Spontaneous rectus sheath haematoma in pregnancy

Abstract

A 20-year-old, primiparous, Caucasian woman presented at 32 weeks and 6 days gestation with sudden onset severe left-sided abdominal pain. She denied any history of recent trauma, falls or vaginal bleeding. She had no history of previous abdominal pain in this pregnancy and had booked at 9 weeks gestation. Her booking weight was 96 kg with a body mass index of 39 kg/m2 and her booking haemoglobin was 13.6 g/dl. No relevant past medical or surgical history was noted and so far her pregnancy had been uneventful. Clinically she was very distressed with the pain, was sweaty and had cold extremities. Her pulse was 130/minute, blood pressure was 130/87 mmHg and her temperature was 36.4°C. Abdominal examination revealed marked tenderness in the left upper quadrant of the abdomen over the upper pole of the uterus, which had a symphysiofundal height of 34 cm. Her haemoglobin was 8.8 g/dl, white cell count was 9.1×109/litre, and platelet count was 454×109/litre with a normal clotting screen. The cardiotocograph (CTG) was normal. On ultrasound scan a large haematoma was noted associated with the left uterine wall. This was directly associated with her tenderness. With a presumptive diagnosis of placental abruption a decision was made to perform emergency caesarean section delivery under general anaesthetic. At laparotomy a large rectus sheath haematoma (RSH) was noted. There were no signs of intraperitoneal bleeding and the uterus was 32 weeks in size. Both tubes and ovaries appeared normal. Caesarean delivery was not performed. About 400 ml of blood clot was evacuated from the left rectus muscle. No active bleeding vessels were noted. The peritoneum was closed followed by the rectus sheath after leaving a sub-rectus drain in the haematoma cavity. Postoperatively fetal CTG monitoring remained normal. She did not require blood transfusion. On her second postoperative day her haemoglobin was 9.7 g/dl and the abdominal drain was removed. She was allowed home on the fifth postoperative day on oral ferrous sulphate. At 34 weeks sonographic fetal biometry was on the 50th centile, liquor volume was normal and the haematoma was resolving (size 72 mm × 60 mm × 35 mm). She was seen again at 36 and 38 weeks. At 39 weeks and 2days she presented in spontaneous labour and proceeded to a forceps delivery, for failure to progress, of a 2.81 kg healthy baby. Her 6-week postnatal follow-up scan showed complete resolution of the RSH.