926 SA MEDIESE TYDSKRIF 18 Junie 1977

Postpartum Ruptured Abdominal Aortic Aneurysm

A Case Report

J. R. PARKES, D. T. H. HENDRY, B. W. HELLBERG, L. L. THERON

SUMMARYThe successful management of a postpartum ruptured

abdominal aortic aneurysm is described. The rarity ofthe condition in the Black South African parturient isemphasized. Recent advances in 9lJrgery have improved

the prognosis of this condition and early recognition and

surgery are essential components of a successful result.

s. Afr. med. l., 51, 926 (1977).

Abdominal aortic aneurysms are less common in BlackSouth Africans than in their White counterparts. Louwel al.' had only 2 Black patients out of a total of 255patients admitted for abdominal aortic aneurysms. Inaddition, female patients contributed only 25°~ of theirseries.

It is not surprising therefore that very little referencecould be found to the condition in the pregnant BlackSouth African. Lavery' reported one maternal death fromdissecting aneurysm in a 17-year survey covering 196 029obstetric admissions, but gave no further details. Crichtonand Knobel' made no reference to the condition whenreporting on 530 maternal deaths in 316053 deliveries atKing Edward VIII Hospital, Durban.

Nevertheless, the association between pregnancy anddissecting aortic aneurysm has been recognized elsewhereand is well described.' There does not seem to be a similarassociation between aneUrysm of the abdominal aortaand pregnancy.

This article presents a case of postpartum rupturedabdominal aneurysm in a Black South African womanwhich was successfully treated.

CASE REPORTThe patient, aged 40 years, para 14, was delivered at aperipheral hospital. She was discharged on the secondday but was readmitted on the 7th postpartum day com­plaining of a 2-day history of abdominal pain and weak­ness. Examination revealed a distended abdomen with a

Department of Obstetrics and Gynaecology, Edendale Hospi-tal, Pietennaritzburg

J. R. PARKES, M.B. B.CH., M.R.C.O.G., F.C.O.G. (s ..-\.)

Department of Surgery, Edendale Hospital, PietermaritzburgD. T. H. HENDRY, M.B. CH.B., F.R.C.S.B. W. HELLBERG, :M.B. CH.B., F.R.C.S.

Department of Anaesthetics, Edendale Hospital, Pietermaritz­burg

L. L. THERON, L.R.C.P., L.R.C.S., F.F.A., D.A.

Date received: 25 February 1977.

tender mass in the left lower quadrant. 0 vaginal bleed­ing was present and the haemoglobin was 8 gjlOO ml.

The patient was given a transfusion of 2 units of bloodand was transferred to Edendale Hospital.

At the Outpatient Department the findings were Con­firmed and a differential diagnosis of broad ligamenthaematoma, ovarian tumour or retroperitoneal haema­toma was made.

The patient was admitted and prepared for operationthe following day. During that evening the patient col­lapsed, her abdomen was noted to be distended andacutely tender and she was clinically severely anaemicand shocked. The patient was taken to the theatre forlaparotomy, a diagnosis of ruptured uterus or rupture ofa major abdominal vessel having been made.

The abdomen was opened through a left paramedianincision and an enormous retroperitoneal haemorrhagewas found. The descending colon was reflected mediallyand the source of bleeding was found to be a rupturedaneurysm which involved the aorta from immediatelybelow the renal arteries and both common iliac arteries.

Bleeding was initially controlled by direct pressure andsubsequently by clamping the aorta immediately belowthe renal vessels. Regrettably, in achieving this the leftkidney and its vascular pedicle were damaged, necessitat­ing a nephrectomy.

A Cooley dacron bifurcation graft was anastomosedsuccessfully to the aorta proximally and to the left com­mon iliac artery distally.

Repeated attempts to perform an anastomosis betweenthe graft and the right common iliac artery proved abor­tive owing to the degenerative consistency of the arterywhich resulted in sutures tearing out as soon as the clampswere removed and blood flow was re-established.

Extension of the graft to the femoral artery was con­sidered, but was rejected for several reasons. The patienthad at that stage already received 20 un: Is of blood, andlife preservation was considered the major issue. Thegroin had not been adequately cleaned and prepared ini­tially and it was feared that the risks of sepsis would behigh. There was excellent back bleeding from theiliac artery, which was indicative of a good collateral bloodsupply. It was accordingly considered wisest to tie off theright limb of the graft and the right common iliac artery,and if necessary at a later date, to perform further re­constructive arterial surgery. A persistent problem was thetremendous vascularity of all pelvic tissues, resulting inpersistent profuse oozing which could not be adequatelycontrolled. Finally, the ·abdomen was closed with tensionsutures.

