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Rectus sheath and retroperitoneal haematomas in patients with Coronavirus 2019 infection

High rates of venous thromboembolism (VTE) have been observed in Coronavirus 2019 disease (COVID-19). Regulatory bodies in the UK advise pharmacological VTE prophylaxis with standard prophylactic low-molecular-weight heparin (LMWH) dosing, escalating to a therapeutic dose if there is a high clinical suspicion of VTE. Furthermore, in December 2020, an interim analysis of pooled data from the ACTIV-4a, REMAPCAP and ATTACC randomised clinical trials suggested that LMWH was beneficial for patients not requiring intensive care support. However, there is growing awareness of the bleeding risk associated with COVID-19. The interim analysis of the afore-mentioned clinical trials paused enrolment of critically ill patients due to futility and a potential for harm due to higher rates of bleeding in these patients. Additionally, a systematic review of incidence of VTE and bleeding amongst hospitalised patients with COVID-19 found that pooled incidence was 17% for VTE, 7 1% for pulmonary embolism (PE), 7 8% for bleeding and 3 9% for major bleeding. The highest pooled incidence estimate of bleeding was reported for patients receiving intermediate or therapeutic dose anticoagulation (21 4%). Cases of spontaneous rectus sheath (RSH), and retroperitoneal haematomas (RPH) have also been described, both of which were rare pre-COVID-19. Spontaneous RSH typically occurs in elderly patients and approximately two thirds of these bleeds are associated with therapeutic anticoagulation, whereas RPH characteristically occurs following trauma. Recognised risk factors for RSH/ RPH include therapeutic anticoagulation, underlying coagulopathy, hypertension, abdominal wall injections, steroid therapy, cough and old age. As patients admitted with COVID-19 are typically prescribed steroid therapy and exhibit symptoms of severe cough, it is plausible that this could in part explain a higher risk of RPH/RSH in this population. Here, we describe 12 patients exhibiting RPH/RSH complications whilst admitted for management of COVID-19 infection and evaluate the importance of this specific bleeding complication and the implications for management. This was a retrospective study of data from electronic radiology reports and patient records, using code search terms for ‘retroperitoneal haematoma’ and ‘rectus sheath haematoma’, for patients admitted to two hospitals in Liverpool, from 1 March 2020 to 20 January2021. Cases were included if they had: (i) either positive SARS-CoV-2 nucleic acid amplification test or probable diagnosis of COVID-19 disease based on WHO Case Definition Criteria; and (ii) RSH/RPH diagnosed with computed tomography (CT) scan during their inpatient stay. Data collection was approved as a service evaluation project by the Trust Audit Department. A total of 1 389 patients were admitted with COVID-19 infection and had a length of stay >24 h. Of these, six cases of RPH and six cases of RSH were identified, all with a confirmed diagnosis of COVID-19. None of the patients had chronic liver disease or a history of major bleeding. Tables I and II describe demographic data, clinical information, management and outcomes in patients with RSH and RPH, respectively. Six patients with RSH were identified, all of whom survived to discharge. Four patients were managed conservatively and two patients required intervention because of haemodynamic instability which did not respond to resuscitation. Both patients showed immediate post-procedure haemodynamic stabilisation, however, one developed a myocardial infarction secondary to hypoperfusion during the bleed and the other developed urinary tract obstruction due to the size of the haematoma. Four of six patients in the RPH group died. One patient was treated conservatively successfully, but died after six days from COVID-19 pneumonia. Three patients with active extravasation on CT and haemodynamic instability underwent intervention, all of whom died. The first patient had consecutive sessions of coil embolisation, separated by 24 h, due to persistent bleeding. This patient died 24 h after the second embolisation. The second patient had coil and glue embolisation of a bleeding lumbar artery but died one day later. The third patient underwent angiography but no embolisation was performed as no bleeding point was identified. This patient died the same day after a second episode of rapid haemodynamic instability. Five of the RSH cases presented with abdominal pain, whereas four patients with RPH presented with hypotension. All patients in this cohort demonstrated a fall in haemoglobin (between 14 and 90 g/l) which was gradual over 3– 25 days, but this was not usually investigated until other symptoms of the bleed had manifested. Eleven patients were on therapeutic-dose LMWH, of whom six had been admitted on oral anticoagulation for pre-existing conditions and converted to LMWH on admission as per local policy; five were prescribed LMWH whilst awaiting a CT pulmonary angiogram (CTPA) for suspected PE. However, only two out of five of these patients Correspondence