Fatal retroperitoneal haemorrhage associated with enoxaparin and impaired renal function

Abstract

Fig. 1. CT scan showing a huge retroperitoneal haematoma. Two different densities are visible inside the haematoma, possibly reflecting different bleeding times. A 66-year-old woman with previous renal transplantation—baseline creatinine of 1.6 mg/dl—was admitted to the hospital with the diagnosis of unstable angina and treated with enoxaparin (1 mg/kg/12 h, subcutaneously). On the 12th day of admission, the patient developed diffuse abdominal tenderness and hypotension. Hemoglobin suddenly decreased 4 g/dl compared to baseline levels. Abdominal/pelvic CT revealed a right retroperitoneal haematoma measuring 14 14 2 cm (Fig. 1). The patient was transferred to the intensive care unit, but her medical status continued to deteriorate. She became anuric, requiring highdose dopamine as well as intravenous fluids and blood products to maintain her blood pressure. Finally, she developed a refractory hypovolemic shock causing her death. Enoxaparin has been shown to be superior to unfractionated heparin (UFH) in the management of patients with an acute coronary syndrome [1,2]. However, no prospective data are available about its safety and efficacy in patients who are obese and patients with severe renal impairment (creatinine level>2 mg/dl or creatinine clearance 30 ml/min if an adjusted enoxaparin dose was used.