploratory laparotomy revealed a large retroperitoneal haematoma and two SAAs (1.5 cm intact, proximal and 2.5 cm ruptured, distal), which were managed via splenic artery ligation and splenectomy. Total estimated blood loss was 4400 mL, requiring intraoperative transfusions of 5U packed red cells, 4U fresh-frozen plasma and 1U cryoprecipitate. Postoperative CT angiogram identified no additional aneurysms but revealed multiple partially occlusive pulmonary emboli, which were managed in ITU with intravenous heparin and, subsequently, low molecular weight heparin. Both mother and baby were discharged in stable condition on day 10. Discussion SAA commonly presents with abdominal pain but is frequently misdiagnosed, as it can mimic other abdominal and obstetric pathologies. We highlight a unique presentation of ruptured SAA with chest pain, which can resemble severe SARS-Cov-2 infection and complicate diagnosis. Importantly, early diagnosis and intervention are critical to reducing mortality. Aggressive fluid resuscitation, emergency Caesarean section and laparotomy remain the mainstay of treatment for symptomatic ruptured SAAs. Additionally, postpartum patients after surgery are at significant risk of venous thromboembolism due to their intrinsically hypercoagulable state;thus, clinicians should have a low threshold for investigation. Conclusion This case stresses the importance of recognising both the typical and atypical clinical features of ruptured SAAs and considering it as a differential for obstetric patients, especially during the COVID-19 pandemic. A multidisciplinary approach with early involvement of the surgical team is imperative to reduce morbidity and mortality.