Rectus Sheath Hematoma (RSH) is a rare condition that frequently affect elderly women on anticoagulant therapy. Risk factors include trauma, surgery, cough, iatrogenic, renal or blood disorders. Most patients present a painful mass at the moment of admission, accompanied of a drop of hemoglobin level. Although the vast majority of cases are self-limiting, and managed with conservative treatment (anticoagulation reversal, fluid replacement, blood transfusion, analgesics), there is still a minority of cases that will present hemodinamically inestability and will need selective embolisation or even surgery. US and CT are useful imaging techniques, especially intravenous contrast CT that will select patients for embolisation. Management is a dilemma, and decision of when reintroducing anticoagulation can convert into a challenge. There is a lack of consensus and guidelines about how to manage this entity, and most of literature consist of series of case reports. We report a case of giant rectus sheath hematoma that caused abdominal compartment syndrome and required two embolisation and surgery. This is a peculiar case because although rectus sheath hematoma has been reported, previously, as cause of abdominal compartment syndrome, this is an uncommon presentation and few cases reported in the English literature.