Puerperal genital haematomas

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Puerperal genital haematomas Prof Aboubakr
Elnashar Benha university Hospital
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• Contents
• Introduction
• Incidence
• Types
• Etiology
• Risk factors
• Presentation and DD
• Investigations
• Management
• Prevention
• Conclusion

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• Introduction
• Relatively uncommon
• serious morbidity and even maternal death.
• difficult to diagnose
• symptoms non-specific and
• bleeding is often concealed.
• Haematoma
• localized collection of blood outside of blood
  vessels
• gt 2.5 cm

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• Incidence
• 1300 to 11000 deliveries
• (Thakar and Sultan 2009)
• gt4 cm 1/1000 deliveries.
• Supralevator lt infralevator
• Surgical intervention
• 1/1000 deliveries

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• Types
• I. Infralevator
• below the levator ani muscle
• usually around vulva, perineum and lower vagina
• 1. Vulval
• limited to the vulval tissues superficial to the
  anterior urogenital diaphragm.
• Haematoma evident on the vulva.
• 2. Vulvovaginal
• Evident on the vulva but
• extend into the paravaginal tissues.

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Vulvovaginal
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• 3. Paravaginal
• confined to the paravaginal tissues in the space
  bounded inferiorly by the pelvic diaphragm and
  superiorly by the cardinal ligament.
• not obvious externally but can be diagnosed by
  vaginal examination.
• often occludes the vaginal canal and extends into
  the ischiorectal fossa.

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• II. Supralevator Supravaginalsubperitoneal
• Spread
• upwards and outwards beneath the broad lig. or
• downwards to bulge into the wall of the upper
  vagina, or
• backwards into the retroperitoneal space.

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Paravaginal haematoma Supralevator
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• Aetiology
• Injury
• Direct episiotomy, forceps or
• Indirect radial stretching of the birth canal as
  the fetus passes through.
• 80 failure to achieve haemostasis
• e.g. at the apex of an episiotomy or tear.
• 20 concealed ruptured vessel with an
  apparently intact perineum
• (Thakar and Sultan 2009)
• 50 spontaneous delivery.
• Coagulopathies von Willebrand disease, are rarer
  causes.

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I. Infralevator Usually associated with vaginal
birth 1.Vuval or vulvovagial injury to the
branches of the pudendal artery posterior
rectal transverse perineal posterior labial
arteries 2. Paravaginal Injury to descending
branch of the uterine artery.
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Supralevatolr
Infralevator paravaginal
???
Vulval vulvovaginal
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• II. Supralevator
• Injury to uterine artery branches in the broad
  ligament.
• May occur after spontaneous birth
• More commonly
• operative vaginal birth
• difficult CS
• Due to an extension of a tear of the cervix,
  vaginal fornix or uterus

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Risk factors Episiotomy Instrumental
delivery Primiparity Prolonged 2nd stage of
labour Macrosomia Vulval varicosities
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• Presentation and differential diagnosis
• Onset
• usually within a few hours of delivery.
• Speed of diagnosis depend on
• extent of the bleeding
• associated consequences
• level of awareness of medical staff.

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• Classical symptoms
• Pain
• Excessive perineal pain is a hallmark symptom
• its presence should prompt pelvic examination.
• Over a few days in a small haematoma in an
• Episiotomy
• Restlessness
• Rectal tenesmus (constant need to empty bowels)
  within a few hours after birth

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• Collapse
• within a few hours of delivery in large
  haematoma
• Bleeding
• Continued vaginal
• if a haematoma ruptures into the vagina
• DD from other causes of PPH e.g. atonic uterus.
• Rare symptoms
• Retention of urine
• unexplained pyrexia.

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• Vulval and vulvovaginal haematomas
• Typical symptoms
• pain and swelling in the perineum.
• DD
• abscesses.
• pain of an episiotomy
• tear or
• haemorrhoids Examination

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• Paravaginal haematomas
• Typical symptoms
• Rectal pain
• lower abdominal pain (often vague)
• symptoms of hypovolaemia often out of proportion
  to revealed blood loss.
• These non-specific symptoms can readily be
  attributed to other causes delay the correct
  diagnosis.

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• Supravaginal haematoma
• Symptoms
• Abdominal pain
• no vaginal symptoms.
• Signs
• hypovolaemia collapse.
• shock elevated pulse, decreased BP, pale,
  sweaty, clammy, dizzy
• Abdominal examination
• uterus is deviated upward and laterally, to the
  opposite side from the broad ligament haematoma.
• DD
• pelvic mass abscess
• intra-abdominal bleeding.

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• Investigations
• Blood tests
• CBC
• Coagulation screen
• mandatory determine baseline values
• should be repeated as necessary.
• Cross matching
• according to the clinical picture.
• Transfusion
• more likely to be necessary with paravaginal and
  subperitoneal than with vulval haematomas.
• .

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• Imaging
• US, CT and MRI
• diagnosing haematomas above pelvic diaphragm
• assess any extension into the pelvis
• MRI
• location, size and extent of a haematoma
• monitoring progress or resolution.
• DD between other causes of a pelvic mass
  abscess or endometrioma.

