Recombinant Activated Factor VII Treatment of Life-Threatening Rectus Sheath Hematoma in a Patient Receiving Enoxaparin, Aspirin, and Clopidogrel: A Case Report

Abstract

Rectus sheath hematoma is a rare complication of anticoagulant therapy. We have described the case of a 78-yearold woman with unstable angina who developed a life-threatening rectus sheath hematoma during treatment with antiplatelet drugs and enoxaparin. The patient had underlying diseases of hypertension and triple vessels disease status post coronary artery bypass graft. She was admitted initially with an asthmatic attack. Three days later, she developed unstable angina and thus received aspirin, clopidogrel, and enoxaparin. After the fifth dose of enoxaparin, she developed progressive suprapubic pain with a newly palpable mass, anemia, hypotension, and oliguria. Abdominal computed tomography revealed a rectus sheath hematoma sized 15 cm., (about 2,000 mL by volume). Her coagulogram was normal. Despite rapid fluid resuscitation, packed red cell transfusion (1,300 mL), platelet transfusion, and protamine sulfate injection, the patient’s hemodynamic status remained unstable. Finally recombinant activated factor VII (rFVIIa) injection improved her hemodynamic status and stabilized her hemoglobin level without a thrombotic complication. This case report provides evidence of the benefit of rFVIIa use as a part of the treatment of refractory bleeding from enoxaparin.