Pelvic hematomas can have several anatomical manifestations following childbirth. One classification is anatomical and describes vulvar, vulvovaginal, paravaginal, and retroperitoneal hematomas. Vulvar hematomas may involve the vestibular bulb or branches of the pudendal artery, which are the inferior rectal, perineal, and clitoral arteries (Fig.
Paravaginal hematomas may involve the descending branch of the uterine artery. In some cases, a torn vessel lies above the pelvic fascia, and a supralevator hematoma develops. These can extend into the upper portion of the vaginal canal and may almost occlude its lumen. Continued bleeding may dissect retroperitoneally to form a mass palpable above the inguinal ligament. In some cases, it may even dissect up behind the ascending colon to the hepatic flexure (Rai, 2010).
Risks for puerperal hematomas include vaginal or perineal laceration, episiotomy, or an operative delivery (Iskender, 2016). Any hematoma can also develop following stretch and rupture of a blood vessel without an associated laceration (Nelson, 2012). This may be especially true with forceps delivery. Occasionally, they are associated with an underlying coagulopathy (p. 782).
Perineal, vulvar, and paravaginal hematomas can develop rapidly and frequently cause excruciating pain (Fig. 41-12). A tense, tender swelling of varying size rapidly develops, encroaches on the vaginal lumen, and causes overlying skin or epithelium to become ecchymotic. A paravaginal hematoma may escape detection initially. However, symptoms of pelvic pressure, pain, or inability to void should prompt evaluation. Others may go undetected until other measures of hypovolemia become evident. When there is a supralevator extension, the hematoma extends upward in the paravaginal space and between the leaves of the broad ligament. The hematoma may escape detection until it can be felt on abdominal palpation or until hypovolemia develops. Imaging with sonography or computed tomographic scanning may be useful (Cichowski, 2017; Kawamura, 2014; Takeda, 2014).
Small hematomas often remained contained and show minimal expansion. In others, the tissues overlying an expanding hematoma may rupture from pressure necrosis. In some, profuse hemorrhage may follow, but in other cases, the hematoma drains in the form of large clots and old blood. In those that involve the paravaginal space and extend above the levator sling, retroperitoneal bleeding may be massive and occasionally fatal. Finally, we have encountered a few that rebled up to 2 weeks postpartum (Cunningham, 2017 a).
Vulvovaginal hematomas are managed according to their size, location, duration since delivery, and expansion. If bleeding ceases, then small-to moderate-sized hematomas may be treated expectantly until absorbed. But, if pain is severe or if the hematoma continues to enlarge, sutgical exploration is preferable. Blood loss with arge puerperal hematomas is neary always consideraby more than the clinical estimate. Hypovolemia is common, and transfusions are frequently required when surgical repair is necessary.
For repair, an incision is made at the point of maximal distention, blood and clots are evacuated, and bleeding points ligated. The cavity may then be obliterated with absorbable sutures. Often, no sites of bleeding are identified. Nonetheless, the evacuated hematoma cavity is surgically closed, and the vagina is packed for 12 to 24 hours. Supralevator hematomas are more diicult to treat. Although some can be evacuated by vulvar or vaginal incisions, laparotomy or interventional embolization, described next, is a consideration if bleeding continues.
Angiographic embolization has become popular for management of some puerperal hematomas. This is especially true