Rectus Sheath Hematoma Following Cesarean Section: A Concealed Extrauterine Cause of Postpartum Hemorrhage

Rectus sheath hematoma (RSH) is a rare but potentially life-threatening extrauterine cause of postpartum hemorrhage, particularly following cesarean delivery in high-risk patients, like those with severe preeclampsia. It usually results from injury to the epigastric vessels or rectus muscle and may be aggravated by preeclampsia-related endothelial dysfunction. Because its presentation can mimic common postoperative or postpartum complications, diagnosis is often delayed. Severe cases that go unnoticed or are missed result in concealed bleeding, shock, organ failure, or death. A 30-year-old primigravida underwent an emergency cesarean delivery at term for severe preeclampsia and subsequently developed abdominal distension, acute anemia with hypovolemic shock, and acute kidney injury in the immediate postoperative period. Initial ultrasonography was non-diagnostic; however, repeat imaging identified a significant collection beneath the rectus sheath, which was confirmed intraoperatively as an RSH. The patient was managed with aggressive volume resuscitation, surgical evacuation of the hematoma, and hemodialysis support, following which she recovered clinically. This case emphasizes the need to consider RSH in post-cesarean patients with unexplained postpartum hemorrhage, abdominal pain or distension, hemodynamic instability, and falling hemoglobin levels in the absence of an identifiable uterine or genital source of bleeding. The report also acknowledges the benefits and limitations of ultrasonography and emphasizes the importance of early recognition, prompt imaging evaluation, and multidisciplinary management in optimizing maternal outcomes.