Spontaneous iliopsoas haematoma during heparin anticoagulation: cause of fetal loss

A Rapid Fatal Outcome of Iliopsoas Hematoma: Clinical and Autopsy Findings

A case of massive muscular bleeding of iliopsoas resulting in lethal exsanguination is presented. The intramuscular bleeding occurred spontaneously in an old man with heart failure, presented to the emergency department after the acute onset of shortness of breath, and treated with therapeutic doses of antiplatelets and heparin to prevent thrombosis. On the sixth day of recovery, pain in the left lumbar region develops while there was a decrease in hemoglobin level. Computed tomography (CT) scan revealed a 10 × 3 cm hematoma of the left iliac muscle. The treatment was immediately stopped, but within 6 hours, the death was confirmed. The autopsy revealed that the hematoma, and its increased size since the latest imaging assessment, was the leading cause of death. Particularly in older patients with comorbidity, even in those with clotting parameters in the therapeutic range, the potential for fatal result of iliopsoas muscle bleeding should be considered. Identifying potential patience with increased risk of this complication could be important, especially in pandemic time of COVID-19, when the use of anticoagulant therapy—both for treatment and for prevention of severe disease—has become massive and addressed also to people without previous and specific pathologies.

Atypical Aortic Coarctation in a Patient with an Acute Exacerbation of Multiple Organ Failure: Successful Endovascular Therapy and Spontaneous Retroperitoneal Bleeding

We experienced a case of acute multiple organ ischemia and multiple organ failure due to atypical aortic coarctation (AAC). Since the patient's hemodynamics were too unstable to perform surgical revascularization, we performed urgent endovascular therapy (EVT) with a stent. Eventually, the patient achieved remission from multiple organ failure and a satisfactory clinical outcome. We feel that EVT for AAC is a sufficiently effective treatment option if the purpose of EVT is to save a patient's life in the acute phase. In the present case, spontaneous retroperitoneal bleeding (SRB) occurred after EVT of AAC, but this is a rare incident, although noteworthy in the clinical course.

Delayed lumbar plexus palsy due to giant psoas hematoma associated with vertebral compression fracture and direct oral anticoagulants: a case report

Background

Osteoporotic vertebral compression fractures (VCFs) are commonly observed in elderly people and can be treated by conservatively with minimal risk of complications in most cases. However, utilization of direct oral anticoagulants (DOACs) increases the risks of secondary hematoma even after insignificant trauma. The use of DOACs increased over the past decade because of their approval and recommendation for both stroke prevention in non-valvular atrial fibrillation and treatment of venous thromboembolism. It is well known that DOACs are safer anticoagulants than warfarin in terms of major and nonmajor bleeding; however, we noted an increase in the number of bleeding events associated with DOACs that required medical intervention. This report describes the first case of delayed lumbar plexus palsy due to DOAC-associated psoas hematoma after VCF to draw attention to potential risk of severe complication associated with this type of common and stable trauma.

Case presentation

An 83-year-old man presented with his left inguinal pain and inability to ambulate after falling from standing position and was prescribed DOACs for chronic atrial fibrillation. Computed tomography angiography revealed a giant psoas hematoma arising from the ruptured segmental artery running around fractured L4 vertebra. Because of motor weakness of his lower limbs and expansion of psoas hematoma revealed by contrast computed tomography on day 8 of his hospital stay, angiography aimed for transcatheter arterial embolization was tried, but could not demonstrate any major active extravasation; therefore spontaneous hemostasis was expected with heparin replacement. On day 23 of his stay, hematoma turned to decrease, but dysarthria and motor weakness due to left side cerebral infarction occurred. His pain improved and bone healing was achieved about 2 months later from his admission, however the paralysis of the left lower limb and aftereffects of cerebral infarction remained after 1 year.

Conclusion

In patients using DOACs with multiple risk factors, close attention must be taken in vertebral injury even if the fracture itself is a stable-type such as VCF, because segmental artery injury may cause massive psoas hematoma followed by lumbar plexus palsy and other complications.

Spontaneous retroperitoneal haemorrhage post-coronary angioplasty: a case report

Background

Spontaneous retroperitoneal haemorrhage (SRH) is a rare cause of retroperitoneal haemorrhage in patients who are on anticoagulants or antiplatelet agents or both.

Case summary

We report here a rare and catastrophic complication of use of anticoagulants and antiplatelet drugs in a case undergoing coronary angioplasty. The patient had multiple coronary risk factors and developed acute myocardial infarction with pulmonary oedema and hypotension during hospitalization for treatment of lower respiratory tract infection and diabetic ketoacidosis. He underwent successful angioplasty of the culprit vessel but later developed hypotension attributable to retroperitoneal haemorrhage. No bleeding site was identified despite extensive evaluation of the aorta and iliac vessels.

Discussion

A diagnosis of SRH is considered when a patient on anticoagulants or antiplatelet drugs develops retroperitoneal haemorrhage without any specific identifiable site of bleeding in the retroperitoneum. Diffuse vasculopathy and atherosclerosis or vasculitis of the small vessels in the retroperitoneum may result in rupture of the most friable vessels and result in bleeding. Intense cough, forceful vomiting or sneezing may also be responsible for traumatizing the vessels and resulting in bleeding. Most cases recover with conservative management but some may benefit from interventional occlusion of the leak or surgical decompression in cases of abdominal compartment syndrome.

