Aboubakr elnashar

1. PUERPERAL GENITAL HAEMATOMAS
Prof Aboubakr Elnashar
Benha university Hospital

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

3. Introduction
Relatively uncommon
 ± serious morbidity & 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

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

5. Types
I. Infralevator:
 below the levator ani muscle
 usually around vulva, perineum& lower vagina
1. Vulval:
 limited to the vulval tissues superficial to the
anterior urogenital diaphragm.
 Haematoma: evident on the vulva.

6. 2. Vulvovaginal
 Evident on the vulva but
 extend into the paravaginal tissues.

8. Vulvovaginal

9. 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
 extends into the ischiorectal fossa.

10. II. Supralevator: Supravaginal= Subperitoneal
 Spread
 Upwards&outwards beneath the broad lig. or
 Downwards to bulge into the wall of the upper
vagina, or
 Backwards into the retroperitoneal space.

11. Paravaginal haematoma: Supralevator

13. Aetiology
 Injury
 Direct: episiotomy, forceps or
 Indirect: 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
 50 %: spontaneous delivery.

14.  Coagulopathies:
 von Willebrand disease
 rarer causes.

15. 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.

16. {‫عمر‬Vulval vulvovaginal
Infralevator
paravaginal
Supralevatolr

17. II. Supralevator
 Injury to uterine artery branches in the broad lig.
 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

18. Risk factors
 Episiotomy
 Instrumental delivery
 Primiparity
 Prolonged 2nd stage of labour
 Macrosomia
 Vulval varicosities

19. 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.

20. Classical symptoms
 Pain:
 Excessive perineal pain is a hallmark symptom
 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

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

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

23.  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.

24.  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.

25. 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 with paravaginal and
subperitoneal than with vulval haematomas}.

26.  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.

27. Management
 Aims
 prevent further blood loss,
 minimise tissue damage,
 relieve pain
 reduce the risk of infection.
 Prompt resolution: reduced
 Scarring
 postpartum pain
 dyspareunia.

28.  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
 often underestimated
 Monitor ongoing blood loss:

29. 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.

30. 2. Conservative management
 Indication
Small (5 cm), static haematomas
 Not for
 Larger haematomas:
{longer stays in hospital
An increased need for antibiotic, blood
transfusion & operative intervention}.
 Expanding haematoma
{unlikely to settle with conservative measures}.

31.  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}.

32. 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.

33.  Primary closure
 The exact origin of the bleeding is rarely identified
 The space should be closed with deep mattress
sutures
 Overlying skin reapproximated without tension.
 Avoid damage to contiguous structures:
ureters, bowel and bladder
 Compression
The vagina should be packed tightly for 12–24 h.

34.  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.

35.  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 bleeding has settled and haematoma has
resolved}.

36.  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

37. 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
 permanent: metal coils.
 Performed under light sedation
 take 1–2 h

38.  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.

39.  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

40. (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).

41. Post embolisation image showed blockage of the
inferior vesicle artery and the bleeding was
successfully arrested.

42. Prevention
 Good surgical technique, with attention to
haemostasis in the repair of lacerations and
episiotomies
 However, haematomas are not unavoidable.

43. 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.

44.  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

45.  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