Ultrasound Obstet Gynecol 2001; 17: 453 – 454
Ultrasound diagnosis and Doppler monitoring of
Case Report
Blackwell Science, Ltd
a pelvic spleen in pregnancy
L. COBELLIS, F. DI PIETTO*, L. DI PIETTO*, L. STRADELLA*, F. M. REIS, F. M. SEVERI and
F. PETRAGLIA
Department of Obstetrics and Gynecology, University of Siena, Siena and *Department of Obstetrics and Gynecology, Second University of Naples,
Naples, Italy
K E Y W OR DS: Spleen, Ectopic spleen, Pelvic mass, Pregnancy, Doppler monitoring
ABSTRACT
We describe a patient with a pelvic spleen diagnosed during
pregnancy and monitored through gestation which we
believe to be the first reported case. A 40-year-old woman
was referred at 8 weeks of gestation because of a chronic
intense pain in the left iliac cavity which had spread to her
lower back. Clinical examination revealed a poorly defined
pelvic mass. Pelvic ultrasound demonstrated a gestational sac
containing a viable embryo whose size was consistent with
the period of amenorrhea. While the splenic area in the left
hypocondrium was found to be empty, a homogeneous and
elongate mass measuring 152 × 123 mm with a maximum thick-
ness of 53.4 mm was observed in the left iliac cavity above the
uterus. This mass, the ectopic spleen, was monitored by Doppler
velocimetry at monthly intervals until delivery and no vari-
ation throughout gestation was observed; therefore, despite
the occasional occurrence of heavy pain, it was possible to
exclude circulatory complications such as thrombosis or
torsion. Doppler ultrasound proved to be a useful tool for
the differential diagnosis of this rare anatomical variation.
INTRODUCTION
The ectopic or migrant spleen in the pelvic area is a rare
occurrence which, with the increasing use of imaging methods,
especially ultrasound, has become relatively easy to diagnose
in the non-pregnant patient1–5. It should be differentiated
from an accessory spleen which has occasionally been observed
during surgical operations6,7.
Pregnancy, because of its continuous evolution, has the
potential to modify the position of an anomalous spleen and lead
to circulatory complications such as torsion or compression.
To our knowledge this is the first case of a migrant spleen
in the pelvic area to be diagnosed during pregnancy. The
ultrasound diagnosis at 8 gestational weeks and the findings
of serial Doppler examinations until delivery are described.
Correspondence: Dr L. Cobellis, Via Santa Lucia n.39, 80132 Napoli, Italy (e-mail: luigicobellis@yahoo.it)
Received 29-2-00, Revised 27-10-00, Accepted 21-2-01
CASE REPORT
CASE REPORT
A 40-year-old primigravida woman was referred at 8 weeks
of gestation because of a continuous and intense pain in her
lower abdomen which spread to the lower back. Her blood
count was normal and no associated urinary or gastrointest-
inal symptoms were reported.
The clinical examination showed the uterus to be slightly
increased in volume and displaced to the right by a relatively
immobile mass of poorly defined limits which partially occupied
the pelvis and the left iliac cavity and which was not painful
on palpation. Pelvic ultrasound evaluation (transabdominal
and transvaginal scan) confirmed the uterus to be displaced
to the right. It contained a gestational sac and a single embryo
with evidence of cardiac activity and a crown–rump length of
10.7 mm, corresponding to 7 + 4 weeks of gestation.
A uniformly echogenic elongate mass (Figure 1) with a lon-
gitudinal diameter of 152 mm, a width of 123 mm and a
maximum thickness of 53.4 mm was detected in the pelvis
above the anterior uterine wall. The splenic area in the left
hypocondrium was empty. Color and pulsed Doppler scan-
ning of the mass demonstrated that it was richly perfused and
color signals were uniformly present throughout. The vessels
converged in the postero-inferior pole (Figure 2). These find-
ings were characteristic of a pelvic spleen. Color Doppler
imaging showed a hilus at the inferior pole of the spleen with
three vessels corresponding to two arteries and one vein. The
vessels emerged from the posterior surface and continued in
the cranial direction on the left side up to the hypocondrium.
