Figure 41-9. With agents given for tocolysis, a combined efort is made to reposition the uterus by simultaneously pushing upward from below and pulling upward from above. Application of atraumatic clamps to each round ligament and upward traction may be helpul-the Huntinton procedure. In some cases, placing a deep traction suture in the inverted fundus or grasping it with tissue forceps may be of aid. Either or both of these may be technically diicult. If a constriction ring still prohibits repositioning, a sagittal surgical cut-Haultain incisionis made posteriorly through the muscular ring to release it. he exposed fundus can then be reinverted (Sangwan, 2009). After uterine replacement, tocolytics are stopped, oxytocin and other utero to nics are given, and the uterine incision is repaired. Risks of separation of this posterior hysterotomy incision during subsequent pregnancy, labor, and delivery are unknown. Further illustration and discussion is found in Cunningham and
Gilstrapis Operative Obstetrics, 3rd edition (Zahn, 2017).
Clitoral crus Batholin gland , Bulbospongiosus m. A Colles fascia Ischioanal fossa hematoma c B Pudendal artery Vulvar hematoma branches Colles fascia cut edge Ischiocavenosus m. Dorsal atery of the clitoris Bulbospongiosus m. Perineal a. Superficial transvese perineal n. External anal sphinter n. Inferior rectal a. Levator ani m. --Gluteus maxinus m.
FIGURE 41-11 Schematic drawing showing types of puerperal hematomas. A. Coronal view showing a supralevator hematoma. B. Coronal view showing an anterior perineal triangle hematoma. C. Perineal view showing posterior perineal triangle anatomy and an ischioanal fossa hematoma. (Reproduced with permission from Cunningham FG: Genital tract lacerations and hematomas. In Yeomans ER, Hofman BL, Gilstrap LC III, et al (eds): Cunningham and Gilstrap's Operative Obstetrics, 3rd edition. New York, McGraw-Hili Education, 201o7a.)
FIGURE 41-12 Let-sided anterior perineal triangle hematoma associated with a vaginal laceration following spontaneous delivery in a woman with consumptive coagulopathy from acute fatty liver of pregnancy.
for supralevator or retroperitoneal hematomas. Embolization can be used primarily, or more likely secondarily, if surgical attempts at hemostasis have failed or if the hematoma is difficult to access surgically (Distefano, 2013; Lee, 2012; Poujade, 2012). he use of a Bakri balloon for a paracervical hematoma has also been described (Gizzo, 2013; Gronvall, 2013). Finally, ultrasound-guided drainage of a recurrent supralevator hematoma has been reported (Mukhopadhyay, 2015) .
Uterine rupture frequently is catastrophic. It may be primay, deined as occurring in a previously intact or unscarred uterus, or may be seconday and associated with a preexisting incision, injury, or anomaly of the myometrium. Some of the etiologies associated with uterine rupture are presented in Table 41-3. Importantly, the contribution of each of these underlying causes has changed remarkably during the past 50 years. Speciically, before 1960, when the cesarean delivery rate was much
TABLE 41 -3. Some Causes of Uterine Rupture
Surgery involving the myometrium:
Myomectomy incision through or to the endometrium Deep cornual resection of interstitial fallopian tube Metroplasty
Coincidental uterine trauma:
Abortion with instrumentation-sharp or suction curette, sounds