Puerperal genital haematomas

1. Puerperal genital haematomas
Prof Aboubakr Elnashar
Benha university HospitalAboubakr Elnashar

2. Contents
 Introduction
 Incidence
 Types
 Etiology
 Risk factors
 Presentation and DD
 Investigations
 Management
 Prevention
 Conclusion
Aboubakr Elnashar

3. 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
> 2.5 cm
Aboubakr Elnashar

4. Incidence
1:300 to 1:1000 deliveries
(Thakar and Sultan 2009)
>4 cm: 1/1000 deliveries.
Supralevator < infralevator
Surgical intervention:
1/1000 deliveries
Aboubakr Elnashar

5. 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.
Aboubakr Elnashar

6. Aboubakr Elnashar

7. Vulvovaginal Aboubakr Elnashar

8. 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.
Aboubakr Elnashar

9. II. Supralevator: Supravaginal=subperitoneal
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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10. Paravaginal haematoma: Supralevator
Aboubakr Elnashar

11. Aboubakr Elnashar

12. 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.
Aboubakr Elnashar

13. 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.
Aboubakr Elnashar

14. {‫عمر‬Vulval vulvovaginal
Infralevator
paravaginal
Supralevatolr
Aboubakr Elnashar

15. 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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16. Risk factors
Episiotomy
Instrumental delivery
Primiparity
Prolonged 2nd stage of labour
Macrosomia
Vulval varicosities
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17. 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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18. 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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19. 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.
Aboubakr Elnashar

20. 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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21. 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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22. 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.
Aboubakr Elnashar

23. 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}.
.
Aboubakr Elnashar

24. 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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25. 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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26. 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
Aboubakr Elnashar

27. 1. Resuscitative measures
first line of treatment.
 Fluid replacement:
crystalloids/colloids: Hartmann’s, 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.
Aboubakr Elnashar

28. 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}.
Aboubakr Elnashar

29.  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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30. 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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31.  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 12–24 h.
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32.  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.
Aboubakr Elnashar

33. 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}.
Aboubakr Elnashar

34. 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
Aboubakr Elnashar

35. 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 1–2 h
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36. 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.
Aboubakr Elnashar

37. 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.
Indication
first line treatment for persistent bleeding
Aboubakr Elnashar

38. (a) 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.
(b) An oblique view showing more extravascular contrast
accumulation in the delayed phase (arrows).
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39. Post embolisation image showed blockage of the
inferior vesicle artery and the bleeding was
successfully arrested.
Aboubakr Elnashar

40. Prevention
Good surgical technique, with attention to
haemostasis in the repair of lacerations and
episiotomies
However, haematomas are not unavoidable.
Aboubakr Elnashar

41. 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.
Aboubakr Elnashar

42.  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
Aboubakr Elnashar

43.  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
Aboubakr Elnashar

44. Aboubakr Elnashar

45. Thank You
Aboubakr Elnashar
Aboubakr Elnashar