JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
considered curative. However, splenectomy is usually reserved for individuals with severe hemolysis. Although our patient was reportedly anemic during adolescence, she had not required blood transfusions prior to her current pregnancy. Reports indicate that pregnancy may precipitate hemolytic crises and anemia in patients with hereditary spherocytosis. 2 While maternal morbidity and fetal outcomes have been reported to improve following splenectomy to treat hereditary spherocytosis, during pregnancy, the anatomical and physiological changes in body habitus, coagulation status, the cardiovascular system, and nearly every other organ system can pose unique challenges for surgery. 2–4 Non-obstetric surgical procedures are estimated to occur in 1 of every 5000 pregnancies. 5 In a 2005 systematic review of 54 studies of surgeries during pregnancy, overall rates of miscarriage and major birth defects were similar to that of the general obstetrical population. 6 In a recent retrospective cohort study of 6.5 million pregnancies, Balinskaite et al. estimated that there was one additional stillbirth for every 287 surgeries during pregnancy and one additional preterm delivery for every 31 surgeries during pregnancy. 7 Although it was not possible to separate out whether these outcomes were due to surgery, anesthesia, or the underlying disease itself, the authors concluded that risks of non-obstetric surgery during pregnancy were relatively low. 7 While fetal outcomes have been shown to be generally good, outcomes of non-obstetric surgery for maternal morbidity and mortality are still under debate. A retrospective cohort study of nearly 5600 pregnant women in Taiwan who underwent non- obstetric surgical procedures showed significantly increased adverse events including increased mortality, postoperative septicemia, and longer hospital stays. 8 However, a similarly designed retrospective cohort study matching over 2500 pregnant women in the United States to non-pregnant controls undergoing non-obstetric surgical procedures found no difference in overall morbidity or 30-day mortality rates. 9 Despite conflicting evidence, surgical delay in acute conditions such as appendicitis has been associated with worse outcomes for both the mother and fetus. 10 Non-obstetric surgery when indicated is generally recommended given their comparable fetal outcomes, encouraging maternal morbidity and mortality outcomes, and the potential for worse outcomes when surgery is postponed in acute conditions. Pregnancy was previously a contraindication for laparoscopic surgery due to the potential of insufflation to decrease the blood flow to the placenta causing fetal hypoxia, in addition to the risk of perforating the gravid uterus during trocar insertion. However, the technological advances in laparoscopic surgery have improved outcomes of laparoscopic abdominal surgeries outcomes relative to laparotomy during pregnancy. 11 Laparoscopic benefits include shorter operative time, which leads to reduced fetal exposure to anesthesia, decreased length of stay, and decreased wound complications. 11
Laparoscopic hand-assisted splenectomy has been shown to have favorable outcomes compared to an open approach including lower morbidity, lower transfusion rate, and shorter hospital stays. 12–14 Splenectomy during pregnancy poses a more difficult challenge given the spleen’s high vascularity and its frequent enlargement indiseaseprocessesnecessitatingsurgery. Some studies have shown that splenectomy during pregnancy is associated with increased risk of preterm delivery, higher transfusion rates, and longer hospital stays. 15,16 Splenectomy during pregnancy is relatively rare, but several cases have been reported in patients with immune thrombocytopenia (ITP), splenic artery rupture, and hereditary spherocytosis. 17–20 Laparoscopic splenectomy has been shown to be successful and safe during pregnancy in several cases. 20,21 A hand-assisted approach to laparoscopic splenectomy, as was performed in our case, may be used to provide better vascular control, improved visualization, and decreased operative time while still retaining benefits of laparoscopy such as faster healing time and decreased length of hospital stay. 22 Given the significant splenomegaly in our case, the hand-assisted port provided an improved surgical approach for splenectomy.
CONCLUSIONS
This case demonstrates a successful laparoscopic splenectomy in a pregnant patient with significant splenomegaly secondary to hereditary spherocytosis. Splenectomy during pregnancy was previously considered a high-risk procedure due to the increased risk of fetal loss and poor maternal outcomes. Planning to perform surgery during the early part of the second trimester when organogenesis of the first trimester is complete and the gravid uterus is minimal in size would be most advantageous to improve fetal and maternal outcomes. A hand-assisted port can provide improved vascular control during splenectomy while preserving advantages that laparoscopy offers. Advances in surgical and laparoscopic techniques have made laparoscopic splenectomy a feasible approach in pregnant patients.
REFERENCES
1. Perrotta, S., Gallagher, P. G. & Mohandas, N. Hereditary spherocytosis. Lancet Lond. Engl. 372, 1411–1426 (2008). 2. Pajor, A., Lehoczky, D. & Szakács, Z. Pregnancy and hereditary spherocytosis. Report of 8 patients and a review. Arch. Gynecol. Obstet . 253, 37–42 (1993). 3. Brenner, B. Haemostatic changes in pregnancy. Thromb. Res . 114, 409–414 (2004). 4. Ouzounian, J. G. & Elkayam, U. Physiologic changes during normal pregnancy and delivery. Cardiol. Clin. 30, 317–329 (2012). 5. Kammerer, W. S. Nonobstetric surgery during pregnancy. Med. Clin. North Am. 63, 1157–1164 (1979). 6. Cohen-Kerem, R., Railton, C., Oren, D., Lishner, M. & Koren, G. Pregnancy outcome following non-obstetric surgical intervention. Am. J. Surg . 190, 467–473 (2005). 7. Balinskaite, V. et al. The Risk of Adverse Pregnancy Outcomes Following Nonobstetric Surgery During Pregnancy: Estimates From a Retrospective Cohort Study of 6.5 Million Pregnancies. Ann. Surg . 266, 260–266 (2017). 8. Huang, S.-Y. et al. Outcomes After Nonobstetric Surgery in Pregnant Patients: A Nationwide Study. Mayo Clin. Proc. 91, 1166–1172 (2016). 9. Moore, H. B. et al. Effect of Pregnancy on Adverse Outcomes After General Surgery. JAMA Surg . 150, 637–643 (2015).
156 J La State Med Soc VOL 169 NOVEMBER/DECEMBER 2017
Made with FlippingBook Digital Publishing Software