2009, Cilt 22, Sayý 3, Sayfa(lar) 240-242
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POST-CAESAREAN RECTUS SHEATH HAEMATOMA: A CASE REPORT
Imtiaz Wani
S.M.H.S Hospital , Srinagar, Surgery, Srinagar, Hindistan
Keywords: Rectus sheath hematoma, Post caesarean
Abstract
The author reports a case of rectus sheath hematoma after Lower Segment caesarean section (LSCS).The hematoma extended to the pelvic wall. The aberrant course of vessels or injudicious dissection may contribute to this catastrophe. Clinical suspicion, Carnett’s test and ultrasonography were used to confirm the diagnosis. The management was conservative.
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  • Abstract
  • Introduction
  • Case Presentation
  • Disscussion
  • References
  • Introduction
    In developing countries, where simple diagnostic facilities are not available all times, diagnosis of rectus sheath hematoma remains elusive and has to rely on the doctors clinical judgment to diagnose this uncommon, but well-documented mimic of acute abdomen1. A keen clinical sense, ultrasound and the invaluable Carnett’s test for diagnosis is available in developing countries. Prompt consideration of this rare mimic of acute abdomen may reduce the burden of performing expensive and invasive diagnostic tests and in some cases unnecessary hospitalization and laparotomy2.
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  • Abstract
  • Introduction
  • Case Presentation
  • Disscussion
  • References
  • Case Presentation
    A 26-year-old female was referred to our surgical services with persistent lower abdominal pain of two days duration .She had undergone LSCS three days previously. She was primi. The patient has already received pain killers. Initially the pain was attributed to the wound site pain of LSCS. Tachyardia was present. The rest of parameters were normal. Perabdominal examination revealed tenderness on palpation of lower abdomen. Due to the tenderness, no swelling could be assessed. Carnett’s test was positive. Hemoglobin was 10 gm%. There was no significant finding on the abdomen X-ray. Abdominal sonography showed a multiseptate cystic swelling 11.4×8.1 cm. in front of the bladder extending int the anterior abdominal wall, as shown in Fig.1 suggestive of rectus sheath hematoma. In our case the abnormal course of vessels in the rectus sheath, abnormal insertion of the rectus muscle which was torn during insertion with lax and thinned out abdominal wall layers may account for rectus sheath hematoma. The patient was managed conservatively, discharged on the seventh day and is routinely attending our follow up clinics.


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    Figure 1: A multiseptate cystic swelling in front of the bladder extending into the anterior abdominal wall, suggestive of rectus sheath hematoma.

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  • Abstract
  • Introduction
  • Case Presentation
  • Disscussion
  • References
  • Discussion
    Rectus sheath hematoma has been a well-known entity from the ruin of ancient Greece3 Rectus sheath presents as acute abdomen. Females are more prone to develop rectus sheath haematoma.The presentation is a painful, tender abdominal swelling of sudden onset. This haematoma results from bleeding into the rectus sheath due to damage to the superior and the inferior epigastric arteries or their branches, or a direct tear of the rectus muscle when small branches bleed. Sometimes it can expand and lead to the hypovolemic shock and subsequent death. This haematoma usually lies posterior to the muscle. Haematomas near the umbilicus are rare. Considered causes for rectus sheath are severe exertion4, pregnancy5, insulin injection6, laparoscopy and cholecystectomy7. Berna et al, proposed that rectus sheath haematoma should be suspected in women of advancing age undergoing treatment with anticoagulants who present with triad of acute abdominal pain, infraumbilical mass and anemic syndrome8. Other causes being coughing, thrombocytopenia and contusion9. Ultrasound is a good investigation for diagnosis10, showing the mass of mixed echogenicity with no internal vascularity5. CT abdomen in particular is more useful, permits a more correct diagnosis and is considered the investigation of choice11. Technetium -99 labeled RBC scintigraphy confirms the presence of the haematoma, site of bleeding and reveals continued bleeding6. Selective percutaneous transcatheter arterial embolisation is considered an effective haemostatic in the treatment of a patient with a large haematoma12. Because of the diagnostic dilemma of differentiating this condition from other acute abdominal conditions the majority of cases are treated with operative procedures3. Non-surgical therapy is considered appropriate, but leads to a greater need for analgesics. Surgical intervention is necessary in cases with large haematomas or free intra operational ruptures10. Early diagnosis permits conservative management even in large haematomas.

    Stress is laid on clinical examination ,Carnett’s test and ultrasonography in the diagnosis of rectus sheath hematoma. A persistent pain in the lower abdomen should arouse suspicion of rectus sheath hematoma in post LSCS. Management is most of the time by conservative measures.

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  • Abstract
  • Introduction
  • Case Presentation
  • Discussion
  • References
  • References

    1) Maharaj D, Ramdass M, Teelucksingh S. Rectus sheath haematoma :a new set of diagnostic features. PMJ 2002;78:755-758.

    2) Edlow JA, Juang P, Margulies S, et al. Rectus sheath hematoma. Ann Emerg Med 1999;34:671–675.

    3) Miyauchi T, Ishikawa M, Miki H. Rectus sheath hematoma in an elderly woman under anti-coagulant therapy. J Med Invest 2001;48:216–220.

    4) Hecker RB, Bradshaw WH, Pinkerton SF. Rectus sheath hematoma: report of a case. Tex Med 1990;86:68–70.

    5) Humphrey R, Carlan SJ, Greenbaum L. Rectus sheath hematoma in pregnancy. J Clin Ultrasound 2001;29:306–311.

    6) Monsein LH, Davis M. Radionuclide imaging of a rectus sheath hematoma caused by insulin injections. Clin Nucl Med 1990;15:539–541

    7) Neufeld D, Jessel J, Freund U. Rectus sheath hematoma: a complication of laparoscopic cholecystectomy. Surg Laparosc Endosc 1992;2:344–345.

    8) Berna JD, Zuazu I, Madrigal M, et al. Conservative treatment of large rectus sheath hematoma in patients undergoing anticoagulant therapy. Abdom Imaging 2000;25:230–234.

    9) Hegenbarth R, Reiser C, Leib P.The sonographic diagnosis of a spontaneous rectus sheath hematoma. Aktuelle Radiol 1991;1:201–203.

    10) Klingler PJ, Wetscher G, Glaser K, et al. Use of ultrasound to differentiate rectus sheath hematoma from other acute abdominal disorders. Surg Endosc 1999;13:1129–1134.

    11) Berna JD, Garcia-Medina V, Guirao J, et al. Rectus sheath hematoma: diagnostic classification by CT. Abdom Imaging 1996;21:62–64.

    12) Rimola J, Pirendru J, Falco J. Clinical observations. Percutaneous arterial embolisation in the management of rectus sheath haematoma. AJR 2007;188: W497-W502.

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  • Abstract
  • Introduction
  • Case Presentation
  • Discussion
  • References
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