Low molecular weight heparin and fatal spontaneous extraperitoneal hematoma in the elderly

An 80-year-old woman suffering from severe pump failure and chronic atrial fibrillation (AF) presented to the emergency department (ED) with weakness and abdominal pain. She had been on oral anticoagulants due to prosthetic mechanical valves, and two weeks before presentation she begun therapy with nadroparin 100 U/kg twice a day for pacemaker-implantable cardioverter (PMK-ICD) replacement. Upon examination cutis was pale and her abdomen appeared tender over the right quadrants with a palpable mass in this area. Her blood pressure was 70/40 mmHg and laboratory examinations revealed hemoglobin (Hb) 9 g/dL and creatinine 5,4 mg/dL (clearance 10 mL/min). She had no history of renal failure. Fluids and red blood cells were immediately given and a computed tomography (CT) scan showed a 7 ¥ 10 cm rectus sheath hematoma (Fig. 1a). Angiographic selective embolization was performed, but the patient’s general condition progressively worsened. Although an aggressive therapy with fluids, red blood cells, inotropic drugs, high dose diuretics, bicarbonate and dialysis was administered, she died after a few days due to cardiogenic shock. A 79-year-old man suffering from chronic lung and renal failure, diabetes mellitus, hypertension and chronic AF was referred to the ED for three episodes of loss of consciousness in 24 h. Since about 1 month earlier he had been on therapy with nadroparin 100 U/Kg twice daily instead of oral anticoagulants because he was expecting to undergo a lung needle biopsy. On examination cutis was pale and dry, blood pressure was 130/80 mmHg, heart rate 140 bpm and irregular and there were no signs of neurological deficit. Laboratory data showed creatinine 1.4 mg/dL (clearance 42 mL/min) and Hb 7.7 g/dL, without signs of external bleeding. Red blood cells were administered, but, in the following hours, the patient became restless and complained of hip pain. His blood pressure dropped to 100/60 mmHg and Hb remained to 8 g/dL.