Maternal Survival Following Ruptured Splenic Artery Aneurysm in Late Pregnancy Managed by Emergency Splenectomy in a Resource-Limited Setting: A Case Report from Yemen

Maternal Survival Following Ruptured Splenic Artery Aneurysm in Late Pregnancy Managed by Emergency Splenectomy in a Resource-Limited Setting: A Case Report from Yemen

Fares Ayyash Ahmed ^1*, Taha Hussain ², Gamal M. Ismail KhudaBux ³
 

1. Consultant General, Trauma and Vascular Surgery, Médecins Sans Frontières (MSF), Yemen.
2. Medical Doctor and Public Health Specialist, Former Médecins Sans Frontières (MSF), Yemen.
3. Consultant Vascular Surgeon, Aden University, Aden, Yemen.

*Correspondence to: Fares Ayyash Ahmed, Consultant General, Trauma and Vascular Surgery, Médecins Sans Frontières (MSF), Yemen.

Copyright.

© 2026 Fares Ayyash Ahmed, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 09 June 2026

Published: 01 July 2026

DOI: https://doi.org/10.5281/zenodo.21063831

Abstract

Background : Ruptured splenic artery aneurysm (SAA) is a rare but catastrophic vascular complication of pregnancy, associated with high maternal and fetal mortality. In resource-limited settings where advanced imaging like Computed Tomography (CT) and endovascular facilities are unavailable, diagnosis depends entirely on clinical suspicion and basic bedside ultrasonography.

Case Presentation: A 32-year-old multigravida (G2P1) at 35 weeks of gestation presented with sudden-onset epigastric pain and profound hemorrhagic shock (blood pressure 80/40 mmHg). Diagnosis was prioritized based on clinical findings and a bedside Focused Assessment with Sonography for Trauma (FAST) showing massive hemoperitoneum. An emergency midline xiphopubic laparotomy was performed. Approximately 3500 ml of blood and clots were evacuated. A stillborn male infant (2.4 kg) was delivered via cesarean section. Intraoperative findings revealed a ruptured 3.5 cm SAA at the splenic hilum. Total splenectomy and splenic artery ligation were achieved within a 120-minute operative time. The patient received 6 units of packed red blood cells and 4 units of fresh frozen plasma. The mother had an uneventful recovery and was discharged on postoperative day 10.

Conclusion: Early recognition based on clinical suspicion and bedside ultrasonography remains crucial in resource-limited settings where advanced vascular imaging and endovascular interventions are unavailable. Prompt multidisciplinary surgical intervention is life-saving for the mother, although fetal mortality remains exceedingly high. This case highlights the educational value for surgeons and obstetricians working in global surgery environments.

Keywords: Splenic artery aneurysm, Pregnancy, Rupture, Splenectomy, Stillbirth, Resource-limited setting, Yemen.

Abbreviations

SAA: Splenic Artery Aneurysm

G2P1: Gravida 2 Para 1

BP: Blood Pressure

HR: Heart Rate

FAST: Focused Assessment with Sonography for Trauma

PRBCs: Packed Red Blood Cells

FFP: Fresh Frozen Plasma

ICU: Intensive Care Unit

POD: Postoperative Day

MTP: Massive Transfusion Protocol

OPSI: Overwhelming Post-Splenectomy Infection

Hib: Haemophilus influenzae type b

Introduction

Splenic artery aneurysm (SAA) accounts for approximately 60% of all visceral artery aneurysms, with an estimated prevalence ranging from 0.04% to 0.1% in the general population [1]. Although uncommon, pregnancy significantly increases the risk of rupture, particularly during the third trimester, owing to hormonal and hemodynamic changes affecting the arterial wall [2]. Approximately 95% of SAA ruptures in women occur during pregnancy [3]. The risk of rupture is also correlated with aneurysm size, with those exceeding 2 cm being at particularly high risk [4].

Rupture of SAA during pregnancy is a catastrophic event. Historically, maternal mortality has reached 75% and fetal mortality often exceeds 90% [5, 6]. While modern surgical and anesthetic techniques have improved maternal survival in high-resource centers, outcomes in resource-limited environments remain poor due to delayed presentation and lack of advanced diagnostics [7]. In settings like Yemen, where CT angiography and endovascular repair are often unavailable, management relies on clinical acumen and emergency open surgery. This report highlights the successful maternal management despite these limitations.

Epidemiology and Pathophysiology of Splenic Artery Aneurysm During Pregnancy

Splenic artery aneurysm (SAA) is the most common visceral arterial aneurysm, accounting for approximately 60% of visceral artery aneurysms. Its reported prevalence in the general population is low, estimated between 0.04% and 0.1%, although the true incidence may be underestimated because many cases remain asymptomatic and are discovered incidentally.

Pregnancy is considered a major risk factor for SAA formation and rupture. Approximately 95% of reported SAA ruptures in women occur during pregnancy or the peripartum period. The highest risk period is the third trimester, when physiological cardiovascular changes reach their maximum effect.

The pathophysiology of pregnancy-associated SAA rupture is multifactorial. During pregnancy, increased circulating blood volume, increased cardiac output, and increased splenic arterial flow increase mechanical stress on the arterial wall. In addition, hormonal changes, particularly increased levels of estrogen and progesterone, may weaken the arterial media by altering connective tissue composition and reducing vascular wall elasticity.

