Nontraumatic symptomatic hypotension in all patients requires prompt diagnosis and appropriate treatment for optimum outcome. The female population specifically has an expanded differential diagnosis that should be considered when these patients present with hemodynamic collapse. While the most common causes of hypotension in pregnant patients are dehydration, ruptured ectopic pregnancy, and placental and uterine abnormalities, less common nonobstetrical etiologies such as hepatic rupture and ruptured abdominal and visceral artery aneurysms should also be considered. Splenic artery aneurysms are associated with high rates of mortality and in cases of pregnancy, maternal and fetal mortality. These high rates can be attributed to the asymptomatic nature of the aneurysm, rapid deterioration after rupture, and frequent misdiagnosis. In patients with hemodynamic collapse, the role of traditional imaging is limited mainly due to the critical condition of the patient. Bedside ultrasound has emerged as a diagnostic imaging resource in patients with undifferentiated hypotension and in patients with traumatic injuries. However, its use has not been studied specifically in the female population. We present two patients with ruptured splenic artery aneurysms, discuss the role of bedside ultrasound in their management, and introduce a new ultrasound protocol for use in reproductive age female patients with hemodynamic collapse. 1. Introduction Nontraumatic symptomatic hypotension in any patient requires prompt diagnosis and appropriate treatment for optimum outcome. The female population has specific and unique causes of hypotension that should be evaluated. Severe dehydration and ruptured ectopic pregnancy are common etiologies of hypotension and, in known pregnant patients, placental abruption, placenta previa, uterine rupture, and pulmonary embolus should be considered [1]. Less common nonobstetrical etiologies such as hepatic rupture, ruptured abdominal aneurysm, and visceral artery aneurysms should also remain in the differential diagnosis. Misdiagnosis of these intra-abdominal sources of bleeding is common and brings potentially devastating outcomes. In the diagnostic evaluation of unstable patients, the use of a CT scan, MRI, or angiography has a limited role primarily because of their time consuming nature. Ultrasound can be used to diagnose common obstetrical emergencies such as placental abruption, placenta previa, and uterine rupture [1]. Furthermore, several case reports comment on the use of bedside ultrasound to detect intra-abdominal free fluid to aid
References
[1]
M. Walfish, A. Neuman, and D. Wlody, “Maternal haemorrhage,” British Journal of Anaesthesia, vol. 103, supplement 1, pp. i47–i56, 2009.
[2]
S. Jack, R. Hammond, and D. K. James, “Diagnosis and treatment of ruptured splenic artery aneurysm in pregnancy,” Journal of Obstetrics and Gynaecology, vol. 18, no. 1, pp. 86–87, 1998.
[3]
S. Sarikaya, B. Ekci, C. Aktas, A. Cetin, D. Ay, and A. Demirag, “A rare clinic presentation of abdominal pain: rupture of splenic artery aneurysm: a case report,” Cases Journal, vol. 2, no. 10, article 148, 2009.
[4]
M. J. Thomson, S. Seshadri, S. Swami, G. F. Strandvik, and K. Neales, “The pitfalls of protocols—a case of postpartum splenic artery aneurysm rupture,” BMJ Case Reports, 2010.
[5]
M. C. Yagmurdur, F. Agalar, and C. E. Daphan, “Spontaneous hepatic rupture in pregnancy,” European Journal of Emergency Medicine, vol. 7, no. 1, pp. 75–76, 2000.
[6]
M. G. McKenney, L. Martin, K. Lentz et al., “1, 000 consecutive ultrasounds for blunt abdominal trauma,” Journal of Trauma, vol. 40, no. 4, pp. 607–612, 1996.
[7]
P. R. T. Atkinson, D. J. McAuley, R. J. Kendall et al., “Abdominal and Cardiac Evaluation with Sonography in Shock (ACES): an approach by emergency physicians for the use of ultrasound in patients with undifferentiated hypotension,” Emergency Medicine Journal, vol. 26, no. 2, pp. 87–91, 2009.
[8]
A. E. Jones, V. S. Tayal, D. M. Sullivan, and J. A. Kline, “Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients,” Critical Care Medicine, vol. 32, no. 8, pp. 1703–1708, 2004.
[9]
J. S. Rose, A. E. Bair, D. Mandavia, and D. J. Kinser, “The UHP ultrasound protocol: a novel ultrasound approach to the empiric evaluation of the undifferentiated hypotensive patient,” American Journal of Emergency Medicine, vol. 19, no. 4, pp. 299–302, 2001.
[10]
P. Perera, T. Mailhot, D. Riley, and D. Mandavia, “The RUSH exam: rapid ultrasound in SHock in the evaluation of the critically lll,” Emergency Medicine Clinics of North America, vol. 28, no. 1, pp. 29–56, 2010.
[11]
J. C. Stanley, N. W. Thompson, and W. J. Fry, “Splanchnic artery aneurysms,” Archives of Surgery, vol. 101, no. 6, pp. 689–697, 1970.
[12]
M. He, J. Zheng, S. Zhang, J. Wang, W. Liu, and M. Zhu, “Rupture of splenic artery aneurysm in pregnancy: a review of the literature and report of two cases,” American Journal of Forensic Medicine and Pathology, vol. 31, no. 1, pp. 92–94, 2010.
[13]
J. M. Barrett, J. E. van Hooydonk, and F. H. Boehm, “Pregnancy-related rupture of arterial aneurysms,” Obstetrical and Gynecological Survey, vol. 37, no. 9, pp. 557–566, 1982.
[14]
J. C. Stanley, T. W. Wakefield, and L. M. Graham, “Clinical importance and management of splanchnic artery aneurysms,” Journal of Vascular Surgery, vol. 3, no. 5, pp. 836–840, 1986.
[15]
C. J. Shanley, N. L. Shah, and L. M. Messina, “Common splanchnic artery aneurysms: splenic, hepatic, and celiac,” Annals of Vascular Surgery, vol. 10, no. 3, pp. 315–322, 1996.
[16]
P. C. Lee, R. Y. Rhee, R. Y. Gordon, J. J. Fung, and M. W. Webster, “Management of splenic artery aneurysms: the significance of portal and essential hypertension,” Journal of the American College of Surgeons, vol. 189, no. 5, pp. 483–490, 1999.
[17]
J. F. Ha, M. Phillips, and K. Faulkner, “Splenic artery aneurysm rupture in pregnancy,” European Journal of Obstetrics & Gynecology and Reproductive Biology, vol. 146, no. 2, pp. 133–137, 2009.
[18]
G. Condous, E. Okaro, A. Khalid et al., “The accuracy of transvaginal ultrasonography for the diagnosis of ectopic pregnancy prior to surgery,” Human Reproduction, vol. 20, no. 5, pp. 1404–1409, 2005.
[19]
T. W. Wong, C. C. Lau, A. Yeung, L. Lo, and C. M. Tai, “Efficacy of transabdominal ultrasound examination in the diagnosis of early pregnancy complications in an emergency department,” Emergency Medicine Journal, vol. 15, no. 3, pp. 155–158, 1998.
