Spontaneous Rectus Sheath Hematoma in Pregnancy: A rare case report
Dr. Vaidehi Nene, Mr. James Thomas, Mr. Tennyson Idama 
Whiston Hospital, Mersey and West Lancashire Teaching Hospital

CASE REPORT

A 40-year-old woman, gravida 3 para 2, at 37+3 weeks of gestation with a BMI of 37.6 and prior twin cesarean delivery, presented with sudden left upper quadrant pain after a coughing episode. Her medical history included hypothyroidism, bipolar disorder, anxiety, and insulin-managed gestational diabetes.

She also reported reduced fetal movements and generalized edema. Urinalysis revealed proteinuria with a raised protein-creatinine ratio (PCR 158), though her blood pressures remained below the hypertensive threshold.

Initial ultrasound detected a mixed echogenic area in the upper abdomen measuring 8.7 x 2.8 x 6.6 cm, prompting further evaluation. 

MRI confirmed a left-sided rectus sheath hematoma measuring 14 x 13 x 3 cm, located between the rectus abdominis and its posterior sheath (see images). Surgical review recommended conservative management given stable maternal and fetal status.

Despite clinical improvement, she returned at 38+2 weeks with persistent RFM and non-reassuring cardiotocography. A Category 2 caesarean section was performed, during which a large organized hematoma and significant adhesions were encountered above the rectus sheath. A bilateral salpingectomy was carried out for sterilisation at the patient’s request. Postoperative recovery was uncomplicated.