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Postpartum rupture of the spleen

rhage occurred. Pain and bleeding in early pregnancy are common reasons for patients presenting to gynaecological departments. In view of the ultrasound findings we felt that ectopic pregnancy was unlikely and therefore out patient management was appropriate. In addition, serial estimation of hCG was not deemed necessary. In retrospect, we consider this patient most fortunate to have been an in patient. The value of ultrasound in the management of early pregnancy complications is dependent on several factors. This patient’s obesity resulted in poor transabdominal image quality. While transvaginal imaging enabled better resolution, the typical snowstorm appearance of molar pregnancy is dependent on gestational age and may not be recognised by the relatively inexperienced sonographer. Intra-operative management options were limited due to the acute presentation. Evacuation of the uterus was a reasonable option in the circumstances but the use of Carboprost tromethamine is more controversial. This potent oxytocic agent was administered in the hope that after suction evacuation had emptied the uterine cavity, sustained uterine contraction would result in haemostasis. It could be argued that ergometrine would have been a more appropriate first line measure. Mitani et al. (1984) recommend partial resection for young women if invasive moles are complicated by internal haemorrhage. They have reported five women treated this way, four of which subsequently were delivered of healthy babies by caesarean section. Goldstein and Berkowitz (1982) used local uterine resection together with bilateral internal iliac artery ligation in an attempt to control the bleeding and preserve fertility. Should a hysterectomy be necessary, there is the theoretical possibility of operative dissemination of trophoblast tissue. Therefore, hysterectomy does not eliminate the need for follow up of hCG, as some of these women may still develop secondary malignant gestational trophoblast neoplasia.