LZ, is a 31-year-old Caucasian white woman, normal weight (BMI 20 kg/m2), primigravida, with no pathological history, pharmacologic chronic therapy, or allergies reported.
Mild thrombocytopenia was found in previous blood examinations, with a minimum value of 959 platelets/L in 2016, never examined with second-level examinations.
During the first obstetrical ultrasound check, a vascularized and capsulated mobile mass in the abdomen was detected, with a major axis of 12.5 cm, characterized by a hypertrophic and elongated hilar vascular axis. In parallel, there was no spleen in the left hypochondrium, confirming the WS diagnosis.
The WS had some parenchymal calcific strias, per previous parcellar ischemic infarctions.
This condition was asymptomatic, and the physical examination was negative for any pathological finding, with no palpable masses, and no abdominal evocable pain.
The result of the multidisciplinary consult executed was an indication of the close monitoring of WS through frequent ultrasound examinations and blood examinations, with conservative treatment because of the initial weeks of the pregnancy.
During week 17th of the pregnancy, the patient had blood examinations, demonstrating a reduction of platelets (PLTs) count to 879/L, with the stability of the WS in ultrasound check.
MRI has been planned to have more precise information and set the best treatment for the patient. During the waiting days for the scheduled MRI, on October 30, 2019, in course of the 22nd week of pregnancy, the patient got to the ER because of the onset of intense and diffuse abdominal pain during the night, without fever or any other clinical manifestation. Clinical examination confirmed the relevant widespread abdominal pain, Blumberg sign absent.
Blood examinations performed in the ER were in the range of normality, except for further thrombocytopenia, with a PLTs count of 749/L.
An urgent ultrasound examination was performed, observing the augmented volume of the WS (diameter 18 × 8 cm) and parenchymal ischemic injury; no vascular signal was detected at the splenic hilum with color Doppler technique, without free fluid in the belly (Fig. 1).
For this reason, the patient underwent an urgent surgical procedure.
A laparoscopic approach was decided, noticing a hypertrophic mobile spleen in subhepatic space, surrounded by a multitude of ectasic and congested vessels. The principal vascular axis of the WS was also hypertrophic, with a diameter of around 4 cm (Fig. 2).
After initial mobilization of the WS, partial dissection of the perisplenic vessels, and isolation of the principal vascular axis, a median mini-laparotomy was performed to dissect and tie the hypertrophic splenic vessels with non-resorbable suture (Fig. 3).
Using laparoscopy, a complete mobilization of the WS was performed from its remaining ligaments.
Subsequent extraction of the spleen from the laparotomy was executed from the service laparotomy. Fetal parameters resulted in physiological and unaltered after surgery.
The postoperative course was regular and the PLTs count normalized in a few weeks, with a median of 3009/L. Subsequent blood examinations confirmed the normalization of PLTs values (Fig. 4).
The patient had natural childbirth at week 39th with no complications.
The patient, two weeks after delivery, received Streptococcus Pneumoniae, Haemophilus Influenzae, and Neisseria Meningitidis vaccinations, as standard prevention for most frequent severe infections after splenectomy.