[Hypovolemic shock during surgery caused by a rectus sheath hematoma]

Prophylactic treatment with low molecular weight heparins (LMWH) is currently widely used to prevent thromboembolic events. However, such treatment is not free of risk. Among the possible complications described is rectus sheath hematoma. We report the case of a patient undergoing surgery for a hypophysial adenoma approached by the transsphenoidal route. He received LMWH prophylaxis for thromboembolism and showed a tendency to hypotension during surgery. The patient's condition deteriorated to hypovolemic shock accompanied by episodes of atrial fibrillation with rapid ventricular response. With the transfusion of medications, blood products and plasma volume expanders, the patient was stabilized and surgery was completed. A computed tomography scan then revealed a hematoma occupying the greater part of the left anterior rectus muscle. With conservative wait-and-see treatment the abdominal symptoms disappeared and the hematoma gradually receded until fully resolved. Spontaneous rectus sheath hematoma is a rare condition. Presentation is quite nonspecific and computed tomography is needed for reaching a firm diagnosis. When a hematoma is large, the initial clinical picture may include hypovolemic shock, which may develop during surgery if the hematoma is not diagnosed early. Intraoperative management will be much more difficult than it would have been if diagnosis and treatment had taken place before the operation.