From the Guidelines
Management of a post-cesarean rectus sheath hematoma should prioritize a conservative approach for stable patients with small to moderate hematomas, while unstable patients or those with large, expanding hematomas require prompt surgical intervention. The goal of management is to minimize morbidity, mortality, and improve quality of life. For stable patients, conservative management includes bed rest, analgesics such as acetaminophen 650 mg every 6 hours or ibuprofen 600 mg every 6 hours 1, close vital sign monitoring, and serial hemoglobin checks every 6-12 hours. Applying ice packs to the affected area for 20 minutes every 2-3 hours during the first 48 hours can help reduce swelling and pain. Ensuring adequate intravenous hydration and considering iron supplementation (ferrous sulfate 325 mg daily) for patients with significant blood loss are also crucial 2.
Some key considerations in the management of post-cesarean rectus sheath hematoma include:
- Early mobilization after cesarean delivery is recommended, as it can help prevent complications such as venous thromboembolism 2
- Tight control of capillary blood glucose is recommended to prevent hyperglycemia-related complications 2
- Multimodal analgesia, including regular nonsteroidal anti-inflammatory drugs and paracetamol, is recommended for enhanced recovery after cesarean delivery 1
- A regular diet within 2 hours after cesarean delivery is recommended to promote recovery and prevent malnutrition 1
For unstable patients or those with large, expanding hematomas (>5 cm), surgical intervention is necessary, involving evacuation of the hematoma, ligation of bleeding vessels, and possible drain placement. Patients may require blood transfusion if hemodynamically unstable or if hemoglobin drops below 7 g/dL. Abdominal binders can provide support and comfort during recovery. Ultrasound monitoring helps track hematoma resolution, with follow-up scans recommended at 1 week and 4 weeks post-diagnosis. This approach balances the risks of surgical intervention against the body's natural ability to reabsorb smaller hematomas, while ensuring patient safety through appropriate monitoring and timely intervention when necessary.
From the Research
Management of Post Cesarean Rectus Sheath Hematoma
- The management of post cesarean rectus sheath hematoma typically involves conservative treatment, with the goal of preventing complications such as hemodynamic instability, abdominal compartment syndrome, or multiorgan dysfunction 3, 4.
- Expectant management is often the recommended first line of treatment, however, this may not be sufficient for pregnant and post-partum patients, and may require closer monitoring and earlier intervention 5.
- In cases where anticoagulant therapy is the cause of the rectus sheath hematoma, temporary suspension of anticoagulant administration may be necessary to prevent further expansion of the hematoma 6.
- Surgical intervention should be reserved for cases with hemodynamic instability, and may involve procedures such as embolization of the inferior epigastric artery or ligation of the bleeding vessel 4, 5.
- The use of hemostatic agents, such as carbazochrome and tranexamic acid, may also be effective in controlling the expansion of bleeding and promoting resolution of the hematoma 7.
Diagnostic Considerations
- Computed tomography (CT) scan is the gold standard for diagnosis of rectus sheath hematoma, and can help to confirm the diagnosis and assess the size and location of the hematoma 3, 4, 5, 7, 6.
- Ultrasonography can be used in follow-up to monitor the size and resolution of the hematoma 4.
Special Considerations for Post-Partum Patients
- Post-partum patients with rectus sheath hematoma may be at higher risk for complications, and may require closer monitoring and earlier intervention 5, 6.
- The role of infection in post-partum rectus sheath hematoma is not well understood, and may require further study to determine the best course of treatment 5.