Early diagnostis of splenic ectopic pregnancy: A case report and review literature

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Splenic ectopic pregnancy is extremely rare but carries a high risk of life-threatening intraperitoneal bleeding. Here, we present a 40-year-old woman presenting with vaginal bleeding. Although the intrauterine device (IUD) had been in place for 6 years, urinary and serum tests were positive for pregnancy.

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Nội dung Text: Early diagnostis of splenic ectopic pregnancy: A case report and review literature

JOURNAL OF MEDICAL RESEARCH EARLY DIAGNOSTIS OF SPLENIC ECTOPIC PREGNANCY: A CASE REPORT AND REVIEW LITERATURE Pham Hong Duc1,2,, Pham Huu Khuyen3 Radiology Department, Saint Paul Hospital of Hanoi 1 2 Radiology Department, Hanoi Medical University 3 Medical imaging & nuclear medicine Center, Viet Duc Hospital, Ha Noi Splenic ectopic pregnancy is extremely rare but carries a high risk of life-threatening intraperitoneal bleeding. Here, we present a 40-year-old woman presenting with vaginal bleeding. Although the intrauterine device (IUD) had been in place for 6 years, urinary and serum tests were positive for pregnancy. However, transvaginal ultrasound showed an empty uterus, no apparent adnexal masses or free fluid. An abdominal ultrasound was subsequently performed, which revealed a viable gestational sac in the spleen. An MRI that did not induce ionizing radiation was also performed, confirming the diagnosis of this splenic pregnancy. The gastrointestinal surgeon completed a laparotomy which successfully removed the spleen's superior pole containing an ectopic pregnancy. Keywords: Splenic pregnancy, Ectopic pregnancy, Ultrasound, MRI, Partial splenectomy . I. INTRODUCTION The most common site of ectopic implantation Primary splenic pregnancy was common at is within the fallopian tube, accounting for young maternal age (27.3-28.7), with few births 95.5% of all ectopic pregnancy, the remaining (the average parity was 1.1).2,3 As with other extratubal ectopic pregnancy include ovaries abdominal pregnancy sites, splenic pregnancy and abdomen, accounting for 3.2% and 1.3%, occurred with several risk factors, including respectively.1 Abdominal pregnancies have a history of pelvic inflammatory disease, been described in a diverse of extra-pelvic endometriosis, in vitro fertilization (IVF), previous organs, with the spleen being one of the rarest pelvic surgery, previous ectopic pregnancy, sites. A Systematic review of the literature, uterotubal anomalies, and intrauterine device Poole A et all. showed that in 225 abdominal (IUD).4,5 Most cases of symptomatic splenic ectopic pregnancies, splenic gestations pregnancy are diagnosed between 6th - 8th accounted for only 5.3%. The remaining sites week of gestation, and tended to occur earlier were divided into the following categories in than other sites in the abdomen, but later order from most reported to least: pouches than tubal ectopic pregnancy.1,2,3,6 Kalof et al around uterus (24.4%), uterus-adnexa (24.0%), postulated most splenic pregnancies at clinical multiple abdominal organs (12.9%), omental presentation ranged in size from 2.0 to 3.5 cm, (11.1%), bowel-appendix (6.7%), hepatic and suggested that the risk of rupture in ectopic (5.8%), retroperitoneal (4.5%), abdominal wall gestation exceeds this size.3Herein, we would (3.1%) and others (2.2%).2 like to present a case preoperatively diagnosed Corresponding author: Pham Hong Duc by adbominal ultrasound and MRI as a splenic Saint Paul Hospital of Hanoi pregnancy with live embryos implanted at the Email: phamhongduc@hmu.edu.vn superior pole of the spleen in a middle-aged Received: 16/01/2024 woman who had an IUD in situ, successfully Accepted: 15/02/2024 treated by partial splenectomy before its rupture. JMR 177 E14 (04) - 2024 1
JOURNAL OF MEDICAL RESEARCH II. CASE REPORT A 41-year-old woman, gravida 2 para 2, was (normal