Numerous collateral vessels were observed in the paren-
chyma. The arterial and venous vessels at the hilus and in the
extrasplenic side were patent and without signs of thrombosis.
At the hilus, the mean venous flow velocity was 18 cm/s, with
a waveform showing steady flow; the arterial flow velocity
(peak systolic) was 68 cm/s. The extrasplenic side recorded
a venous flow velocity of 38 cm/s with powerful modulation of
the waveform by maternal respiration; the arterial peak systolic
velocity was 70 cm/s. The flow velocity of the splenic vein at
453
Ultrasound diagnosis of pelvic spleen in pregnancy
Figure 1 Transabdominal scan of the normal gestational sac (SACCO
GESTAZIONALE) with embryo (dotted line) and ectopic spleen seen as
a uniformly echogenic mass (MILZA ECTOPICA).
Figure 2 Color Doppler interrogation of the ectopic spleen vessels
demonstrates a typical arterial blood flow pattern.
Figure 3 Ectopic spleen at Cesarean section.
454
Cobellis et al.
the point of convergence with the portal vein was 27 cm/s with
steady respiratory modulation. Doppler examination per-
formed after the disappearance of the pain showed the same
characteristics. The spleen gradually shifted from the pelvic
area to the left iliac fossa and its dimensions remained unchanged.
Doppler was repeated at monthly intervals and did not
show any variation until at the end of pregnancy. A Cesarean
section was performed at 38 weeks because of the anomalous
position of the spleen; a female neonate weighing 3450 g was
delivered. During surgery the spleen was examined and was
found to be smooth with no residue of any ligament (Figure 3).
The vascular pedicle arose from the splenic hilus and continued
upwards through the omentum to the left hypocondrium.
The postoperative course and the puerperium were normal. Six
days after surgical intervention an ultrasound examination con-
firmed that the spleen was still positioned in the pelvic area.
DISCUSSION
This case shows that the presence of a pelvic spleen does
not necessarily produce complications during the course of
pregnancy and that it can continue to function despite its
anomalous position. One might expect the developing preg-
nancy to modify the position of the spleen causing com-
plications, particularly of the circulation, such as torsion
or compression. However, the uneventful outcome in our
patient indicates that an uneventful evolution is possible in
similar cases.
Although rare, pelvic spleen is a well-documented entity
that should be considered in the differential diagnosis of all
pelvic masses. Although usually asymptomatic, the ectopic
spleen in our case was characterized by some symptoms includ-
ing pelvic pain, heaviness and urinary frequency. Doppler
monitoring of the ectopic spleen circulation through gestation
offered reassurance by demonstrating the absence of vascular
complications. In fact, the use of Doppler ultrasound in our
case enabled expectant management until term.
REFERENCES
1 Cendrowsky K, Sawicki W, Stelmachow J, Wypych K. Ectopic
spleen in pelvis minor — a case report. Ginekol Pol 1992; 63: 312–4
2 Azar GB, Awwad JT, Mufarrij IK. Accessory spleen presenting as
adnexal mass. Acta Obstet Gyn Scan 1993; 72: 587–8
3 Popovic M, Knezevic S, Colovic R, Petrovici M, Antunovic P,
Diordejvic Z. Ectopic spleen — 2 case reports. Acta Chir Jugosl 1995;
42: 59–62
4 Kalid A, Lawton F. Pelvic spleen masquerading as an ovarian neo-
plasm. Ann Acad Med Singapore 1998; 27: 710–1
5 Cohen MS, Sper NJ, Underwood RA, Brut LM. Laparoscopic
splenopexy for wandering (pelvic) spleen. Surg Laparosc Endosc
1998; 8: 286–90
6 Hatfield PM, Clouse ME, Cady B. Ectopic pelvic spleen. Arch Surg
1976; 111: 603–5
7 Carswell JW. Wandering spleen: 33 cases from Uganda. Br J Surg
1974; 61: 495–7
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