Postoperatively the patient was ventilated by means ofa Bird Ventilator Mark 14 for 10 hours, after which shepersonally removed the endotracheal tube. Arterial blood

J Line 1977 SA MEDICAL JOURNAL 927

gas tudies showed no evidence of defective ventilationand apart from the necessity of further blood transfu­sions, the postoperative course was uncomplicated. Duringthe illness the patient received a total of 28 units (approxi­mately 14 litres) of blood.

At the time of discharge on the 35th postoperative day,the patient had good pulses and function in her left leg.The right leg had weak peripheral pulses and goodfunction but the patient complained of some 10 s ofsensation on the dorsum of the right foot.

Investigations showed a negative blood test for yphiliand normal blood lipid values.

DISCUSSIO

Rupture of major intra-abdominal blood vessels in asso-iation with pregnancy is more commonly found to in­

volve the splenic artery than any other ves eis,' a splenicartery aneurysm being twice as common in women as inmen. It is therefore most unusual for the obstetrician tobe a ked to manage a case of ruptured abdominal aorticaneurysm.

Aetiology

The most common cause of aortic aneurysm in thepregnant patient is a medial necrosis associated withcongenital defects and arteriosclerosis:' In our patient theappearance of the aorta and iliac arteries uggested a de­generative type of lesion; no arterio clerosi wa visibleand the serological test for syphilis was negative. Thecongenital defect most commonly associated with dissect­ing aneurysm is a coarctation of the aorta.'

The timing of vascular accident in pregnancy is opento que tion. Pedowitz and PereW reported that a peak ofvascular acidents associated with pregnancy occurred inthe third trimester. while Waiter' found a higher incidencein the puerperium. as was the case in our patient.

Management

The management of a ruptured abdominal aorticaneurysm is not affected by pregnancy: in either ca e.operation is essential or the patient will die. Thus. any­thing less than 100°:' mortality is a gain.

The tremendou collateral blood supply een in thepregnant patient is a further point of intere t. Our patientsuffered no unpleasant effects after ligation of her rightcommon iliac artery. and the 'backftow' at the time ofoperation was remarkable.

Because mortality from surgically treated rupturedabdominal aortic aneury ms fell from 9°~ in the 1956­1960 series to 56°:, in the 1966 - 1970 series of Louw ef al ..'obstetricians should be aware both of the condition andof the succes rate from prompt surgical intervention.

If the condition i diagnosed in the third trimester.caesarean section should be performed without delay andthe aneurysm hould be surgically corrected.

REFEReNCES

I. LOllW. J. H .. rahlam:h~. l .. Birken"tuck. W. et lIl. (1971): S. Afr.med. J., ~. III

2. Lavery. D. W. P. (1970). !bid.. -1-1. 1230.3. CrichlOn. D. and Knobd. J. (1973): !hid.. -17. 2()<)5.-I. Kilchen. D. H (197-1): J. Ob"et. Gynaec. Brit. CWllh. HI. -1111.5. Abramovich. D. R .. Fran,is. W. and Helsby. C. R. (1969): !hld.• 76.

1037.6. P~dowi(l. P. ami Pndl. A. (1957): Amcr. J. Obstd. Gynec .. 73, 720.7. Hirst. A. E.. John<. Y. J. and Kime. S. W. (1958): Medicine. 37. 217.~. \Valtcr .... \V. A. \V. (1969): Au"'l. ~.Z.J. Ob... td. Gynaec.. 9. I.

South African Society of Pathologists: Abstracts of PapersThe following are the abstracts of papers read at the Annual Congress of the South African Society of Pathologists,held in Cape Town on 15 - I July 1976:

HUMAN VIBRIOSIS IN SO TH AFRICA

A. F. HALLETT, P. L. BOTHA AND A. LOGA '. Deparl­men! of Microhiology and Thoracic Surgery, Universifyof NaJaI, Durhan. and Deparrmel1/ of BaCleriology, Uni-

versify of Cape Town

Human infection due to Vibriu ft'lIls has been reported fromvarious parts of the world and this is the first documentedreport from South Africa. Two cases are presented. The firstpatient presented with pericarditi and V. ft'flls was cultllred

from a pericardial a pi rate. The culture was identified asV. fe/lls illlesfillalis serol\ pe 01 which is frcqucntly isolatedfrom cattle in outh Africa. erum from the patient alsoagglutinated V. fews antigens. The second patient pre entedwith a pyrexia of unknown origin and V. fellls was i olatedfrom a blood culture. The organism grew well under in­creased se, atmosphere. Electron mi roscopy revealed thetructurc of a vibrio with a single flagellum at one pole.

The importance of considering this infec{ion under certaincircum tances is stressed. These organisms may be ovcrlookedunless a uitable milieu is provided. These isolatcs should beincluded in the genus ClImp-,",ol>lICft'l'.