Embolization of a rectus sheath hematoma in pregnancy

Abstract

A 37-year-old woman (gravida 3, para 1) was admitted at 33 weeks of pregnancy following acute onset of left abdominal pain and general malaise. The patient had normal vital signs and fetal cardiotocography but a painful left abdominal mass with guarding. Blood tests showed moderate anemia. Abdominal ultrasound revealed a large left heterogeneous cystic mass in the abdominal wall. Magnetic resonance imaging showed a large rectus sheath hematoma (Fig. 1). A coronal T2-weighted magnetic resonance image showing a large left-sided rectus sheath hematoma measuring 160 × 70 × 55 mm (arrow). Note the subcutaneous fat stranding and a small hemoperitoneum coexisting with a fetus of 33 weeks of gestation. The patient developed an acute abdomen and surgical drainage was performed. Despite the drainage, massive hemorrhage recurred in the postoperative period. The patient had multiple blood transfusions, and embolization was decided on as the best treatment path. Arteriography revealed active bleeding from the left epigastric artery. Superselective catheterization was performed and the artery was occluded at the level of the bleeding using microparticles and microcoils. The patient delivered a 3740 g healthy female neonate at 38 weeks with vacuum extraction. Rectus sheath hematoma during pregnancy is a rare cause of abdominal pain, with 52 cases of the condition described in the literature. In addition to pregnancy and labor, other risk factors for rectus sheath hematoma include coagulation disorders, anticoagulant use, trauma, previous surgery, cardiovascular diseases, degenerative muscle diseases, obesity, coughing, and vomiting [1], [2]. Rectus sheath hematoma in pregnancy is a challenging condition owing to a number of alternate diagnoses, such as placental abruption, uterine rupture, and necrobiosis of leiomyoma; it has a reported maternal mortality rate of 11% and a perinatal morbidity rate of 34% [2]. Management includes conservative therapy if the patient and the hematoma are stable. In other conditions, surgical drainage and ligation of the vessel by laparotomy must be considered [1], [2]. Successful outcomes with arterial embolization in nonpregnant women have been reported in the literature [3]. Embolization might allow a reduction of prematurity-associated morbidity and mortality by allowing rapid identification of the injured vessel, selective treatment, and delaying delivery. With regard to the safety of embolization during pregnancy, the general late onset of this pathology reduces the risks associated with fetal irradiation. In the present case, the large hematoma displaced the uterus and fetus to the right, which reduced the dose of X-rays delivered to the fetus. Selective epigastric embolization in severe rectus sheath hematoma during the third trimester of pregnancy should be considered as the potential primary and alternative management path to classical laparotomy. Further studies are required to confirm that the maternal and fetal benefits outweigh the fetal risks associated with embolization.