398. Catastrophic rectus sheath haematoma in pregnancy

• Published in: Pregnancy hypertension 2018-10, Vol.13, p.S144-S144
• Main Authors: Partridge, Gemma dr, McKelvey, Alastair mr
• Format: Article
• Language: English
• ISSN: 2210-7789; 2210-7797
• DOI: 10.1016/j.preghy.2018.08.428

We present a case of rectus sheath haematoma (RSH) resulting in intra-uterine fetal demise, in a woman who was therapeutically anti-coagulated for a massive pulmonary embolism. This relatively rare complication of anticoagulation therapy is easily misdiagnosed in the pregnant population and the publication of this case seeks to highlight the diagnostic and management challenges faced by obstetricians. A woman receiving anticoagulant treatment for a large saddle pulmonary embolus diagnosed at 34 weeks gestation, complained of increasing abdominal pain and swelling at 37 weeks gestation. The pain was associated with a fall in haemoglobin concentration and ultrasonography was consistent with a large rectus sheath haematoma (10 × 10 × 2 cm). Despite initial conservative management her condition deteriorated and she collapsed as a result of hypovolaemia. Intra-uterine fetal demise was diagnosed and a caesarean section was performed with evacuation of a 2000 ml RSH and ligation of the inferior epigastric artery. A pubmed literature search and review of results. There are few reported cases of RSH in pregnancy; the key discussion points are addressed below. RSH is a rare presentation, more commonly found in patients who are anticoagulated. Risk factors for the development of RSH include conditions which increase the intra-abdominal pressure, such as coughing. The patient presented above had been complaining of a cough, and subsequent imaging confirmed a lobar pneumonia. These features, in combination with her anticoagulation predisposed her to the development of a RSH. In the context of a haemodynamically stable patient the management of RSH should be conservative, hence the importance of accurate diagnosis and early management to avoid unnecessary laparotomy which could result in further bleeding. In unstable patients surgical and/or radiological intervention is indicated. We present a rare case of antepartum rectus sheath haematoma requiring surgical intervention.