Spontaneous retroperitoneal hematoma in COVID-19 patients


  • Teodor D. Atanasov Department of Surgery, Sofiamed Hospital, Sofia, Bulgaria
  • Katya T. Todorova Department of Surgery, Sofiamed Hospital, Sofia, Bulgaria
  • Alexandar I. Tsvetanov Department of Surgery, Sofiamed Hospital, Sofia, Bulgaria




Retroperitoneal hematoma, Low molecular weight heparin, COVID-19, Non-operative treatment


Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus that has led to a global pandemic and unfortunately has caused a health crisis. Severe coronavirus disease 2019 (COVID-19) can manifest with bilateral pneumonia and hypoxemic respiratory failure but also can affect different organ systems. Spontaneous rectus sheath haematomas and retroperitoneal haematomas are recognized, rare, complications of anti-coagulation therapy, including LMWH. A prompt diagnosis is important to antagonize anticoagulation and prevent further bleeding. Massive bleeding into the retroperitoneum represents a problem not only because of the loss of intravascular volume, but also because the increase in abdominal pressure may compromise perfusion to different organs, such as the liver, gut, and kidneys. We present 3 cases of severe spontaneous soft tissue hematomas (SSTH) in patient with SARS-CoV-2 infection, who were taking low molecular weight heparin for prophylaxis of DIC and venous thromboembolism. First one is 56-yeard-old female patient with retroperitoneal and extraperitoneal haematoma presenting with dysuria and haematuria, the second one is 67-year-old male patient with iliopsoas haematoma and the third one is 51-year-old female patient with rectus sheath haematoma. All patients were treated conservatively. Clinicians should be attentive about bleeding complications as retroperitoneal haematomas in COVID-19 patients on anticoagulant therapy. There is no consensus on management of retroperitoneal haematomas. Each decision as conservative treatment, embolization or surgery should be made according to the clinical stability of the patient and by risk and benefit assessment.


Erdinc B, Raina JS. Spontaneous Retroperitoneal Bleed Coincided with Massive Acute Deep Vein Thrombosis as Initial Presentation of COVID-19. Cureus. 2020;12(8):e9772.

Cattaneo M, Bertinato EM, Birocchi S, Brizio C, Malavolta D, Manzoni M, et al. Pulmonary embolism or pulmonary thrombosis in COVID-19? Is the recommendation to use high-dose heparin for thromboprophylaxis justified? Thromb Haemost. 2020.

Patel I, Akoluk A, Douedi S, Upadhyaya V, Mazahir U, Costanzo E, et al. Life-Threatening Psoas Hematoma due to Retroperitoneal Hemorrhage in a COVID-19 Patient on Enoxaparin Treated with Arterial Embolization: A Case Report. J Clin Med Res. 2020;12(7):458-61.

Mahboubi-Fooladi Z, Arabi PK, Khazaei M, Nekooghadam S, Shadbakht B, Moharamzad Y, et al. Parenteral Anticoagulation and Retroperitoneal Hemorrhage in COVID-19: Case Report of Five Patients. SN Compr Clin Med. 2021:1-6.

Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1054-62.

Ranucci M, Ballotta A, Di Dedda U, Bayshnikova E, Dei Poli M, Resta M, et al. The procoagulant pattern of patients with COVID-19 acute respiratory distress syndrome. J Thromb Haemost. 2020;18(7):1747-51.

Li Y, Xu Y, Shi P. Antiplatelet/anticoagulant agents for preventing thrombosis events in patients with severe COVID-19: a protocol for systematic review and meta-analysis. Medicine. 2020;99(32):e21380.

Moores LK, Tritschler T, Brosnahan S. Prevention, diagnosis, and treatment of VTE in patients with coronavirus disease: CHEST Guideline and Expert Panel Report. Chest. 2019;158(3):1143-63.

Antithrombotic Therapy in Patients with COVID-19. Available at: https://www.covid19treatmentguidelines.nih.gov/therapies/antithrombotic-therapy. Accessed on 11 February 2021.

Tang N, Bai H, Chen X, Gong J, Li D, Sun Z. Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy. J Thromb Haemost. 2020;18(5):1094-9.

Talasaz AH, Sadeghipour P, Kakavand H, Aghakouchakzadeh M, Tassell B, Kordzadeh-Kermani E, et al. Antithrombotic therapy in COVID-19: systematic summary of ongoing or completed randomized trials, 2021.

Jimenez D, Garcıa-Sanchez A, Rali P, Muriel A, Bikdeli B, Ruiz-Artacho P, et al. Incidence of VTE and bleeding among hospitalized patients with coronavirus disease 2019: a systematic review and meta-analysis. Chest. 2020;159(3):1182-96.

González C, Penado S, Llata L, Valero C, Riancho JA. The clinical spectrum of retroperitoneal hematoma in anticoagulated patients. Medicine (Baltimore). 2003;82(4):257-62.

Balkan C, Kavakli K, Karapinar D. Iliopsoas haemorrhage in patients with haemophilia: results from one centre. Haemophilia. 2005;11(5):463-7.

Llitjos JF, Daviaud F, Grimaldi D. Ilio-psoas hematoma in the intensive care unit: a multicentric study. Ann Intensive Care. 2016;6:8.

Cattaneo M, Bertinato EM, Birocchi S, Brizio C, Malavolta D, Manzoni M, et al. Pulmonary Embolism or Pulmonary Thrombosis in COVID-19? Is the Recommendation to Use High-Dose Heparin for Thromboprophylaxis Justified? Thromb Haemost. 2020;120(8):1230-2.

Nannoni S, de Groot R, Bell S, Markus HS. Stroke in COVID-19: A systematic review and meta-analysis. Int J Stroke. 2021;16(2):137-49.






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