The Obstetrician & Gynaecologist 2007;9:3:195-200
doi: 10.1576/toag.9.3.195.27341
Copyright © 2007 by the Royal College of Obstetricians and Gynaecologists.
Puerperal genital haematoma: a commonly missed diagnosis
Sandra Mawhinney, MRCGP MRCOG, Specialist Registrar in Obstetrics and Gynaecology1 and
Ruth Holman, MRCOG, Consultant in Sexual and Reproductive Health2
1. Craigavon Area Hospital Craigavon BT63 5QQ, Northern Ireland Email: sandramawhinney{at}dsl.pipex.com (corresponding author)
2. Ayrshire Central Hospital Ayrshire KA12 8SS, UK
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Abstract
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Key content:- Although uncommon, puerperal genital haematomas can be associated with serious maternal morbidity.
- An abnormally high level of perineal pain following childbirth is a hallmark symptom.
- The primary aims of treatment are to prevent further blood loss and correct hypovolaemia.
- There is debate regarding the optimal management of genital haematoma.
Learning objectives:
- To understand the aetiology of puerperal genital haematoma.
- To recognise the signs and symptoms and know how they are classified according to their location.
- To learn about the most appropriate methods of treatment.
Ethical issues:
- How should we choose the most appropriate treatment when research on the condition is scarce?
- Should resources be used to ensure interventional radiology services are available to all maternity units?
Please cite this article as: Mawhinney S, Holman R. Puerperal genital haematoma: a commonly missed diagnosis. The Obstetrician & Gynaecologist 2007;9:195–200.
Keywords blood loss / episiotomy / pelvic artery embolisation / perineal pain / puerperal genital haematoma
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Introduction
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Puerperal genital haematomas are relatively uncommon but can be a cause of serious morbidity and even maternal death.1 They can be difficult to diagnose, as symptoms can be non-specific and bleeding is often concealed.
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Incidence and risk factors
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Case series estimate incidences of 1 in 500 to 1 in 12 500 deliveries, with surgical intervention required in approximately 1 in 1 000 deliveries.2,3 Risk factors include: nulliparity, prolonged second stage of labour, instrumental delivery, a baby > 4 kg, genital tract varicosities and maternal age > 29 years.4 There is no published information on the risk of recurrence in subsequent deliveries.
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Types of haematoma
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Anatomically, puerperal haematomas can be vulval, vulvovaginal, paravaginal or subperitoneal (affecting the broad ligament). See Figures 1–45,19
Vulval and vulvovaginal
In vulval haematomas bleeding is limited to the vulval tissues superficial to the anterior urogenital diaphragm. The haematoma will be evident on the vulva. Vulvovaginal haematomas are also evident on the vulva but they extend into the paravaginal tissues. Both types arise from injury to the branches of the pudendal artery (the posterior rectal, transverse perineal and posterior labial arteries).
Vaginal
Paravaginal haematomas arise from damage to the descending branch of the uterine artery. The haematoma is confined to the paravaginal tissues in the space bounded inferiorly by the pelvic diaphragm and superiorly by the cardinal ligament. Hence, a paravaginal haematoma will not be obvious externally but can be diagnosed by vaginal examination.6 The mass often occludes the vaginal canal and extends into the ischiorectal fossa.
Supravaginal or subperitoneal
These are the result of damage to the uterine artery branches in the broad ligament. The haematoma can dissect retroperitoneally or develop within the broad ligament. It can be clinically occult despite significant blood loss. A high index of suspicion is required to diagnose and manage these haematomas promptly before signs of cardiovascular collapse develop.
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Aetiology
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Injury can be direct (for example, from a pudendal needle or episiotomy) or indirect (for example, from radial stretching of the birth canal as the fetus passes through). Case series have reported that up to 87% of haematomas are associated with sutured perineal tears or episiotomies but superficial tissues are not always lacerated.7 Good surgical technique, with attention to haemostasis in the repair of lacerations and episiotomies, should limit the occurrence of this complication. However, haematomas are not unavoidable.8
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Presentation and differential diagnoses
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Symptoms usually develop within a few hours of delivery. The significance they are given and the speed of diagnosis will depend on the extent of the bleeding, its associated consequences and the level of awareness of the midwifery and medical staff. Thus, a woman with a large haematoma may present with collapse within a few hours of delivery, whereas a woman with a small haematoma in an episiotomy may present with persisting pain over a few days.
