A Case of Spontaneous Splenic Rupture in Newborn

Introduction

With the advancement in delivery room care, the incidents of traumatic injuries while birthing have become rare. Spontaneous rupture of spleen can occasionally occur and present as diagnostic and management dilemma. This report describes the case of a neonate with spontaneous splenic rupture who was managed conservatively.

Case Report

A full term 2.3 kg female child was born by spontaneous vaginal delivery to a primigravida mother. The delivery was smooth and uneventful without any significant post-natal events. The child was kept with mother and was accepting feed well till 15 hours of life. In the next 4 hours, there was rather rapid onset of abdominal distension, with refusal to feed. The child was diagnosed to be suffering from shock and was given volume resuscitation and transferred to our institute at 20 hours of age.

In our institute, we observed the child to be pale with tachycardia and poor peripheral circulation, lethargy, acidotic breathing and abdominal distension. On further investigations, severe metabolic acidosis (pH 6.82, HCO3 3.9 mmol/L), severe anemia (Hb 4.3gm/dL), deranged coagulation profile (PT 62 sec, INR 4.64, PTT>180 sec), increased BUN and creatinine, D-dimer <0.2 and FDP 1218 ng/mL was observed. Ultrasonography of abdomen revealed gross hemoperitoneum with perisplenic hematoma and spleen showed altered echotexture. The child was intubated and ventilated, given fluid resuscitation, blood and fresh frozen plasma transfusion, Vit K₁ and inotropes. Surgical opinion was obtained and peritoneal tap was performed. It confirmed hemoperitoneum. As the child was stabilising, it was decided to observe the child closely and not to perform emergency laparotomy. After 10 hours of admission, Hb improved to 7.3 gm/dL, acidosis was corrected and coagulation profile improved. The child made gradual recovery over next six days with conservative treatment and was discharged on Day 7. On subsequent follow up at one and a half months of age, child was well grown with Hb of 10 gm/dL, normal coagulation profile and normal spleen on USG.

Discussion

Splenic rupture is rare in newborns. Causes of splenic rupture include birth trauma from a difficult delivery,¹ trauma to mother,² coagulation or bleeding disorders, erythroblastosis fetalis,³ deficiency of Vit K-dependent clotting factors, disseminated intravascular coagulation from sepsis, or immune-mediated thrombocytopenia. Historically, congenital syphilis was sometimes implicated in neonatal splenic rupture.⁴ However, in our case, no cause for splenic rupture was found. Therefore, we postulated that this was a spontaneous splenic rupture. There have been reports of splenic injury in cases with an uneventful perinatal history and where spleen was otherwise normal.^5,6 Many cases of neonatal splenic bleeding are spontaneous and idiopathic.⁷

Splenic rupture presents with shock, anemia, abdominal distension, and other features such as oliguria, refusal to feed, abdominal mass or bluish scrotum. The diagnosis is confirmed by ultrasound or CT scan and abdominal paracentesis confirming hemoperitoneum.

Splenectomy has been recommended as the treatment of choice for neonates with ruptured spleen.^8.9 It was also the standard of care few years ago. However, more recently attempts have been made to conserve the spleen. The surgical options include achieving hemostasis by either suturing or using absorbable mesh.^10,11 An early report showed that in selected cases with splenic lacerations, bleeding could be stopped completely by application of oxidised cellulose and pressure.³ In a study done in 2002, it was shown that splenectomy is no longer the standard treatment because it increases the chances of post-splenectomy sepsis. Instead, treatment should aim for hemostasis and preservation of spleen.¹²

If bleeding is small, it may be managed conservatively with fluid resuscitation and continuous monitoring. In our case, as the bleeding did not recur, and the child’s condition remained stable for the next week, conservative management was preferred. Such conservative management has been reported before.⁷ The case reported is of splenic rupture that occurred without any known cause in a neonate and showed favourable outcome following conservative management.

Conflict of interest

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Financial support

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