Rectus sheath and retroperitoneal haematomas in patients with Coronavirus 2019 infection

Abstract

High rates of venous thromboembolism (VTE) have been observed in Coronavirus 2019 disease . 1 Regulatory bodies in the UK advise pharmacological VTE prophylaxis with standard prophylactic low-molecular-weight heparin (LMWH) dosing, escalating to a therapeutic dose if there is a high clinical suspicion of VTE. 2 Furthermore, in December 2020, an interim analysis of pooled data from the ACTIV-4a, REMAPCAP and ATTACC randomised clinical trials suggested that LMWH was beneficial for patients not requiring intensive care support. 3 However, there is growing awareness of the bleeding risk associated with COVID-19. 4 The interim analysis of the afore-mentioned clinical trials paused enrolment of critically ill patients due to futility and a potential for harm due to higher rates of bleeding in these patients. 3 Additionally, a systematic review of incidence of VTE and bleeding amongst hospitalised patients with COVID-19 found that pooled incidence was 17% for VTE, 7Á1% for pulmonary embolism (PE), 7Á8% for bleeding and 3Á9% for major bleeding. The highest pooled incidence estimate of bleeding was reported for patients receiving intermediate or therapeutic dose anticoagulation (21Á4%). 5 Cases of spontaneous rectus sheath (RSH), and retroperitoneal haematomas (RPH) have also been described, 6 both of which were rare pre-COVID-19. 7 Spontaneous RSH typically occurs in elderly patients and approximately two thirds of these bleeds are associated with therapeutic anticoagulation, whereas RPH characteristically occurs following trauma. 7 Recognised risk factors for RSH/ RPH include therapeutic anticoagulation, underlying coagulopathy, hypertension, abdominal wall injections, steroid therapy, cough and old age. 7 As patients admitted with COVID-19 are typically prescribed steroid therapy and exhibit symptoms of severe cough, it is plausible that this could in part explain a higher risk of RPH/RSH in this population.Here, we describe 12 patients exhibiting RPH/RSH complications whilst admitted for management of COVID-19 infection and evaluate the importance of this specific bleeding complication and the implications for management.This was a retrospective study of data from electronic radiology reports and patient records, using code search terms for 'retroperitoneal haematoma' and 'rectus sheath haematoma', for patients admitted to two hospitals in Liverpool, from 1 March 2020 to 20 January2021. Cases were included if they had: (ⅰ) either positive SARS-CoV-2 nucleic acid amplification test or probable diagnosis of COVID-19

Rectus Sheath Hematoma in COVID-19 Patients as a Mortal Complication: A Retrospective Report

“…There are concerns over RSH in hospitalized patients with COVID-19 [ 8 – 13 ]. On the one hand, these patients receive anticoagulants for thromboprophylaxis; on the other hand, any bleeding prompts clinicians to discontinue anticoagulants and control vital signs [ 14 ].…”

Spontaneous rectus sheath and retroperitoneal haemorrhage secondary to enoxaparin injections

“…Hazenberg et al . noted in a case series 12 patients who had developed either RSH or RPH secondary to enoxaparin injection in COVID-19 positive patients [ 14 ]. Their study identified patients who were predominantly on therapeutic dose enoxaparin and likely developed RPH/RSH due to an extended period of time receiving anticoagulation.…”

Retroperitoneal Hemorrhage in Patients with COVID-19 Undergoing Hemodialysis: Three Case Reports

“…Some reports have described retroperitoneal hemorrhage as a fatal bleeding complication ( 19 , 20 ), most of which occurred during anticoagulant therapy in patients with background factors such as older age, hypertension, and combination with aspirin. There are three possible mechanisms for retroperitoneal hemorrhage.…”