pp hematoma

Hematomas:Postpartum Complications: 

Hematomas: Postpartum Complications Darrel J. Bell, MD Memphis, TN November 11, 2004

A Day in the Life of a 3rd Year: 

A Day in the Life of a 3rd Year 18 y/o G1 at 410 weeks presented to the evaluations where she was admitted in active labor with a cervix dilated to 5cm/80%/vertex/intact contracting every 5 minutes PMH/PSH/FamH/SocH – Noncontributory GynH – Denied STDs, Abnl Paps

The Labor Curve: 

The Labor Curve 1:00pm  Admitted @ 5cm, complains of contractions 3:30pm  6-7cm, with epidural, improved pain 6:00pm  8-9cm, complains of pressure 7:30pm  Delivery of a 6lb 11oz baby. Apgars 81 and 95, EBL 400cc, primary right periurethral laceration hemostatic with single stitch

The Rest of the Story: 

The Rest of the Story 9:00pm – gather blankets, brush teeth, go to bed 10:00pm – finally fall asleep 12:15am – awoken by pager and massive heartburn again, considering reflux vs AMI 8:55pm – finally eat reheated pizza for dinner 10:45pm – wake up with roaring heartburn 11:15pm – finally get back to sleep

Recovery Room: 

Recovery Room

Types of Hematomas: 

Types of Hematomas Vulvar Paravaginal Retroperitoneal Chronic Expanding 

Vulvar Hematomas: 

Vulvar Hematomas Painful Involves pudendal artery/vein Blood loss limited by Colle’s fascia and urogenital diaphragm Treatment Conservative: <10cm, asymptomatic, stable Surgical: foley, evacuation and close dead space. Do not pack cavity. 

Paravaginal Hematomas: 

Paravaginal Hematomas Associated with forceps deliveries Complain of rectal pressure Involves descending branch of uterine artery/vein Blood accumulates above pelvic diaphragm Treatment Evacuation, ligation of bleeders, however, no need to close vaginal incision, pack vagina and remove in 12-24 hours 

Retroperitoneal: 

Retroperitoneal Least common, most dangerous Asymptomatic until hypotension Involves vessels from hypogastric Damage during CD or rupture during TOL Blood may dissect up to renal vasculature Treatment Ex-lap and ligation of hypogastric vessel possibly bilaterally 

Anatomy: 

Anatomy

Chronic Expanding Hematomas: 

Chronic Expanding Hematomas May accompany vulvar hematomas Repetitive episodes of bleeding from capillaries in the granulation tissue of the hematoma Treatment is drainage and debridement

Risk Factors: 

Risk Factors Nulliparity Episiotomy/laceration may develop without laceration of the superficial tissues Operative Deliveries Straddle injuries Consider urethral injuries Sexual abuse Vaginal slings (retropubic hematomas)* *Kobashi and Govier, J Urology 2003 Nov;170(5):1918-21 

Research: 

Research Retrospective chart review from 1975 to 1991 at University of North Carolina 29 cases: 19 obstetric (O) and 10 non-obstetric (NO) vulvar hematomas 13 O and 3 NO managed conservatively 4 conservatively managed NO required surgery Most common indication was “rapidly expanding” hematoma Propst and Thorp, South Med J. 1998 Feb;91(2):144-6

Overview: Diagnosis: 

Overview: Diagnosis Symptoms Excruciating pain, pressure, inability to void Signs Tachycardia, decreased hematocrit Physical exam Do serial exams. Abdominal exam. Tense, fluctuant, tender mass with discoloration of the skin on vaginal exam CT scan Can pick up retroperitoneal 

Overview: Treatment: 

Overview: Treatment Expectant management with/without blood transfusions on the labor hall Incision and evacuation Severe pain, rapidly enlarging, >10cm Ligation of bleeding points and obliteration of potential space Don’t pack the potential space Don’t close if infected

Treatment continued: 

Treatment continued Packing the vagina ~12-24 hours Laparotomy for retroperitoneal Embolization Antibiotics Broad spectrum if infected No studies justify using antibiotics for prophylaxis Compression/Ice packs 

Sources: 

Sources Williams Obstetrics, 21st Edition Gabbe, 4th Edition Droegemueller, 4th Edition Telindes, 9th Edition Manual of Pelvic Surgery, 2nd Edition

The Halloween Party: 

The Halloween Party