Puerperal Vulvovaginal Hematoma Case File

Puerperal Vulvovaginal Hematoma Case File

Eugene C. Toy, MD, Edward Yeomans, MD, Linda Fonseca, MD, Joseph M. Ernest, MD

A 28-year-old G1P0 Caucasian female at 38 weeks’ gestation presented in active labor. She progressed to complete dilation and began to push; after 3½ hours of maternal efforts, she underwent an uncomplicated spontaneous vaginal delivery aided by a midline episiotomy. The placenta was delivered and was noted to be intact. Following uterine massage and intravenous oxytocin, the fundus was noted to be firm. The episiotomy was repaired without complication and the site was hemostatic. Blood loss was estimated to be 400 cc. Following delivery and repair of the episiotomy, her pulse was 70 bpm and blood pressure was 124/80 mm Hg.

Approximately 2 hours after delivery she began to complain of severe rectal pain and pressure on the right side. Her lochia remained moderate and her fundus is firm at the level of the umbilicus. Her pulse was 115 bpm and blood pressure 105/60 mm Hg. She had 200 cc of urine output in the first hour postpartum and 30 cc of urine output in the last hour.

➤ What is the most likely diagnosis?

➤ What is your next step?

➤ What are potential complications of the patient’s disorder?

ANSWERS TO CASE 9:

Puerperal Vulvovaginal Hematoma

Summary: This is a 28-year-old woman, G1P1, who had a spontaneous vaginal delivery over a midline episiotomy following a prolonged second stage of labor. In the early postpartum period she developed acute onset of pain out of proportion to her episiotomy repair. She also manifested clinical signs of hypovolemia, despite a firm fundus and absence of vaginal bleeding.

➤ Most likely diagnosis: Puerperal vulvovaginal hematoma.

➤ Next step: Thorough examination (including vaginal and rectal examination and possible evaluation of the uterine cavity) to evaluate for sources of blood loss and pain.

➤ Potential complications:

    ➤ Short-term: severe hemorrhage (including retroperitoneal hematoma), transfusion, coagulopathy.

    ➤ Long-term: infection, scarring/disfigurement, dyspareunia.

ANALYSIS

Objectives

1. Describe the potential clinical presentations of puerperal vulvovaginal hematomas.

2. Describe the evaluation and management of puerperal vulvovaginal hematomas.

3. Discuss risk factors for, and prevention of, puerperal vulvovaginal hematomas.

4. Summarize complications associated with puerperal vulvovaginal hematomas.

Considerations

In a postpartum patient experiencing perineal or rectal pain greater than that expected following a vaginal delivery, an immediate evaluation for vulvovaginal hematomas is necessary. The tachycardia and decreasing urine output also indicate developing hypovolemia. This patient has three risk factors for puerperal hematoma—primiparous status, prolonged second stage, and episiotomy.

APPROACH TO

Puerperal Vulvovaginal Hematomas

DEFINITIONS

HEMATOMA: A localized mass of extravasated, often clotted blood that is confined to a space or potential space. In the postpartum period, such a mass may be small or large and may vary in location as described in the Clinical Approach section.

JACKSON-PRATT DRAIN: A closed-system drain consisting of a flat white perforated ribbon to be placed in the bed of a hematoma cavity following evacuation of blood and clot. The ribbon connects to a short length of plastic tubing which can be exited through a separate stab wound in the perineum and connected to a “hand grenade” suction device. Such a drain is felt by some investigators to be an important adjunct in the management of moderateto- large vulvovaginal hematomas.

CLINICAL APPROACH

Incidence The incidence of puerperal hematomas varies from 1/1500 to 1/309 deliveries; “large” hematomas have been reported to occur in approximately 1/4000 vaginal deliveries.1-3 The reported incidence varies due to lack of reporting “small” hematomas, lack of agreement regarding the definition of what constitutes a hematoma, and the prevalence of risk factors in a particular population.

Classification Puerperal hematomas are often classified according to location:

1. Vulvar (anterior triangle or posterior triangle [ischiorectal area])
2. Vaginal
3. Vulvovaginal (involving both areas)
4. Subperitoneal

An alternate classification is based on location relative to the levator musculature. Infralevator hematomas are limited by the levator ani, and the perineal body typically prevents these hematomas from spreading across the midline. Additionally, fascial planes prevent involvement of the thigh. Infralevator hematomas are the most common types following vaginal delivery. Supralevator hematomas, by definition, are located above the levator plate, and due to the potential for considerable extension into the retroperitoneal space, may be associated with significant blood loss.

Risk Factors Episiotomy is the most common risk factor for puerperal hematomas; episiotomy was performed in 85% to 93% of the reported cases of puerperal hematomas.4 Both midline and mediolateral episiotomy have been associated with puerperal hematomas, with higher risk associated with the latter.5 Additionally, vaginal lacerations and instrumental vaginal delivery have also been associated with the development of hematomas.3,5 Other risk factors that have been associated with hematomas include primiparity, multiple gestations, preeclampsia, prolonged second stage, and coagulopathy.