Other contributing factors include degeneration of the arterial wall, medial fibrodysplasia, atherosclerotic changes, portal hypertension, and previous multiparity. The combination of increased hemodynamic stress and reduced arterial wall strength may lead to progressive aneurysmal dilatation and eventual rupture.

When rupture occurs, bleeding may initially be contained within the lesser sac (the “double rupture phenomenon”), temporarily masking the severity of hemorrhage. Subsequent rupture into the peritoneal cavity causes massive hemoperitoneum and rapid development of hemorrhagic shock. This clinical pattern explains why diagnosis is frequently delayed and why maternal and fetal mortality remain high.

Maternal mortality after rupture has historically been reported between 25% and 75%, while fetal mortality remains extremely high, often exceeding 70–90%, mainly due to maternal hypotension, reduced uteroplacental perfusion, and fetal hypoxia.

Early recognition of the characteristic presentation—sudden abdominal or epigastric pain, pregnancy, and unexplained hemodynamic collapse—is essential. In resource-limited settings, bedside ultrasound and immediate surgical exploration may represent the only available life-saving diagnostic and therapeutic approach.

Case Presentation

Patient Information and Clinical Findings

A 32-year-old Yemeni woman (G2P1) at 35 weeks of gestation presented to the emergency department with sudden, excruciating epigastric pain, dizziness, and near-syncope. She had no significant medical history or previous surgical interventions. On arrival, she was in Grade IV hemorrhagic shock: pale, cold extremities, and tachycardic (heart rate 130 bpm) with a blood pressure of 80/40 mmHg. The abdomen was distended, tense, and exquisitely tender. Fetal heart sounds were absent on bedside Doppler.

Timeline of Events

Diagnostic Assessment

Given the profound shock and the absence of Computed Tomography (CT) facilities in the hospital, diagnosis was prioritized through clinical evaluation and bedside Focused Assessment with Sonography for Trauma (FAST). The ultrasound revealed massive free fluid in the peritoneal cavity.

Differential Diagnosis

In the setting of a third-trimester pregnancy presenting with sudden abdominal pain and hemorrhagic shock, several critical differential diagnoses were considered:

1. Uterine Rupture: The most immediate concern given the gestational age, although the patient had no prior uterine scars.
2. Placental Abruption: Considered due to the sudden pain and fetal distress, though the absence of vaginal bleeding and the presence of massive free fluid on FAST made this less likely.
3. Aortic Dissection/Rupture: A rare but catastrophic possibility in pregnancy.
4. HELLP Syndrome with Hepatic Rupture: Ruptured subcapsular liver hematoma can present similarly with hemoperitoneum.
5. Ruptured Splenic Artery Aneurysm (SAA): Highly suspected based on the location of the pain (epigastric/left upper quadrant) and the clinical triad of pregnancy, sudden pain, and unexplained shock.

Based on the clinical findings and the localization of fluid on FAST, a ruptured SAA was the primary working diagnosis, necessitating immediate surgical exploration.

Therapeutic Intervention

A midline xiphopubic laparotomy was performed. Approximately 3500 ml of blood and clots were evacuated.

1. Obstetric Management: A stillborn male infant weighing 2.4 kg was delivered via cesarean section.
2. Vascular Control: Exploration of the upper abdomen revealed a ruptured 3.5 cm aneurysm at the splenic hilum. Proximal vascular control of the splenic artery was achieved before splenectomy. Total splenectomy and double ligation of the splenic artery were performed. Total operative time was approximately 120 minutes. A drain was placed in the splenic bed.

Follow-up and Outcomes

The patient received 6 units of packed red blood cells and 4 units of fresh frozen plasma. Histopathological examination was not available due to resource limitations. On POD 5, she received vaccinations against Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae type b (Hib) and was counseled regarding the lifelong risk of overwhelming post-splenectomy infection (OPSI). She was discharged on POD 10.

Discussion

Lessons for Low-Resource Settings

This case highlights the critical challenges of managing vascular emergencies in environments lacking CT angiography, vascular surgery services, and endovascular capabilities. In such settings, the "direct-to-surgery" approach based on FAST and clinical judgment is not only appropriate but life-saving. The limited blood bank resources further necessitate rapid surgical control of hemorrhage to minimize transfusion requirements.

Comparative Literature Review

Fetal Mortality and Diagnostic Difficulty

The fetal demise in this case is a direct consequence of the profound and prolonged maternal hypotension, leading to immediate fetal hypoxia [6, 12]. The "double rupture phenomenon" can lead to diagnostic delays, making high clinical suspicion the most important tool for the surgeon [8].

Conclusion

Early recognition based on clinical suspicion and bedside ultrasonography remains crucial in resource-limited settings. Prompt multidisciplinary surgical intervention is life-saving for the mother, although fetal mortality remains exceedingly high.

Declarations

Ethical Approval: Ethical approval was waived because this study describes a single case report.

Patient Consent: Written informed consent for publication was obtained from the patient.

Funding: None.

Conflict of Interest: The authors declare no conflicts of interest.

Data Availability: Data supporting the findings of this study are available from the corresponding author upon reasonable request.

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