Postpartum-acquired hemophilia A presenting as a recurrent rectus sheath hematoma following cesarean section: a case report.
Mohamed Rishard, K S C Gunasinghe, K Jeykrishna et al.
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Case in brief
A 30-year-old woman presented 17 days after an uncomplicated second cesarean section with severe abdominal pain and a rectus sheath hematoma. After two evacuations for recurrent hematomas without an identifiable bleeding source, she developed hematuria and wound oozing. Testing showed an isolated prolonged APTT and a time-dependent inhibitor consistent with a factor VIII inhibitor, supporting postpartum-acquired hemophilia A. Treatment included recombinant activated factor VII, tranexamic acid, blood products, and prednisone; despite a polymicrobial wound infection, she improved markedly within 48 hours of immunosuppression and was discharged on day 11.
What made this case unusual
The initial isolated rectus sheath hematoma resembled a cesarean surgical complication; recurrent bleeding without a discrete source and subsequent bleeding at other sites revealed the acquired coagulation inhibitor.
Diagnostic / clinical pearl
In postpartum bleeding with an isolated prolonged APTT, especially when exploration finds no focal source, consider acquired hemophilia A and pursue inhibitor screening.