Keywords
spontaneous retroperitoneal hematoma - low-molecular weight heparin - COVID-19
Introduction
Severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) was initially reported
to affect the respiratory system, with severe cases causing acute respiratory distress
syndrome (ARDS), leading to multiorgan failure and death. As the pandemic grew, multiple
reports emerged where patients with moderate-to-severe COVID-19 presented with alterations
in blood coagulation profile and increased risk of thromboembolic phenomenon.[1] Low-molecular weight heparin (LMWH) was used prophylactically and therapeutically
for the management of such patients. One of the recognized complications of LMWH is
spontaneous extraperitoneal hemorrhage (SEH) or spontaneous retroperitoneal hemorrhage
(SRH). We describe the clinical details and management strategy of three COVID-19
patients below, presenting as SEH or SRH.
Case 1
A 63-year-old Indian gentleman with severe COVID-19 pulmonary manifestation was on
invasive mechanical ventilation in ICU for hypoxia (arterial PO2 74%). Anticoagulant
(subcutaneous LMWH 0.5 mg/kg body weight per day) in prophylactic dose was administered
in addition to other drugs as per the Ministry of Health protocol for serious COVID-19
patients. The patient developed abdominal distention 1 week after his admission. His
hemoglobin level dropped from 14.1 to 7.2 mg/dL.
A contrast-enhanced computed tomography (CECT) revealed a large abdominopelvic hematoma
on the left side with active contrast extravasation (
[Fig. 1]
). It was decided to treat endovascularly. On angiography through right femoral access,
an active contrast extravasation was seen from a branch of the anterior division of
the left internal iliac artery, assumed to be obturator artery. Selective cannulation
was done with a 2.8 F Progreat microcatheter (Terumo; Somerset, New Jersey, USA).
Embolization of the artery was performed with 2 to 4 mm diameter 0.018” coils (Cook
Medical, Bloomington, Indiana, United States) successfully (
[Fig. 1]
). The hemoglobin values were stable during immediate postprocedure period. However,
he succumbed due to cardiac arrest 3 days later.
Fig. 1 A large left abdominopelvic extraperitoneal hematoma. Contrast-enhanced computed
tomography (CECT) axial, arterial phase image (A) showing the hematoma as an ill-defined hypodensity with focal contrast extravasation
(black arrow). Three minutes delayed phase axial CT image (B) showing pooling of contrast (arrow). Digital subtraction angiography (DSA) (c) showing contrast extravasation from a branch of the left internal iliac artery (obturator
artery). Postembolization angiogram (D) demonstrating coil embolization of the arterial branch with cessation of the extravasation.
Case 2
A 57-year-old Kuwaiti lady presented with complaints of fever, cough, and vomiting.
Screening for COVID-19 was positive. The treatment protocol with other medications
included a prophylactic dose of anticoagulant (subcutaneous LMWH 0.5 mg/kg body weight
per day). On the sixth day after admission, she complained of severe abdominal pain
with a sudden drop of serum hemoglobin level from 12 to 9 mg/dL.
A CECT revealed a large extraperitoneal abdominopelvic hematoma on the left side (
[Fig. 2]
). A diagnostic angiography revealed contrast extravasation from the left 3rd lumbar
artery. Superselective catheterization with embolization of the bleeding artery was
done with gel foam (
[Fig. 2]
). She had an uneventful recovery.
Fig. 2 A large abdominal wall hematoma on the left side. Contrast-enhanced computed tomography
(CECT) coronal image in the arterial phase (A) and 3 minutes delayed phase (B) showing the hematoma as a large hypodense lesion involving the abdominal wall muscles
with contrast extravasation (arrow in A) and pooling (arrow in B) (arrow). Angiogram of left 3rd lumbar artery (C) demonstrating active extravasation of contrast (arrow). Postembolization angiogram
(D) showing occlusion of the branch.
Case 3
A 63-year-old Kuwaiti gentleman presented with complaints of shortness of breath and
cough with stable vital parameters and arterial PO2 95% on room air. He was diagnosed
to have COVID-19.
LMWH 0.5 mg/kg body weight per day was administered subcutaneously. He complained
of severe abdominal pain on the third day of his admission. He had abdominal distention,
tachypnea with a drop in systolic blood pressure to 70 mmHg. The hemoglobin level
dropped from 15 to 8.9 g/dL.
CECT revealed thickened edematous left psoas muscle and adjoining large extraperitoneal
hematoma extending to the left anterolateral abdominal wall (
[Fig. 3]
). Contrast extravasation was seen from the left 4th lumbar artery, which was successfully
embolized with coils, ([Fig. 3]) similar to case 1. He gradually improved and was discharged from the hospital after
a week.
Fig. 3 A large left retroperitoneal hematoma. Contrast-enhanced computed tomography (CECT)
axial image in the arterial phase (A) showing a large hematoma in the left psoas, quadratus lumborum, and adjacent retroperitoneum
with contrast extravasation. Three minutes delayed phase CECT coronal image (B), showing further pooling of contrast (arrow). Angiogram of the left 4th lumbar artery
pre-embolization (C) showing contrast extravasation (arrow in C) and postembolization angiogram (D) showing the coils and successful occlusion of the artery.
Discussion
Spontaneous intramuscular bleeding in COVID-19 patients is likely to be multifactorial.
Such hematomas are a known complication of LMWH therapy.[2] Cough, a common symptom of COVID-19 pneumonia, may increase intra-abdominal pressure,
resulting in arterial rupture.[3] Invasive ventilation with continuous positive pressure ventilation (CPAP) is also
likely to increase intra-abdominal pressure.[4] Retroperitoneal hemorrhage has also been described as a rare and severe complication
in patients undergoing extracorporeal membrane oxygenation.[5] Early suspicion by clinical evaluation, confirmation by CECT scan, and endovascular
embolization may be life-saving in these scenarios.
Conclusion
Severe COVID-19 pneumonia patients are treated with prophylactic or higher doses of
LMWH. SEH may be suspected in patients with sudden localized pain and drop in hematocrit.
CECT is the imaging of choice to localize the site of bleeding and plan the endovascular
treatment. Embolization in such patients is safe and effective.