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Management Aims prevent further blood
loss, minimise tissue damage, relieve pain
reduce the risk of infection. Prompt resolution
reduced Scarring postpartum pain dyspareunia.
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• Assessment high index of suspicion is required.
• Prompt examination of vulva, perineum, vagina
• Identify site of haematoma
• Whether it is still expanding
• Estimate blood loss
• Monitor ongoing blood loss often underestimated

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• 1. Resuscitative measures
• first line of treatment.
• Fluid replacement
• crystalloids/colloids Hartmanns, sodium
  chloride 0.9 , Gelafusine
• Assessment of coagulation status essential if
  heavy bleeding or signs of hypovolaemia.
• Blood should be available for transfusion.
• Urinary catheter
• monitor fluid balance
• avoid possible urinary retention resulting from
  pain, oedema or the pressure of a vaginal pack.

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• 2. Conservative management
• Indication
• Small (5 cm), static haematomas
• Not for
• Larger haematomas
• longer stays in hospital
• An increased need for antibiotics and blood
• transfusion and greater subsequent operative
• intervention.
• Haematoma that expands acutely is unlikely to
  settle with conservative measures.

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• Steps
• Broad spectrum antibiotics
• Ice packs
• Analgesia
• 1. Regular paracetamol
• 2. NSAID diclofenac Voltaren 50 mg tds),
  contraindications pp hge, PET, renal disease,
  concurrent use of other NSAIDs, aspirin, digoxin
• 3. intramuscular opioid
• 4. Avoid rectal administration of analgesics
• Regular review
• ensure that bleeding has settled and haematoma
  has resolved.

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• 3. Surgical
• Indication
• Large (5 cm) vulval haematomas
• Steps
• Adequate anaesthesia
• Evacuation
• Incisions should be placed to minimise scarring
  (this is often medially).
• Clot should be evacuated
• Any apparent bleeding points ligated.

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• Primary closure
• The exact origin of the bleeding is rarely
  identified
• The space should be closed with deep mattress
  sutures and the overlying skin reapproximated
  without tension.
• Care must be taken to avoid damage to contiguous
  structures (such as the ureters, bowel and
  bladder) during repair procedures.
• Compression
• The vagina should be packed tightly for 1224 h.

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• Drains
• usually brought through a separate site distant
  from the repair.
• useful to highlight ongoing or recurrent
  bleeding.
• defeat the object of packing, which is to
  tamponade bleeding vessels.
• What is optimal management ?
• primary repair (with or without drains)
• primary repair with packing, and
• packing alone have all been advocated.

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• Subperitoneal haematomas
• 1. Small, stable
• conservative.
• 2. Larger
• Surgical abdominal approach
• identification and ligation of bleeding vessels.
• Arterial embolisation
• under radiological control is now an alternative
• Broad spectrum antibiotic
• Regular review
• ensure that bleeding has settled and
• haematoma has resolved.

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• Persistent bleeding
• Haematomas can recur after surgical management.
• Continued monitoring for signs of blood loss
• essential.
• If first line management fails
• further surgical intervention
• The haematoma cavity should be explored again.
• Ligation of the internal iliac artery, or even
• hysterectomy, may be necessary. or
• occlusion of the internal iliac artery/ies by
  balloon catheter or embolisation

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4. Pelvic arteriography and arterial
embolisation Success rate over
90. Steps Pelvic circulation is accessed via
the femoral a Angiography is used to identify
bleeding vessels before selective embolisation.
Embolic agents temporary absorbable,
gelatin-impregnated sponges permanent metal
coils. Performed under light sedation take 12 h
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Complications Uncommon 9 low grade fever pelvic
infection ischaemic buttock pain temporary foot
drop groin haematoma Vessel perforation. Use of
temporary embolic agents reduces the risk of
ischaemic problems.
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Advantages preserve fertility (despite exposure
of the ovaries to ionising radiation) most women
continue to menstruate. avoid the risks of
laparotomy, although the option of surgery is
retained. limitation experience equipment. Indic
ation first line treatment for persistent
bleeding
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1. Digital subtraction angiography (DSA) image of
   left internal iliac artery runs showing contrast
   extravasation (arrows) from the inferior vesicle
   branch (arrowheads) indicating an active bleed.
2. An oblique view showing more extravascular
   contrast accumulation in the delayed phase
   (arrows).

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Post embolisation image showed blockage of the
inferior vesicle artery and the bleeding was
successfully arrested.
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• Prevention
• Good surgical technique, with attention to
  haemostasis in the repair of lacerations and
  episiotomies
• However, haematomas are not unavoidable.

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• Conclusion
• Genital tract haematomas are uncommon and can
  cause diagnostic confusion.
• Clinicians must be alert to haematomas as a dd of
  postpartum pain and bleeding.

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• Key elements of management of puerperal genital
  haematoma
• The most important factor in correct diagnosis is
  clinical awareness
• Excessive perineal pain is a hallmark symptom
  its presence should prompt examination
• Aggressive fluid resuscitation/blood transfusion
  may be required

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• Coagulation status should be monitored
• Treatment should be carried out in an operating
  theatre
• A urinary catheter should be used to prevent
  urinary retention and monitor fluid balance
• The threshold for using antibiotics should be low
• There is no evidence to support best management,
  which can be primary repair or packing, with or
  without insertion of a drain
• Awareness should be maintained after primary
  repair/packing, as recurrence is common

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Thank You Aboubakr Elnashar