SPLENIC PREGNANCY

A TYPE OF ECTOPIC PREGNANCY

An ectopic pregnancy is a pregnancy which takes place outside the uterus. The incidence of ectopic pregnancy is about 20%.  The fertilized egg usually implants itself in different parts of the fallopian tube, sometimes on the ovaries and rarely on other abdominal organs. The tube and the abdominal organs cannot sustain this pregnancy, this can rupture or burst and cause intractable haemorrhage, which becomes life threatening and requires urgent treatment. When the fertilised egg implants to start with on other abdominal organs it is called primary abdominal pregnancy, rarely the pregnancy is expelled from the fallopian tube and settles down on abdominal organs. Such as, Omentum (It is a sheet of fatty tissue with the abdominal lining called the peritoneum that insulates the abdominal organs, Latin for apron) intestines or liver and continues to grow into a baby, the placenta also forms. This is called a secondary abdominal pregnancy. About 1.3% of ectopic pregnancies are abdominal pregnancies many cases of abdominal pregnancy are reported, few above the age of viability,   some even at full term. The ectopic pregnancy at any time is a life threatening problem. In recent decades it has become very much easier to make a diagnosis with the advent of pregnancy tests, very high quality Ultrasounds and MRI’s. Treatments have simplified as well. An operation can be avoided if the diagnosis is made in time. I always remember when a few friends had gone for a picnic about thirty kilometres from our medical school. One of my friends, whose husband was with us, started to feel severe abdominal pain and felt faint, we rushed back to the hospital having immediately made the diagnosis of an ectopic pregnancy, but we could not save her. This was in 1960.The pregnancy I am talking today about was a primary abdominal pregnancy on the spleen. This is one of the rarest sites for an abdominal ectopic pregnancy. So far, only nine such cases have been recorded in English literature to date. I found another case described from India in 2011 bring the total to 10 and I wonder if I can count my case as number eleven, as we never published this. This was in early1960 when I was an intern.

A woman called Katori aged 18 years was rushed to our emergency room, I was on duty. She was thought to be pregnant. Her period was 6 weeks late. It was about 6 AM. She was extremely; restless I was unable to record her blood pressure. I thought that I could feel a very feeble pulse in the neck. There was no time to do too much. Toad pregnancy which was the only pregnancy test available at this time in the world was not possible because it takes a day to get the results. There was no ultrasound in those days. There is a test called shifting dullness, which was positive, which meant that her belly was full of blood. A diagnosis of ruptured (bleeding ectopic) pregnancy was made. I put her on two intravenous drips, one was a dextran drip which was to improve the blood volume and the other was  called a noradrenalin drip to improve her bold pressure. I got her to the operating theatre quickly which was only a few feet away. I sent for my chief resident and my Professor who happened to be a general surgeon as well. The theatre was ready for the patient to be operated on, all the staff we had were there within fifteen minutes.  We had two units of O negative blood (universal donor) which was also started. We had no proper anaesthetist or a person trained in resuscitation. In those days, one of the resident doctors had to give open ether for anaesthesia. I had to do that on the day. One other resident had gone to the pathology laboratory with three of Katori’s relatives to cross match the blood. In those times we had to cross match the blood ourselves. My heart was in my mouth when I started the open ether, it was not difficult as she was very flat any way.  Katori’s  belly was opened it was full with almost  two litres of blood. This blood was filtered in a very simple way and transfused back to her. She was found to have a ruptured pregnancy on the lower pole of the spleen.  A spleenectomy was performed, which did not take much time. The abdomen was closed. For a few moments the woman seemed to have improved. We could record her blood pressure as 60/40.  One further unit of blood was being cross matched from one of her relatives. I was able to wake her up from the anaesthesia, which was such a relief. I could breathe again.  The ectopic pregnancy was confirmed on histology as few chorionic villi were seen.

She continued to show ups and downs in her condition with noradrenalin dextran glucose and saline drips, but she was not conscious or passing much urine. She finally passed away after twenty four hours probably due to kidney failure. We could not save her. There are many cases from my first two years as resident which I will never forget. This was one of them. It was like a war zone, no equipment, no highly trained personal and only the Professor.

Once upon a time ectopic pregnancies were a major cause of maternal death. 1n 1980-2007 as many as 56.5% per 100,000 live births and has been come down slowly to 0.50% of maternal deaths out of 100,000 live births, in 1980-1984. It was estimated that with current improvements this can decline further to 0.36 % of 100,000 live births. Unfortunately the racial and age disparities, persist. In countries with poor facilities, the deaths will continue. It was very reassuring that out of  the ten Splenic pregnancies reported in English literature there were no deaths. The main reasons are awareness, very early and very reliable pregnancy tests (we have come a long way from the toad test) very good ultrasounds and MRI.