Presentation The clinical presentation in patients with puerperal hematomas is primarily due to hemorrhage, most commonly involving the pudendal artery and its branches. Additionally, branches of the uterine artery may be responsible for vaginal hematomas. Subperitoneal hematomas may occur due to vascular injury to the uterine arteries or other vessels in the pelvis. Vascular injury may be immediate or delayed due to pressure necrosis and resultant vascular injury with subsequent hematoma formation.1 The majority of patients with puerperal hematomas will present within 24 hours of delivery.

A large amount of blood may accumulate in the paravaginal and ischiorectal spaces as the anatomy of these spaces involves predominantly soft tissue. As a result, blood loss is often underestimated. Most patients with vulvovaginal hematomas will present with an ischiorectal mass, bruising, and perineal or rectal pain. Other symptoms may include fever, ileus, and extremity pain, although these are much less common in patients presenting within the first 24 hours (see Figure 9–1).

An important characteristic regarding clinical presentation is that pain associated with an infralevator hematoma is typically more severe than that expected relative to vaginal delivery or repair of a laceration or episiotomy. Supralevator hematomas, however, may present with signs and symptoms secondary to significant hypovolemia resulting from retroperitoneal hemorrhage. Supralevator hematomas are uncommonly associated with vaginal delivery, but may occur secondary to uterine scar rupture in trials of labor following previous cesarean section.

Treatment

Initial Considerations The management approach for a woman with a puerperal hematoma is controversial, with opinions differing based on perceived size of the hematoma as well as in the use of drains. Observation only has been suggested in some reports, particularly for “small” vulvovaginal hematomas (described as < 3 cm in diameter).3,5 Observation has also been described for a hematoma in the retropubic space following spontaneous vaginal delivery which had not initially responded to drainage.6 Risks associated with a conservative approach in the setting of larger hematomas include infection, profuse hemorrhage, necrosis, and possibly mortality; therefore, operative intervention in this setting is often recommended. It is critical to remember

Figure 9–1. Left-sided vulvar hematoma in a patient who had a spontaneous

vaginal delivery and coagulopathy due to acute fatty liver of pregnancy.

(Reproduced, with permission, from Cunningham FG,Leveno KJ, Bloom SL, et al.Williams

Obstetrics. 23rd ed.New York,NY: McGraw-Hill; 2010.)

that blood loss is often significantly underestimated in these cases, and delay in diagnosis and treatment can have catastrophic results.

Operative Approach For vulvovaginal hematomas, an incision should be made of appropriate size (often 5-10 cm in length) to gain access to the hematoma. All clots should be removed and the area irrigated copiously. In most settings, a diffuse oozing tissue bed will be identified as opposed to discrete bleeding vessels which could be ligated or cauterized. A layered closure should then be performed to provide hemostasis and close dead space. A vaginal pack can be used if considered necessary; placement of the pack should be done with care to prevent disruption of the closure of the hematoma site and to avoid creation of additional bleeding sites as the vaginal mucosa is often friable and the patient may also be at risk for coagulopathy. Broad-spectrum antibiotics are indicated due to the risk of infection, and transfusion of blood products is often necessary.

The use of drains in the setting of a vulvovaginal hematoma is also not clearly established. The theoretical advantage of placement of drains include further elimination of dead space, reduction of pressure and possible resultant tissue necrosis, and removal of necrotic tissue and blood that may provide a source of infection.7,8 Varied approaches to drainage have been described, including placement of a Penrose drain brought out through the introitus and a closed system Jackson-Pratt drain exiting through a separate perineal site.7

Angiographic Embolization Angiographic embolization has been described for various obstetric and gynecologic conditions, including management of postpartum hemorrhage and leiomyomatous uteri. Embolization has also been described in the management of vulvovaginal hematomas, mainly in the setting of hematomas not responsive to initial therapy.9,10 Theoretically, embolization may also be an option for management of supralevator hematomas, since embolization has been used to successfully control severe retroperitoneal bleeding in other clinical scenarios.11,13

Summary

Puerperal hematomas can be associated with significant morbidity, and possible mortality. Although prevention is desirable, an index of suspicion is imperative, particularly if risk factors are present. Prompt recognition and intervention, including antibiotics and transfusion, if indicated, will often lead to satisfactory results.

Comprehension Questions

9.1 A 23-year-old woman, G2P1, underwent an uncomplicated vacuum delivery. During the repair of her second-degree laceration, an expanding 4.5-cm right vaginal sidewall hematoma is noted. Her vital signs are within normal limits. What is the best treatment option?