Excessive perineal pain is a hallmark symptom of puerperal haematomas and its presence should prompt a gentle pelvic examination. Continued vaginal bleeding is also commonly seen.
If a haematoma ruptures into the vagina, the cause must be differentiated from other causes of postpartum haemorrhage; for example, atonic uterus. Haematomas can also present with retention of urine or, rarely, unexplained pyrexia.
Vulval and vulvovaginal haematomas
The typical symptoms of vulval and vulvovaginal haematomas are pain and swelling in the perineum. These are usually easy to diagnose if the woman is examined but can be confused with abscesses. Failure to carry out an examination can lead to pain being incorrectly attributed to the expected pain of an episiotomy, a tear or haemorrhoids.
Paravaginal and supravaginal haematomas
Paravaginal haematomas typically present with rectal pain, lower abdominal pain (which is often vague) and symptoms of hypovolaemia. These non-specific symptoms can readily be attributed to other causes and can delay the correct diagnosis. The degree of shock is often out of proportion to revealed blood loss.
A supravaginal haematoma can cause abdominal pain but often first presents with signs of hypovolaemia, including cardiovascular collapse. On abdominal examination the uterus is deviated upward and laterally, to the opposite side from the broad ligament haematoma (see Figure 35). Often, there are no vaginal symptoms. The differential diagnoses are those of a pelvic mass, including an abscess, or other sources of intra-abdominal bleeding.
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Investigations
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Blood tests
A full blood count and coagulation screen are mandatory to determine baseline values and should be repeated as necessary. Blood should be taken for cross matching, according to the clinical picture. Transfusion is more likely to be necessary with paravaginal and subperitoneal than with vulval haematomas.
Imaging
Ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) scans will mainly be useful for diagnosing haematomas above the pelvic diaphragm and to assess any extension into the pelvis, particularly as bimanual examination may not find them until they are quite large. MRI can also be particularly useful in providing information on the location, size and extent of a haematoma and in monitoring progress or resolution.9,10 MRI can help to differentiate between other causes of a pelvic mass, such as an abscess or endometrioma.
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Management
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The key elements of management are listed in Box 1. Management aims to prevent further blood loss, minimise tissue damage, ease pain and reduce the risk of infection. Prompt resolution of the haematoma should result in reduced scarring, postpartum pain and dyspareunia.
Resuscitative measures should be considered the first line of treatment. The extent of the blood loss is often underestimated and a high index of suspicion is required. Aggressive fluid replacement and assessment of coagulation status is essential if there is heavy bleeding or signs of hypovolaemia. Blood should be available for transfusion. A urinary catheter is generally advocated to monitor fluid balance and to avoid possible urinary retention resulting from pain, oedema or the pressure of a vaginal pack.
Small, static haematomas (< 5 cm in diameter) can be managed conservatively. Conservative management of larger haematomas has been associated with longer stays in hospital, an increased need for antibiotics and blood transfusion and greater subsequent operative intervention.11 A haematoma that expands acutely is unlikely to settle with conservative measures.12
Large (> 5 cm) vulval haematomas are best managed with surgical evacuation, primary closure and compression for 12–24 hours. Adequate anaesthesia is mandatory. The clot should be evacuated and any apparent bleeding points ligated. Incisions should be sited to minimise scarring (this is often medially).
There is debate as to the optimal management of vaginal haematomas–primary repair (with or without drains), primary repair with packing, and packing alone have all been advocated. Some authors believe that drains defeat the object of packing, which is to tamponade bleeding vessels. They can be useful to highlight ongoing or recurrent bleeding. Drains are usually brought through a separate site distant from the repair.13 The space should be closed with deep mattress sutures and the overlying skin re-approximated without tension. The vagina should be packed tightly. Care must be taken to avoid damage to contiguous structures (such as the ureters, bowel and bladder) during repair procedures.
