CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 6, July 2012
AFRICA
e15
gradually. A total of six units of red blood cells and three units
of fresh frozen plasma was administered to the patient. After 24
hours, the haematocrit and haemogram were steady without the
need for further resuscitation.
We waited 12 hours and then cautiously started intravenous
heparin administration, with close monitoring of the patient as he
had prosthetic heart valves which had thrombosed a year earlier.
Coumadin was started on the second day of hospitalisation and
effective coumadinisation was achieved on the 10th day, so the
heparin infusion was stopped.
Transoesophageal echocardiography revealed normal-
functioning prosthetic mechanical mitral and aortic valves with
no thrombus. The patient was discharged on coumadin.
Discussion
Abdominal trauma, abdominal surgery, pregnancy, collagen
vascular disorders, coagulopathies, anticoagulant therapy
and strenuous exercise may cause RSH. Some patients may
experience RSH without any prior history, which is termed
spontaneous RSH.
1,2
It is more frequently observed in females
and older patients.
1
Injury of the superior epigastric artery causes RSH above
the arcuate line, and is usually self-limiting with a unilateral
small mass. However, when the inferior epigastric artery is
injured, it may bleed profusely and the haematoma may cross
the midline and extend into the pelvic cavity. Patients usually
present with acute abdominal pain, often associated with nausea,
fever and vomiting. Tenderness and swelling of the abdominal
wall is usually noticed in the physical examination, and when
the bleeding is profound, signs of hypovolaemic shock such
as tachycardia and hypotension may be seen. Fothergill’s and
Carnett’s signs may also be observed.
3,4
Gray Turner’s and
Cullen’s signs may be noted later.
Ultrasonography is a useful initial diagnostic modality due to
its low cost, availability and portability.
5
Computed tomography
however is superior to ultrasonography for diagnosis.
5
Management of RSH depends on the severity of the situation.
Conservative therapy is usually sufficient, as RSH is mostly
self-limiting. Urgent reversal of coagulopathy is the mainstay
of therapy when anticoagulants are being used. If there is
haemodynamic compromise, blood transfusion is mandatory.
Interventional procedures are rarely required but in that case,
coil or gel foam embolisation of the epigastric arteries can
be successfully performed.
6
Spontaneous resolution of the
haematoma takes several weeks. Anticoagulation must be
prevented unless it is essential.
Our patient experienced spontaneous RSH, probably
predisposed by taking coumadin. Fresh frozen plasma and
vitamin K were administered to reverse the anticoagulation and
the patient was resuscitated with blood and fluids to achieve
haemodynamic stability.
The timing of anticoagulation is important in patients suffering
from major bleeding because administration of anticoagulants
may restart the bleeding. In patients with thrombotic diathesis,
this anticoagulant-free period may induce thrombosis, as in
patients who have had prior prosthetic valve thrombosis.
After achieving steady haemoglobin and haematocrit levels,
we waited 12 hours before restarting anticoagulation. The
patient was discharged uneventfully after transoesophageal
echocardiography, which showed normal-functioning prosthetic
mitral and aortic valves.
Conclusion
Patients with mechanical heart valves experience problems due
to both the mechanical valves and the medication. Coumadin is
the mainstay of therapy in these individuals but it predisposes
to bleeding, as in our patient. Management of the bleeding is
problematic as the coumadin must be stopped and its effects
reversed, despite risking thrombosis of the heart valves. This
process needs fine adjustment and close follow up.
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