Ruptured Splenic Ectopic Pregnancy: The Importance of Considering Nontubal Sites

<b>Objective:</b> Splenic ectopic pregnancy is an exceptionally rare and life-threatening form of abdominal ectopic pregnancy, often presenting significant diagnostic and management challenges. We report a case of ruptured splenic ectopic pregnancy initially suspected to be a tubal miscarriage. <b>Case Report:</b> A 36-year-old woman presented with mild left-sided pelvic pain, no vaginal bleeding and a positive pregnancy test. This was an unplanned pregnancy, and she was not sure of her LMP. This presentation in early pregnancy requires ruling out an ectopic pregnancy through clinical assessment and laboratory investigations. Clinical examination showed normal observations and generalized abdominal tenderness with no signs of peritonism. Initial investigations revealed a significantly elevated <i>β</i>-hCG of 24,076 IU/L, and transvaginal ultrasound showed an empty uterus. Given the findings, an ectopic pregnancy was suspected, and diagnostic laparoscopy was performed. During laparoscopy, no ectopic pregnancy was identified in the pelvis, both tubes looked normal, but a left fimbrial cyst was noted, and 300 mL of haemoperitoneum was observed, without active bleeding. A tubal miscarriage was presumed with the plan to follow up <i>β</i>-hCG to confirm resolution of the pregnancy. Postoperatively, the patient developed worsening pain and a significant haemoglobin drop to 97 g/L, inconsistent with the amount of intraoperative blood loss which raised the suspicion of extrapelvic ectopic pregnancy with active bleeding. A contrast-enhanced CT scan identified free blood surrounding the spleen and a 25-mm peripherally enhancing lesion with venous drainage into the splenic vein, consistent with a ruptured splenic ectopic pregnancy. An urgent multidisciplinary team discussion led to surgical management via midline laparotomy and splenectomy. The postoperative course was complicated by ileus, which resolved with conservative management. The patient's <i>β</i>-hCG levels progressively declined, confirming resolution. <b>Conclusion:</b> This case highlights the importance of considering splenic ectopic pregnancy when <i>β</i>-hCG is markedly elevated, and no pelvic ectopic pregnancy is identified. Prompt imaging and diagnosis are crucial to prevent morbidity associated with delayed management.