Conservative management of gigantic splenic cyst during pregnancy; a differential diagnosis for chest pain caused by the forgotten organ

Abstract

Splenic cyst is extremely rare in pregnancy. All the six cases that had been described in literatures were treated surgically. However, we report the first case of a huge splenic cyst during pregnancy managed by conservative approach in the form of analgesia, antibiotics and percutaneous aspiration.Keywords Pregnancy . Spleen . Cyst . Haemorrhage Case reportA 34-year-old woman presented in her second pregnancy at 24 weeks gestation with a 4-week history of increasing left upper abdominal and left shoulder pain. There was no history of abdominal trauma or foreign travel.She was admitted to the hospital to investigate the pain, particularly to exclude a pulmonary embolism and computed tomography pulmonary angiography (CTPA) was performed. This excluded a pulmonary embolism, but revealed a large splenic cyst. Palpation of the abdomen showed an enlarged spleen. The diagnosis was then confirmed by abdominal ultrasound scan, which revealed a huge round 20 cm splenic cyst with a smooth thin wall, filled by 2 l of homogenous fluid with no signs of malignancy (Fig. 1). The serology for hydatid IgG was negative. Platelets, liver and kidney function tests were normal. However, the haemoglobin level (Hb) on admission was 8.3 g/dl, a reduction of 1.3 g/dl compared to the previous week. This raised the possibility of a haemorrhage into the cyst. However, the ultrasound didn't suggest this.In liaison with the surgical and radiology teams, it was decided to postpone aspiration of the cyst until a time of fetal maturation, to avoid unwarranted effect on the fetus should laparotomy be needed. Pain was controlled by morphine and pethidine. Iron tablets were given for anaemia and a daily full blood count revealed no further drop in the Hb level. Two units of cross-matched blood were made available for any emergency.At 26 weeks the patient experienced shivering and a fever of 39°C. Haemoglobin dropped to 7.8 g/dl with raised C-reactive protein of 99 mg/l. Two units of blood were transfused and intravenous co-amoxiclav was started to treat the septicaemia which was presumed to be from the infected haemorrhagic cyst. Betamethasone was also given in case of preterm delivery. Abdominal ultrasound showed no increase in the size of the cyst and satisfactory fetal growth. The patient's general condition improved with the treatment.At 27 weeks a percutaneous aspiration under ultrasound guidance was performed. This was earlier than planned to avoid further episodes of infection. Three and a half litres of greyish brown fluid were aspirated and coagulase negative staphylococci sensitive to co-amoxiclav were cultured. The patient showed a good improvement and was discharged 2 days later on oral co-amoxiclav.Ultrasound scans at 32 and 35 weeks revealed reaccumulation of the cyst to measure 15 cm. No further aspiration was performed, as the patient was asymptomatic. At 40 weeks the patient went into spontaneous labour and had a normal vaginal delivery. Ultrasound scan 6 weeks following the delivery showed persistence of the cyst. This G...

Pseudoquiste esplénico masivo en el embarazo. Una condición poco frecuente

“…Hasta la actualidad se han reportado en la literatura médica mundial 14 casos de quistes esplénicos en pacientes embarazadas [8][9][10][11][12][13][14][15][16][17][18][19][20][21] . En México solo hay tres reportes de pseudoquistes esplénicos: el primero de Rodríguez Paz y Carreón 22 en 2004, el segundo de Beauregard-Ponce 23 en 2006 y el tercero de Grube-Pagola, et al 24 en 2010.…”

Massive splenic cyst in pregnancy: case report

“…In pregnancy, the majority of early case reports of splenic cysts underwent splenectomy either open or laparoscopically [1][2][3][4][5]. In later years, two case reports have tried percutaneous aspiration [7,8]; though both cases had vaginal deliveries at term, both also resulted in cystic fluid re-accumulation and required further intervention. Rotas et al [7], performed an aspiration for a patient diagnosed with a 17 cm symptomatic splenic cyst in the first trimester, followed by biweekly sonographic scans until second trimester.…”

“…The second cystic aspiration was complicated by sepsis and consequently necessitated laparoscopic fenestration and omentopexy. Likewise, after a conservative approach of iron supplementation, analgesia and antibiotics, Mahran et al [8] performed a percutaneous aspiration in the second trimester for a 20 cm splenic cyst. However, there were complications of septicaemia and anaemia requiring blood transfusions.…”

“…We explore the diagnostic dilemma and treatment challenges of a giant primary splenic mass found in pregnancy, a pairing described in only thirteen cases worldwide [1][2][3][4][5][6][7][8][9][10][11][12][13]. This case provides further insight into the optimal management for large abdominal masses in pregnancy as the timing and choice of surgical management remains contentious amongst surgeons and obstetricians due to the lack of robust evidence in the current body of literature.…”

Splenic cyst during pregnancy

“…Moreover, after a normal vaginal delivery at 40 weeks, an ultrasound at 6 weeks demonstrated persistence of the cyst, which required re-aspiration. 19 …”