title: Fatal intrahepatic hemorrhage after nadroparin use for total hip arthroplasty.
abstract: Low-molecular-weight heparins have become the predominant choice for deep venous thrombosis prophylaxis and treatment. However, their use may cause bleeding complications. Intrahepatic bleeding is exceptional and only very few cases have been described. The authors present a unique case of fatal intrahepatic hematoma complicating nadroparin use in a 65-year-old woman with a hepatic cyst who was admitted to hospital for unilateral total hip arthroplasty. At autopsy, hemoperitoneum (2,000 ml of blood and clots) was evident. A ruptured sub-capsular hematoma involving the right lobe of the liver was observed. The hemorrhage within the cyst induced by the nadroparin use was likely responsible for the subsequent hepatic hematoma, liver rupture, and death. This case highlights the need for pathologists and surgeons to be aware of the possibility of intrahepatic hematoma in patients who have received low-molecular-weight heparins, undergone major surgery and present postoperative hemodynamic instability, especially in those with preoperative diagnosis of hepatic cyst.
authors.affiliation: Department of Legal Medicine, University of Genova, Genova, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Ventura
authors.forename: Alessandro
authors.initials: A
authors.lastname: Bonsignore
authors.forename: Francesco
authors.initials: F
authors.lastname: De Stefano
authors.forename: Enrico
authors.initials: E
authors.lastname: Pizzorno
authors.forename: Cristian
authors.initials: C
authors.lastname: Palmiere
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000009:adverse effects*; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects*; D001344:Autopsy; D002423:Cause of Death; D056486:Chemical and Drug Induced Liver Injury / Q000209:etiology* / Q000473:pathology; D003560:Cysts / Q000150:complications; D017809:Fatal Outcome; D005260:Female; D006406:Hematoma / Q000139:chemically induced; D006470:Hemorrhage / Q000139:chemically induced* / Q000473:pathology; D006801:Humans; D017762:Nadroparin / Q000009:adverse effects*; D012307:Risk Factors; D016896:Treatment Outcome; D020246:Venous Thrombosis / Q000209:etiology / Q000517:prevention & control*
chemical_list: D000925:Anticoagulants; D017762:Nadroparin
references.citation: Clin Res Hepatol Gastroenterol. 2014 Apr;38(2):190-4
references.pmid: 24210773
references.citation: Int J Surg Case Rep. 2013;4(10):803-4
references.pmid: 23948260
references.citation: Curr Ther Res Clin Exp. 2013 Jun;74:49-53
references.pmid: 24384784
references.citation: Chest. 2008 Jun;133(6 Suppl):257S-298S
references.pmid: 18574268
references.citation: World J Hepatol. 2013 Sep 27;5(9):462-9
references.pmid: 24073297
references.citation: Chest. 2001 Jan;119(1 Suppl):108S-121S
references.pmid: 11157645
references.citation: Acta Cardiol. 2013 Aug;68(4):421-4
references.pmid: 24187770
references.citation: J Emerg Med. 2012 Aug;43(2):e157-61
references.pmid: 21911282
references.citation: Tex Heart Inst J. 2006;33(4):523-5
references.pmid: 17215987
references.citation: J Forensic Sci. 2013 Jul;58(4):904-9
references.pmid: 23692387
references.citation: Arch Intern Med. 1998 Jul 27;158(14):1525-31
references.pmid: 9679793
references.citation: Am J Health Syst Pharm. 2010 May 15;67(10):806-9
references.pmid: 20479102
references.citation: Arch Surg. 1975 Sep;110(9):1152
references.pmid: 808198
references.citation: Arch Surg. 1979 Jun;114(6):734-5
references.pmid: 454157
references.citation: Am Surg. 2005 May;71(5):430-3
references.pmid: 15986976
references.citation: J Arthroplasty. 1999 Apr;14(3):372-4
references.pmid: 10220193
references.citation: Conn Med. 1983 Jun;47(6):323-5
references.pmid: 6884014
references.citation: Intensive Care Med. 2001 Dec;27(12):1954-7
references.pmid: 11797033
references.citation: J Emerg Med. 2001 May;20(4):349-52
references.pmid: 11348813
references.citation: Thromb Res. 2003 Apr 15;110(1):69-71
references.pmid: 12877912
references.citation: Yonsei Med J. 2011 Mar;52(2):358-61
references.pmid: 21319359
references.citation: Int J Surg Case Rep. 2013;4(12):1080-3
references.pmid: 24240072
references.citation: South Med J. 2003 Jan;96(1):58-60
references.pmid: 12602717