Small, stable subperitoneal haematomas can be managed conservatively. Surgical management of larger subperitoneal haematomas requires an abdominal approach with identification and ligation of bleeding vessels. Arterial embolisation under radiological control is now an alternative and is discussed below.
Broad spectrum antibiotic cover should be given. Regular review is required to ensure that bleeding has settled and that the haematoma has resolved.
Persistent bleeding
Haematomas can recur after surgical management. Continued monitoring for signs of blood loss is essential. If first line management fails, further surgical intervention is traditionally the next step. The haematoma cavity should be explored again. Ligation of the internal iliac artery, or even hysterectomy, may be necessary.
Pelvic arteriography and arterial embolisation
More recently, pelvic arteriography and arterial embolisation under radiological control have been employed to control postpartum haemorrhage from many causes. Across published case reports and series, the aggregate success rate in controlling bleeding from haematomas is over 90%.14–16
The pelvic circulation is accessed via the femoral artery. Angiography is used to identify bleeding vessels before selective embolisation. Embolic agents can be temporary (for example, absorbable, gelatin-impregnated sponges), or permanent (for example, metal coils).
Complications of pelvic arterial embolisation are uncommon (< 9% of cases) and include: low grade fever, pelvic infection, ischaemic buttock pain, temporary foot drop, groin haematoma and vessel perforation. Use of temporary embolic agents reduces the risk of ischaemic problems. Successful radiographic procedures are likely to preserve fertility (despite exposure of the ovaries to ionising radiation) and most women continue to menstruate.17
Embolisation procedures can be performed under light sedation and take 1–2 hours. They avoid the risks of laparotomy, although the option of surgery is retained. Surgical ligation of the internal iliac arteries makes subsequent radiological attempts to control bleeding much more difficult.
It is widely suggested that embolisation be used as the first line treatment for persistent bleeding, but the main limitation of the wider use of interventional radiology for postpartum haemorrhage is the limited availability of expertise and equipment in most units.18
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Conclusion
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Genital tract haematomas are uncommon and can cause diagnostic confusion. Clinicians must be alert to haematomas as a differential diagnosis of postpartum pain and bleeding.
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References
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- Gabbe SG, Niebyl JR, Simpson JL, editors. Obstetrics: Normal and Problem Pregnancies. 3rd ed. New York: Churchill Livingstone; 1996. p. 523–4.
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- Benrubi G, Neuman C, Nuss RC, Thompson RJ. Vulvar and vaginal hematomas: a retrospective study of conservative versus operative management. South Med J 1987;80:991–4. doi:10.1097/00007611-198708000-00014[Medline]
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- Zahn CM, Hankins GD, Yeomans ER. Vulvovaginal hematomas complicating delivery. Rationale for drainage of the hematoma cavity. J Reprod Med 1996;41:569–74.[Medline]
- Bloom AI, Verstandig A, Gielchinsky Y, Nadiari M, Elchalal U. Arterial embolisation for persistent primary postpartum haemorrhage: before or after hysterectomy? BJOG 2004;111:880–4. doi:10.1111/j.1471-0528.2004.00201.x[Medline]
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- Salomon LJ, deTayrac R, Castaigne-Meary V, Audibert F, Musset D, Ciorascu R, et al. Fertility and pregnancy outcome following pelvic arterial embolization for severe post-partum haemorrhage. A cohort study. Hum Repro 2003;18:849–52. doi:10.1093/humrep/deg168[Abstract/Free Full Text]
- Mousa HA, Alfirevic Z. Major postpartum hemorrhage: survey of maternity units in the U.K. Acta Obstet Gynecol Scand 2002;81:727–30. doi:10.1034/j.1600-0412.2002.810807.x[Medline]
- Cull P, editor. The Sourcebook of Medical Illustration. Carnforth: Parthenon; 1989
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Abstract
Introduction
