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12/1/2012

Hematoma after Delivery

Puerperal hematomas occur in 1:300 to 1:1,500 deliveries and may pose life-threatening morbidity.  A puerperal hematoma is an accumulation of blood in a pelvic avascular potential space.  Injury that occurs to pelvic vessels can be direct, from episiotomies, vaginal lacerations, and operative deliveries, or indirect due to stretching of the birth canal from labor that is prolonged or macrosomia.  Risk factors include maternal obesity, excess weight gain, smoking, gestational diabetes, extremes of age, coagulopathies, and hypertensive disorders.

Vulvar hematomas are often encountered postnatally.  These hematomas are a result of laceration or rupture of the pudendal artery and/or its tributaries.  Vulvar hematomas often occur in the anterior and posterior urogenital triangles in areas bound by strong fascia tissue which limits their expansion.  Deep extension of a vulvar hematoma in the anterior triangle is limited by Colles’ fascia and the urogenital diaphragm.  Similarly, deep extension of a hematoma in the posterior triangle is limited by the presence of perirectal and anal fascia.  As a result, expanding hematomas in these areas usually present as a blue-purple mass.  These hematomas are generally self-limiting however they can cause pressure necrosis of the skin.  Surgical intervention and evacuation can prevent spontaneous skin rupture.

Cervical tears, vaginal tears and a large episiotomy can rupture branches of the hypogastric arteries including the descending branch of the uterine artery, the vaginal artery, and the pudendal artery.  Bleeding from these vessels can extend into the paravaginal space, which is bound superiorly by the cardinal ligament, medially by the vagina, laterally by the obturator internus muscle and inferior by muscles of the levator ani.  Hemorrhage in this area can expand medially and occlude the vagina.  Expansion can also occur cephalad in a concealed manner past the inguinal ligament into the retroperitoneal space and result in considerable blood loss.   

Retroperitoneal hematomas (RPH) are another category of rare but potentially life-threatening hemorrhage complication. The most common RPH associated with childbirth occur as a result of injury to branches of the hypogastric and ovarian vessels however lacerations to the posterior vagina such as a sulcus tear can rupture vessels, leading to hemorrhage that dissects into the utero-sacral area and expands into the retroperitoneal space.  Hematomas in the retroperitoneal space can conceal a large volume of blood due to the proximity of well-known and typically avascular areas namely the perivesical, parametrial (the base of the broad ligament) and the perirectal space.

Early recognition, evaluation and expeditious intervention can be lifesaving.  Hemodynamically unstable patients require resuscitation and surgical exploration. Similarly, patients with pressure symptoms resulting in compartment syndrome require surgical intervention.  Embolization is another management option for an expanding hematoma in an otherwise stable patient.

Further Reading:

Rogers RM, Pasic R. Pelvic Retroperitoneal Dissection: A Hands-on Primer [published correction appears in J Minim Invasive Gynecol. 2017 Jul - Aug;24(5):879]. J Minim Invasive Gynecol. 2017;24(4):546-551. doi:10.1016/j.jmig.2017.01.024

Rafi J, Khalil H. Maternal morbidity and mortality associated with retroperitoneal haematomas in pregnancy. JRSM Open. 2018;9(1):2054270417746059. Published 2018 Jan 8. doi:10.1177/2054270417746059

Zahn CM, Hankins GD, Yeomans ER. Vulvovaginal hematomas complicating delivery. Rationale for drainage of the hematoma cavity. J Reprod Med. 1996;41(8):569-574.

Initial Approval: December 2012; Revised September 2018; Previously titled “Hematoma After Delivery” – renamed to current title September 2018; Revised September 2020; Minor Revision March 2024.

 

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