Rectus sheath hematoma with low molecular weight heparin administration: a case series

Abstract

BackgroundRectus sheath hematoma is an uncommon but potentially serious bleeding complication that can occur spontaneously or as a result of anticoagulation administration.Case presentationCase number one: A 62 year old chronically ill Caucasian female develops a rectus sheath hematoma seven days after hospital discharge. The previous hospitalization included low molecular weight heparin administration for deep vein thrombosis prophylaxis. The patient ultimately chooses comfort care and expires due to sepsis and respiratory failure. Case number two: A 79 year old Caucasian male develops a rectus sheath hematoma during hospital admission where LMWH is used for deep vein thrombosis prophylaxis. He is managed conservatively; however, his hematocrit drops from 46 to 25.8%. Case number three: A 44 year old chronically ill Caucasian female is treated with therapeutic low molecular weight heparin for recent deep vein thrombosis during a hospital admission. She develops a large rectus sheath hematoma requiring embolization as well as blood transfusion.ConclusionWe believe this reflects an underreported significant cause of morbidity and mortality with low molecular weight heparin administration. We review the pathophysiology of rectus sheath hematoma as well as its presentation, diagnosis, and treatment. We identify at-risk populations and proposed contributing factors. We also discuss factors leading to underreporting as well as preventive strategies implemented at our institution.

A Case of Rectus Sheath Hematoma Due to Anticoagulants after Total Knee Arthroplasty

“…In rectus sheath hematoma, hemorrhage caused by breakage of the superior and inferior epigastric arteries and veins and muscle fibers leads to the formation of a hematoma in the abdominal wall. The main risk factors for rectus sheath hematoma are anticoagulant therapies [4] [5], coagulation disorders, previous surgical operations [6], abdominal trauma, increased intra-abdominal pressure [7]- [9]. Other causes have been also described in case reports, such as acupuncture [10], subcutaneous injection, foley catheterization [11], HCV-related mixed cryoglobulinemia [12], lymphoproliferative disease after renal transplantation [13], and tetanus [14].…”

Percutaneous drainage in treatment for spontaneous rectus abdominis hematoma due to rivaroxaban usage

“…Management of a rectus hematoma is usually conservative [4]. Invasive treatment is only indicated if the rectus hematoma is progressive or if the patient is hemodynamically unstable [6].…”

“…However, like all anticoagulants, rivaroxaban carries a risk of bleeding [1][2][3]. Hematomas of the rectus abdominis muscle are commonly reported complications of systemic anticoagulation treatment [4]. There is a single reported case of rectus abdominis hematoma due to rivaroxaban use in the literature [5].…”

Fatal Case of Spontaneous Rectus Sheath Hematoma Caused by Anticoagulant and Steroid Therapy during Hospital Admission

“…There are no clear guidelines about the therapeutic approach in RSH; nevertheless, individual clinical decision making should be based on the presence of some alarming signs and symptoms such as: enlarging hematomas, hemodynamic instability unresponsive to fluid resuscitation, signs of peritoneal irritation, refractory pain, and persistent gastrointestinal or urinary symptoms [2,4]. …”