JOURNAL OF MEDICAL RESEARCH A B C D E F Figure 2. Abdomino-pelvic MRI. T2WI axial (A), coronal (B) and sagittal (C); T1WI VIBE FatSat (D); DWI b=800 (E) and ADC (F). The images shows a mass located in the spleen adjacent to the left diaphragm, cystic component, well-margined, with many small septal in the periphery (A, B and C, arrows), interspersed with hyperintense foci of blood stasis (D, arrow), and restricted diffusion edema of peri-lesional splenic parenchyma (E and F, arrows) The initial surgery was exploratory the surgical ward 2 days later where the rest of laparoscopic examination. It revealed a 3x4cm her recovery was uneventful. ß-hCG levels fell pregnant mass in the upper pole of the spleen to 908.83 IU/L 6 days after surgery. The pelvic with villous tissue deeply embedded in the drain was removed on day 3 and the patient spleen parenchyma and easy to bleed. The was discharged on day 5 post-operation. prognosis was difficult, therefore decision was She had an uneventful recovery at home and made to converse from laparoscopic to open ß-hCG levels returned to normal 4 weeks after surgery by the xiphoid-umbilical incision. The surgery. spleen was released from the upper gastric Macroscopic pathology of the resected pole, the tail of the pancreas, and the splenic superior pole spleen revealed a protrusion flexure. the splenic artery branch to the upper with a generally thin and smooth surface. On pole was ligated, and s ubsequently, an sectioning in half, there was a corresponding anatomic resection of the upper pole of the oval mass with well-delineated but non- spleen was performed and hemostasis with encapsulated measuring 20 x 25 x 35 mm, prolene 3.0 suture. Excellent hemostasis was containing cystic and pinkish-white soft tissue achieved and the abdomen was closed up mixed with dark red hemorrhages. Microscopic after being washout with insertion of a drain examination demonstrated numerous chorionic in the peri-splenic region. Postoperatively, the villi and intermediate trophoblasts invading the patient was transferred to the Intensive Care splenic parenchyma (Fig.3). No malignant cells Unit for monitoring, before stepping down to were found. JMR 177 E14 (04) - 2024 3
JOURNAL OF MEDICAL RESEARCH JOURNAL OF MEDICAL RESEARCH Delete A A B B Figure 3. Histopathologic sample. A A (H&E, ×50), chorionicvilli (blue arrow) invading normal Figure 3. Histopathologic sample. (H&E, ×50), chorionic villi (blue arrow) invading normal splenic parenchyma containg the lymphoid follicles (star) and adjacent areas of hemorrhage splenic parenchyma containg the lymphoid follicles (star) and adjacent areas of hemorrhage (black arrows). B (H&E, ×400), chorionic villi (blue arrows)and trophoblastic tissue (black arrows). (black arrows). B (H&E, ×400), chorionic villi (blue arrows) and trophoblastic tissue (black arrows) III. DISCUSSION III. DISCUSSION Due to strong peristalsis of the intestine and Although the spleen is a favorable Due to strong peristalsis of the intestine Nowadays, imaging modalities is always dynamics of intraperitoneal fluid flow, it is environment for embryonic growth, ¶ and dynamics to carry fertilized ovum from the cul- possible of intraperitoneal fluid flow, it is available to the spleen parenchyma cannot the unfortunately help early diagnostic identify A possible to carry fertilized ovum from the cul- de-sac to different abdominal cavities.7,8 The implantation site the blastocyst growth and distend to support of an ectopic gestational Deleted: de-sac spleen providesabdominal cavities.7,8 The to different a smooth and flat surface of the sac. Once a woman with a attachment. cannot accommodate placental missed period thin capsuleaalong with its abundant blood flow spleen provides smooth and flat surface of has abnormallypregnancy is rarely detected no Therefore, splenic elevated β-hCG and the thin capsule along with its the supine position, nature and accessibility in abundant blood intrauterine thepregnancy In complicated at the end of first trimester.6 on transvaginal making it a relatively sustainable site for the cases, patients complain of acute severe flow nature and accessibility in the supine ultrasound, the diagnosis of ectopic pregnancy zygote implantation.8,9,6,10 This explains most abdominal cramping or typically presents as left position, makingmasses are implanted undersite pregnant it a relatively sustainable the can be established, even in the the left upper abdominal pain radiating to absence of for the capsule, protruding outward and often beyond zygote implantation.8,9,6,10 This explains histopathology ofbyuterineofcurettage. and shoulder, followed signs peritonitis Several most pregnant masses are implanted locationthe the border of the spleen, and their under can cases have demonstrated that urgent unstable hemodynamic status leading to ultrasound capsule, protrudingfrom the upper pole to beyond be anywhere outward and often the lower splenectomy.2,3 combined with CT has a role in early diagnosis pole and the hilum.3 the border of the spleen, and their location can of splenic ectopic pregnancy.4,11,12 be anywhere from the upper pole to the lower Ultrasound should be considered the pole and the hilum.3 