A. Immediate incision over the hematoma, layered closure, and

placement of drain

B. Packing the vagina

C. Observation for expansion

D. Vaginal ultrasound

E. Immediate blood transfusion

9.2 A 36-year-old woman, G1P0, underwent induction for severe preeclampsia. Her antepartum course was notable for obesity and gestational diabetes. She underwent a low forceps delivery for fetal distress of a 4000-g male infant. What are her risk factors for a puerperal hematoma?

A. Obesity

B. Large-for-gestational-age infant

C. Forceps delivery

D. Chronic hypertension

9.3 A 27-year-old woman, G3P2, is 4 hours postpartum from a spontaneous vaginal delivery complicated by an 8-cm vulvovaginal hematoma, which was incised, evacuated, and repaired; no expansion was noted. The vagina was packed overnight and she was given broadspectrum antibiotics. She is currently receiving 2 units of packed red blood cells due to hypovolemia associated with an estimated blood loss of 1200 cc. She developed a temperature to 100.8°F. Which of the following is the most likely cause of her fever?

A. Preeclampsia

B. Deep venous thrombosis

C. Infection of the hematoma bed

D. Transfusion reaction

E. Pneumonia

ANSWERS

9.1 A. The hematoma is greater than 3 cm and was discovered during episiotomy repair. Because the hematoma is expanding, the preferred approach would be to incise over the hematoma site, evacuate the clot, perform a layered closure, and place a Jackson-Pratt drain. A vaginal pack should then be placed to maintain pressure on the vaginal suture line. Transfusion should be based on the patient’s clinical status.

9.2 C. Risk factors for puerperal hematomas include episiotomy, operative delivery, vaginal lacerations, prolonged second stage, preeclampsia, multiple gestation, and clotting abnormalities. This patient was diagnosed with preeclampsia and underwent an operative vaginal delivery. A laceration was not described in this scenario; however, if one were to have occurred, that would also be a risk factor.

9.3 D. The patient is currently undergoing a transfusion and nonhemolytic febrile reactions are common. A fever in a patient undergoing blood transfusion must be promptly evaluated and monitored. Infection of the hematoma bed is a common complication of puerperal hematomas and broad-spectrum antibiotics are recommended. However, at only 4 hours postpartum, infection of the hematoma site would be unlikely.

Clinical Pearls

See US Preventive Services Task Force Study Quality levels of evidence in Case 1

➤ Observation should be reserved for nonexpanding hematomas less than 3 cm (Level III).

➤ Be prepared for volume replacement with crystalloids and blood products as hematomas can expand rapidly and blood loss is often underestimated (Level III-3).

➤ A generous incision to evacuate the hematoma and elimination of dead space through layered closure and possible drain placement are key components of operative intervention in the management of puerperal hematomas (Level II-2).

REFERENCES

1. Pieri RJ. Pelvic hematomas associated with pregnancy. Obstet Gynecol. 1958;12:249-258. 

2. Lyons AW. Postpartum hematoma. N Engl J Med. 1949;240:461-463. 

3. Sotto LS, Collins RJ. Perigenital hematomas; analysis of 47 consecutive cases. Obstet Gynecol. 1958;12:259-263. 

4. McElin TW, Bowers VM Jr, Paalman RJ. Puerperal hematomas; a report of 73 cases and review of the literature. Am J Obstet Gynecol. 1954;67:356-366. 

5. Sheikh GN. Perinatal genital hematomas. Obstet Gynecol. 1971;38:571-575. 

6. Fieni S, Berretta R, Merisio C, Melpignano M, Gramellini D. Retzius’ space haematoma after spontaneous delivery: a case report. Acta Biomed. 2005;76:175-177. 

7. Zahn CM, Hankins GDV, Yeomans ER. Vulvovaginal hematomas complicating delivery. Rationale for drainage of the hematoma cavity. J Reprod Med. 1996;41:569-574. 

8. You WB, Zahn CM. Postpartum hemorrhage: abnormally adherent placenta, uterine inversion, and puerperal hematomas. Clin Obstet Gynecol. 2006;49:184-197. 

9. Villella J, Garry D, Levine G, Glanz S, Figueroa R, Maulik D. Postpartum angiographic embolization for vulvovaginal hematoma. A report of two cases. J Reprod Med. 2001;46:65-67. 

10. Chin HG, Scott DR, Resnik R, Davis GB, Lurie AL. Angiographic embolization of intractable puerperal hematomas. Am J Obstet Gynecol. 1989;160:434-438. 

11. Akpinar E, Peynircioglu B, Turkbey B, Cil BE, Balkanci F. Endovascular management of life-threatening retroperitonal bleeding. ANZ J Surg. 2008;78:683-687. 

12. Tulsyan N, Kashyap VS, Greenberg RK, et al. The endovascular management of visceral aneurysms and pseudoaneurysms. J Vasc Surg. 2007;45:276-283. 

13. Velmahos GC, Toutouzas KG, Vassiliu P, et al. A prospective study on the safety and efficacy of angiographic embolization for pelvic and visceral injuries. J Trauma. 2002;53:303-308.

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