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News: The Life Force

Dean, Craig MD

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doi: 10.1097/01.EEM.0000459181.58186.31

    I volunteered for Congressman Mark Kirk's congressional campaign in 2008. My task was quite simple: ring a doorbell and ask if the resident would support the congressman in his reelection bid. I checked off each person's response and thanked him for his time. I did this every Saturday for more than a month, logging about 20 hours and meeting hundreds of Libertyville, IL, residents.

    The fun part was seeing someone I had not seen for years. Ireland greeted me with a smile and insisted I come in and see her son, Sean, who was going to turn 10 that New Year's Eve. He told me about his love of summer baseball, outdoor swimming, and his grade school. But let me move back a decade.

    Near the end of my shift on New Year's Eve, 1998, an ED nurse asked me to see one last patient. The young woman was nearly nine months pregnant, was experiencing difficulty breathing, and had severe abdominal pain. Her blood pressure was a shocking 60/0.

    Ireland had two young children, and her health and pregnancy were fine until just a few minutes earlier. Minutes before arriving at the ED, she was in her car with her family and felt pain in her lower abdominal area, her chest, and her left shoulder.

    “Just fastening my seat belt made me feel winded and short of breath,“ she said. She wondered if she were having a heart attack. Ireland had a sense of impending doom, and asked her husband to rush her to the nearest emergency department.

    Ireland's condition was certainly perplexing. She had no signs of bleeding or a history of trauma. Yet, her blood pressure suggested there must be some unknown blood loss, but where? Some conditions in pregnancy, such as placenta abruptio and placenta previa are associated with shock and bleeding, but they usually cause vaginal bleeding, and Ireland was not experiencing that. An ectopic pregnancy can often cause shock, but that would have been ruled out with ultrasound tests early in her pregnancy.

    Figure
    Figure:
    typical splenic artery aneurysm (not the patient's).

    I was able to hear only the distressed flow of Ireland's decompensated rapid heart sounds through ultrasound. An OB-GYN nurse arrived promptly with more sensitive fetal monitoring equipment. Seconds later, fetal heart rate activity was discovered and recorded, but at a meager 60–70 beats per minute, it was a sign of severe fetal distress and eminent demise. Not only was Ireland's condition critical and unstable, but her neonate was in acute distress and near death.

    We continued our resuscitation efforts as the on-call obstetrician arrived. He quickly examined Ireland and reviewed the history I had obtained. He was also at a loss to explain the etiology of her condition. It was quite clear, however, that the only hope for mother and baby would be an immediate Cesarean section.

    Ireland's condition and disease were graver than expected. A trauma surgeon was urgently summoned to the OB surgical suite when the obstetric surgeons discovered unexpectedly monstrous intra-abdominal bleeding during the C-section. The source of the bleeding was determined to be a spontaneous ruptured splenic artery aneurysm. Almost half of Ireland's circulation was free in her abdomen. An emergent splenectomy would be required to save her life.

    The mortality rate for mothers with a splenic artery aneurysm is about 90 percent, and the mortality rate for their neonates is almost 95 percent. But Baby Sean was delivered and successfully resuscitated by the neonatologist on call. Two obstetric surgeons, one trauma surgeon, and one anesthesiologist worked feverishly to stop the bleeding and save Ireland's life. The source of bleeding was uncovered and treated. The lost blood was replaced, and mother and baby lived. Fewer than one in 10 women with this disease survive.

    When I knocked on his door a decade later, Sean was healthy and vibrant, and was wearing his baseball uniform.

    © 2014 by Lippincott Williams & Wilkins