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A Case Report: Rectus Sheath Hematoma or an Obstetrical Emergency?
Abstract Number: S 49
Abstract Type: Case Report/Case Series
Rectus sheath hematomas(RSHs) are uncommon and may be misdiagnosed during pregnancy. Presenting signs and symptoms are vague and can mimic obstetrical, as well as, surgical emergencies. With a reported mortality rate of 13% for paturients and 50% for the fetus, it is an important but often unrecognized obstetrical diagnosis.
A 36-year-old G10P6035 patient at 29 2/7 weeks gestation with di/di twins and morbid obesity (BMI 47) presented to the labor and delivery suite with severe right upper quadrant(RUQ) pain. Past medical history included asthma, smoking, and current upper respiratory infection(URI) being treated with antibiotics and steroids. On admission, she had an elevated blood pressure of 150/80 and proteinuria noted at a recent office visit. Physical exam included wheezing in all lung fields and extreme abdominal tenderness with a mass palpated in the RUQ. Ultrasound was technically difficult due to patient’s body habitus. Fetal heart tones were only detected for one fetus.
The patient was taken to the OR for an emergency cesarean section. A differential diagnosis of abruption, uterine rupture and liver capsular rupture were all considered. The patient was prepped for surgery while ASA standard monitors were applied and the patient was preoxygenated. The patient was intubated by direct laryngoscopy following a rapid sequence induction. Baby A and B were both delivered and taken to the NICU. A 20% abruption was noted on both placental surfaces with no evidence of uterine rupture. During laparotomy a large, bulging upper RSH of 750 ml was evacuated. There was no evidence of intraperitoneal bleeding and the liver capsule appeared intact. The patient was transferred to the surgical ICU at the end of surgery and was extubated within 24 hours. Post-op course was unremarkable.
Rectus sheath hematomas are uncommon and often misdiagnosed. Sudden rupture of deep epigastric vessels within the rectus muscle can form a hematoma. This can be spontaneous or traumatic and can mimic surgical and obstetrical emergencies. The differential diagnosis includes cholecystitis, appendicitis, dissecting aneurysms, torsion or rupture of ovarian cysts, uterine rupture and abruption. Presenting symptoms are typically vague and include acute abdominal pain, fever, nausea and vomiting. Risk factors consist of anticoagulation, degenerative muscle disease, pregnancy, acute asthmatic attacks, URI and repeated valsalva maneuvers. Our patient had multiple risk factors secondary to her recent URI and asthma exacerbation. Ultrasound is first line in diagnosing RSH, followed by MRI and CT. Given the acuity of the situation, MRI or CT was not appropriate. Although uncommon, RSHs are an important but often unrecognized obstetrical diagnosis.
Tolcher MC,Nitsche JF,Arendt KW,Rose CH.2010.Spontaneous rectus sheath hematoma in pregnancy:case report and review of the literature.Obstet Gynecol Surv:65(8):517-522.