What is the next step in management for a 43‑year‑old woman nine days after vaginal hysterectomy who presents with acute right abdominal pain and a CT‑confirmed right rectus sheath hematoma with active arterial extravasation?

Management of Rectus Sheath Hematoma with Active Arterial Extravasation Post-Hysterectomy

This patient requires immediate interventional radiology consultation for angiographic embolization of the bleeding vessel, as this represents the definitive treatment for hemodynamically stable patients with active arterial extravasation on CT. 1, 2, 3

Immediate Stabilization and Reversal

• Assess hemodynamic stability first: Check blood pressure, heart rate, and signs of ongoing hemorrhage (lightheadedness, tachycardia, hypotension). 2, 3

• Obtain immediate laboratory studies: Complete blood count with hemoglobin/hematocrit, coagulation panel (PT/INR, aPTT), type and crossmatch for packed red blood cells. 2, 3

• Reverse any anticoagulation immediately: If the patient is on anticoagulants (common risk factor in 69% of RSH cases), reverse with appropriate agents—protamine for heparin, PCC/FFP for warfarin, or specific reversal agents for DOACs. Use TEG-guided reversal if available. 2, 3

• Establish large-bore IV access and initiate crystalloid resuscitation if hypotensive. 2

• Transfuse packed red blood cells if hemoglobin drops significantly or patient shows signs of hemorrhagic shock. In the largest series of 126 patients, 86% required blood transfusion as part of conservative management. 3

Definitive Management: Interventional Radiology

For active arterial extravasation on CT, angiographic embolization is the treatment of choice and should be performed urgently. 1, 2, 3

• Interventional radiology embolization has a success rate exceeding 90% for controlling hemorrhage from rectus sheath hematomas with active bleeding. 1, 2

• The bleeding vessel is most commonly the inferior epigastric artery (given the location below the arcuate line where hematomas spread more easily due to absence of posterior rectus sheath). 2

• Embolization should be performed after coagulopathy correction to optimize success and minimize rebleeding risk. 2

Surgical Intervention: Reserved for Specific Scenarios

Surgery is indicated only if: 4, 2, 3

• Hemodynamic instability persists despite resuscitation and embolization is not immediately available
• Abdominal compartment syndrome develops (bladder pressure >20-25 mmHg with organ dysfunction)—requires emergent laparotomy for decompression and packing 2
• Embolization fails to control bleeding or is technically not feasible 2, 3

In the largest retrospective series of 126 RSH patients, only 7.9% required surgery or endovascular intervention, with 86% successfully managed conservatively. 3 However, your patient has documented active arterial extravasation, which shifts management toward intervention rather than observation alone. 2

Conservative Management Components

While arranging embolization, initiate: 4, 3

• Strict bed rest to prevent hematoma expansion
• Serial hemoglobin monitoring every 4-6 hours initially
• Serial abdominal examinations to assess for expansion or development of compartment syndrome
• Bladder pressure monitoring if hematoma is large (>10 cm) or patient develops abdominal distension, oliguria, or respiratory compromise 2

Critical Pitfalls to Avoid

• Do not delay embolization in favor of prolonged observation when active extravasation is documented on CT—this is not a "wait and see" scenario. 2, 3

• Do not perform unnecessary laparotomy without first attempting embolization in hemodynamically stable patients, as surgery increases morbidity. 4, 3

• Do not miss abdominal compartment syndrome development—monitor bladder pressures if the patient develops worsening abdominal distension, difficulty breathing, or oliguria. 2

• Do not restart anticoagulation immediately after treatment—assess DVT risk versus rebleeding risk. Consider inferior vena cava filter if DVT develops and rebleeding risk remains high. 5

Post-Intervention Monitoring

• Monitor for deep venous thrombosis in the postoperative period, as RSH patients have heightened DVT risk despite mechanical prophylaxis. 5

• Serial imaging is not routinely needed unless clinical deterioration occurs. 4, 3

• Mortality from RSH is rare (1.6%) but occurs when diagnosis is delayed or bleeding is not controlled. 3