standard imaging tool of first choice. Screening Although the spleen is a favorable pan-abdominal ultrasound can reveal environment for embryonic growth, gestational sac-like echo image in the spleen, unfortunately the spleen parenchyma cannot and color Doppler imaging can also show distend to support the blastocyst growth and increased vascularity around the sac.4,10 Rarely, cannot accommodate placental attachment. embryos with a live fetal heart can be seen,11,12 Therefore, splenic pregnancy is rarely detected as was in our case. Wu et al published recently at the end of the first trimester.6 In complicated the first case of splenic pregnancy accurately cases, patients complain of acute severe diagnosed by ultrasound prior to treatment.13 abdominal cramping or typically presents as To confirm the results of abdominal JMR 178 E14 (05) - 2024 5 left upper abdominal pain radiating to the left ultrasound, CT or MRI should be employed shoulder, followed by signs of peritonitis and because they have an important role as unstable hemodynamic status leading to urgent diagnostic evidence and detailed assessment splenectomy.2,3 of ectopic gestations to help make management 4 JMR 177 E14 (04) - 2024
JOURNAL OF MEDICAL RESEARCH decisions. Although abdominal CT provided diagnosis is essential because of the high risk accurate diagnosis in most of previous case of uncontrollable life-threatening intraperitoneal reports, it carries the risk of radiation exposure, bleeding. Partial splenectomy is the treatment of therefore, MRI can be considered.5,6,12 Moreover, choice with the benefit of splenic preservation, this method is increasingly available and useful especially in unruptured splenic pregnancy. in earlier or unruptured abdominal pregnancy. Conflict of Interest Statement Our case was similar to that of Makrigiannakis The authors declare no financial disclosures et al, wherein both abdominal sonography and or conflicts of interest. MRI verified the presence the embryonic sac in the splenic parenchyma.6 REFERENCES In unruptured splenic ectopic pregnancy 1. Bouyer J, Coste J, Fernandez H, Pouly cases, even if a patient with ruptured splenic JL, Job-Spira N. Sites of ectopic pregnancy: a pregnancy is hemodynamically stable or non- 10 year population-based study of 1800 cases. surgical candidate, splenic preservation should Hum Reprod. 2002; 17(12): 3224-3230. be considered when possible because of its 2. Poole A, Haas D, Magann EF. Early functional benefit. Several studies have been abdominal ectopic pregnancies: a systematic published showing successful conservative review of the literature. Gynecol Obstet Invest. splenic treatment by minimally invasive 2012; 74(4): 249-260. approaches and non-surgical management in combination with intramuscular methotrexate 3. Kalof AN, Fuller B, Harmon M. Splenic administration has been mentioned. As well pregnancy: a case report and review of the as the laparoscopic injection of methotrexate literature. Arch Pathol Lab Med. 2004; 128(11): in the embryonic sac,14 CT-guided yolk e146-148. sac aspiration with local injection of 4. Yagil Y B-RN, Amit A, Kerner H, Gaitini methotrexate, followed by ultrasound-guided D. Splenic Pregnancy: The Role of Abdominal percutaneous KCl injection,12 ultrasound- Imaging: official journal of the American Institute guided methotrexate injection,10 selective of Ultrasound in Medicine. Journal of Ultrasound embolization of the splenic vessels feeding in Medicine. 2007; 26(11): 1629-1632. ectopic pregnancy by methotrexate,6 and 5. Antequera A, Babar Z, Balachandar C, partial splenectomy or splenorrhaphy,5 as Johal K, Sapundjieski M, Qandil N. Managing well as our aforementioned case. Ruptured Splenic Ectopic Pregnancy Without Splenectomy: Case Report and Literature IV. CONCLUSION Review. Reprod Sci. 2021; 28(8): 2323-2330. In reproductive-age female with abnormally 6. Makrigiannakis A, Raissaki M, Vrekoussis elevated β-hCG levels and no intrauterine or T, et al. Splenic pregnancy treated with pelvic pregnancy revealing on transvaginal transcatheter embolization and methotrexate. ultrasound, it is advisable to examine patients Arch Gynecol Obstet. 2021; 303(1): 55-59. using other imaging modalities, such as 7. Paternoster DM, Santarossa C. Primary abdominal sonography, CT or MRI, to detect abdominal pregnancy. A case report. Minerva any upper abdominal pregnancies. With rare Ginecol. 1999; 51(6): 251-253. abdominal ectopic gestations, early successful 8. Song YJ, Fan T. Primary splenic ectopic JMR 177 E14 (04) - 2024 5
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