Iliopsoas hematoma associated with low-molecular-weight heparin use: A case report

Iliopsoas hematoma is an uncommon clinical entity that may develop in association with anticoagulation states, coagulopathies and hemodialysis, or anticoagulant therapy. Here, we report a case of unilateral iliopsoas hematoma in a 60-year-old man who received low-molecular-weight heparin for anticoagulation due to continuous veno-venous hemofiltration. The patient presented with fever and productive cough for 2 days. He received continuous veno-venous hemofiltration due to rising blood urea nitrogen (22.7 mmol/L; normal references: 3.2-7.1 mmol) and creatinine (1345 µmol/L; normal references: 53-106 µmol/L). Low-molecular-weight heparin (enoxaparin, 3500-5500 Da, 5-10 IU/kg/h) was delivered continuously by pumps for anticoagulation therapy. At day 12 post heparin treatment, the patient complained left back pain. Platelet count (243 × 109/L) was normal, but both activated partial thromboplastin time (67.5 s) and prothrombin time (17.3 s) were prolonged. Abdominal computed tomography scan revealed left iliopsoas swelling with an indistinct border. Low-molecular-weight heparin was discontinued. Anti-Xa was not monitored throughout the treatment. No improvement was seen, and 3 days later, the patient died after his family decided to terminate therapy. This case highlights the needs for careful anticoagulation as well as close monitoring, and particularly the use of anti-Xa to guide the treatment.

Spontaneous Retroperitoneal Bleeding in a Patient with Primary Antiphospholipid Syndrome on Aspirin

Retroperitoneal bleeding is a rare and difficult to diagnose condition, defined as bleeding in the retroperitoneal space without associated trauma or iatrogenic manipulation. It has been associated with hematologic diseases and malignancies and is more common in patients receiving systemic anticoagulation. A 50-year-old man on aspirin presented with abdominal pain. Physical examination revealed abdominal tenderness and a palpable mass at the left abdominal area. An abdominal CT revealed a spontaneous retroperitoneal hematoma due to bleeding of an intraparenchymal branch of the left renal artery. The patient underwent left nephrectomy in order to control the bleeding. Pathology of the kidney showed evidence of acute and chronic microangiopathy, renal artery stenosis, and renal vein thrombosis. Further work-up led to diagnosis of primary antiphospholipid syndrome. Treatment of spontaneous retroperitoneal bleeding varies from conservative in hemodynamically stable patients to invasive or even surgery in hemodynamically unstable patients. In our case, open surgery was performed due to the rapidly deteriorating patient's condition and the inability to embolize the bleeding vessel by interventional radiology. Physicians should always think of retroperitoneal bleeding in patients presenting with abdominal pain and signs of hypovolemia, especially if they have a bleeding disorder or receive anticoagulants or antiplatelets.

Spontaneous retroperitoneal bleeding: a case series

Background

We experienced four Japanese patients with spontaneous retroperitoneal bleeding, a rare disease. We categorized the clinical characteristics of spontaneous retroperitoneal bleeding in these patients treated in our hospital and discuss the risk factors of spontaneous retroperitoneal bleeding.

Case presentation

Three of the 4 patients did not have a bleeding tendency as indicated by laboratory data obtained at the time of retroperitoneal bleeding. The causative blood vessels were the lumbar and superior gluteal arteries and the internal iliac artery. All patients were receiving an anticoagulant, heparin in one and nafamostat mesilate in the other three patients. Three patients were being treated with hemodialysis or continuous hemodiafiltration when the spontaneous retroperitoneal bleeding occurred. We achieved hemostasis with transcatheter arterial embolization in 3 patients and with surgical hemostasis in 1 patient.

Conclusions

We suggest that in patients receiving anticoagulant therapy in whom progressive anemia and unstable vital signs are present, spontaneous retroperitoneal bleeding should be considered as a possible cause. Nafamostat mesilate may be one of the risk factors for spontaneous retroperitoneal bleeding.

Retroperitoneal haematomas in obstetrics: literature review

INTRODUCTION

There is paucity of literature on retroperitoneal haemorrhage/haematomas (RH) as these cases are extremely rare in obstetrics. Experience is available mostly from case reports and therefore the incidence of RH in obstetrics is unknown.

METHODS

Literature search in Medline/Pubmed and Google scholar using MeSH; aneurysm, haematoma, haemorrhage, obstetrics and retroperitoneal.

AETIOLOGY AND PATHOGENESIS

This article discusses aetiology, pathogenesis, diagnostic difficulties and dilemmas, as well as misleading symptoms that often mimic common clinical conditions.

DIAGNOSIS AND MANAGEMENT

Management of RH is complex and continues to improve with advancements in the investigative strategies, treatment options and critical care specialty. Further the authors highlight the importance of basic principles of clinical examination, the need for multidisciplinary input and the current trend in the management options.