Spontaneous rectus sheath hematomas: when to restart anticoagulation?

The aim of the present study was to obtain data regarding the timing of anticoagulation resumption in patients with spontaneous rectus sheath hematomas (RSH).

The study is based on review of patients receiving anticoagulation medication who were diagnosed with a spontaneous RSH (traumatic and iatrogenic excluded) between 14 July 1997 and 17 March 2012.

There were 156 patients (37 % male; aged 73 ± 13 years) with an average body mass index of 29 ± 7 (procedure group 28 ± 6). Anticoagulants included coumadin (64 %), intravenous heparin (21 %), aspirin (8 %), and others (7 %). An intervention was needed in 29 (19 %) of the patients (5 % operative; 16 % embolization). Sixty-two percent of patients had their anticoagulation restarted during their hospitalization, with a median re-initiation time of 4 days after RSH diagnosis (range 2-8 days). Timing of anticoagulant resumption did not differ regardless of the need for intervention (3 vs. 4 days). The complication rate was 19 % (42 % in the procedure group, none specific to the procedure), with the most common being acute renal failure (n = 8; 5 %), death (n = 8; 5 %), and thrombotic events (n = 5; 3 %). After resumption of anticoagulation, two patients suffered enlargement of their RSH, both 2 days after resumption.

Intervention to control hemorrhage was unnecessary in the majority of patients with RSH. In those with resumption of anticoagulation, the majority of patients were safely restarted by day 4. Even though complications secondary to anticoagulation were few, thrombotic complications outnumbered bleeding complications, suggesting that anticoagulation was withheld for too long after RSH diagnosis.