KEY QUESTIONS
How does the location of an obstetric hematoma affect management?
Can adequate examination be performed bedside, or is examination under anesthesia in the operating room required?
When is conservative management versus evacuation and repair or embolization appropriate?
CASE 70-1
A 28-y.o. G1P1 is two hours status post vacuum assisted delivery of a 4100 g, occiput posterior infant at 40 weeks gestation. There was a 2nd degree laceration that was repaired, and estimated blood loss was 300cc. The patient seemed to be recovering appropriately, and epidural was removed 30 minutes ago. She currently complains of 9/10 rectal pain, and upon standing with assistance, became lightheaded. Heart rate is 100 bpm, and blood pressure is 90/60. On examination, the fundus is firm at the level of the umbilicus and there is normal lochia on the pad. The nurse calls you to the bedside. What are the next steps in your evaluation of the patient?
Vulvar and vaginal hematomas can require immediate attention and management from an obstetric and gynecologic (OB/GYN) hospitalist. Hematomas can be the result of obstetric delivery, complications of gynecologic surgery, or the result of trauma. According to a large population–based study, vaginal hematoma occurs in 1 of every 1218 singleton vaginal deliveries.1 Obstetric hematomas more commonly present in those who are primiparous, delivered an infant greater >4500 g, underwent instrumental delivery, or have comorbidities such as preeclampsia, vulvar varicosities, or coagulopathy.2 This chapter reviews the diagnosis and management of vulvar and vaginal hematoma in patients hospitalized following vaginal delivery or gynecologic surgery.
Branches of the pudendal artery injured during delivery are responsible for the majority of vulvar hematomas, whereas injury to the descending branch of the uterine artery accounts for the majority of vaginal hematomas. Although spontaneous hematoma formation is possible in the uncomplicated delivery, episiotomy and the use of vacuum or forceps to facilitate delivery both increase the risk of hematoma.
Vulvar hematomas are collections of blood that are bounded from extension of bleeding, thereby causing an obvious collection of blood protruding to the vulvar skin. These may be located in one of two anatomic areas, often referred to as the anterior and posterior triangles (Fig. 70-1). When the hematoma occurs anterior to the superficial transverse perineal muscles, the perineal membrane (previously called the urogenital diaphragm) and Colles’ fascia prevent the extension of bleeding. Figure 70-2 depicts the anterior triangle as an enclosed space. When posterior to the superficial transverse perineal muscles, it is the anal fascia that prevents extension, although it is possible for these to dissect into the ischiorectal fossa. Figure 70-3 shows a hematoma in this compartment.
FIGURE 70-3.
Extension of a vulvar hematoma in the posterior triangle into the ischiorectal fossa. Injury to perineal vessel branches in the posterior urogenital triangle may result in bleeding into the ischiorectal fossa, which is bound laterally by the pelvic wall, and medially by the levator ani muscles and external anal sphincter. (Modified with permission from Yeomans ER, Hoffman BL, Gilstrap LC, et al: Cunningham & Gilstraps Operative Obstetrics, 3rd ed. New York, NY: McGraw-Hill Companies, Inc; 2017.)
Vaginal hematomas, more concerningly, can extend unbounded into the paravaginal space or isciorectal fossa, without obvious abnormality upon examination of the external genitalia, and with the possibility of delayed diagnosis only once a patient becomes hemodynamically unstable. Similarly, hypotension is often the first symptom of a vessel transected high in the vagina and retracted into the retroperitoneum. Resultant bleeding into the broad ligament leads to retroperitoneal hematoma, a potentially life-threatening condition requiring a high index of suspicion and prompt management.
For hemodynamically stable patients with smaller hematomas, conservative management is an acceptable strategy. The venous bleeding causing hematomas in hemodynamically stable patients may be exceedingly difficult to locate and control during incision and drainage of the hematoma. In these patients, administration of fluids through a large-bore intravenous (IV) line and checking of complete blood count (CBC), prothrombin time (PT) and thromboplastin time (TT), fibrinogen level, and type and screen are appropriate first steps.
A pelvic and rectal examination should be performed promptly. If examination at the bedside is limited due to patient discomfort, examination under neuraxial or systemic anesthesia may be necessary to fully evaluate the hematoma location, size, and possibility of ongoing expansion. In the case of vaginal hematoma, a vaginal packing may be placed during the examination under anesthesia for compression. In the case of vulvar hematoma, cold packs may be applied to encourage vasoconstriction, minimize swelling, and lessen pain.
Given that most obstetric patients are young and healthy at baseline, significant blood loss may occur before a patient manifests with hemodynamic instability. Therefore patients managed conservatively ought to be reevaluated regularly to assess for any interval change. Worsening pain, rectal pressure, lightheadedness, decreased urine output, or new change in vital signs should prompt repeat evaluation. Although routine indwelling Foley catheter use should be avoided for prolonged periods in the uncomplicated postpartum patient, it is essential in a patient with known or suspected hematoma. Hematomas can compress the urethra and cause urinary obstruction, and indwelling catheter use allows for the most precise real-time evaluation of urine output, which may be an early sign of acute blood loss anemia.
Laboratory studies should be rechecked at 4- to 6-hour intervals. Vulvar hematomas may be marked with a surgical marking pen to facilitate recognition of expansion, and serial ultrasound examinations may be performed bedside to more reliably evaluate for expansion of either vulvar or vaginal hematomas. Placing the ultrasound probe on the labia majora and adjusting the depth appropriately, one can use calipers to measure the dimensions of a hematoma and compare these dimensions to prior measurements. The clinician must keep in mind that fresh blood may appear hypoechoic (similar to a simple cyst), while clotted blood has a complex, more echogenic appearance (similar to that of an endometrioma), and both elements must be measured when evaluating hematoma volume. The characteristics of conservatively and operatively managed hematomas are given in Box 70-1.
Box 70-1 Characteristics of Hematomas Managed Conservatively or Operatively
| Conservative Management | Operative Management |
| Hemodynamically stable | Hemodynamic instability |
| No expansion | Inadequate bedside examination |
| Expanding size |
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