A Case of Bladder Flap Hematoma Presenting With Hematuria

Abstract

IntroductionBladder flap hematoma is an unusual complication of cesarean delivery. The exact incidence is unknown (1). A few paper has been written on this surgical complication (2-5). Bladder flap formation has been an important step in standard cesarean delivery. A cesarean delivery can be performed either by suturing or not suturing the visceral peritoneum. When visceral peritoneum is reapproximated, bleeding at the incision site may result in bladder flap hematoma. The traditional method closes visceral and parietal peritoneum, and therefore may lead to this complication (6). Patients with bladder flap hematoma usually present with a mass lesion, signs of hypovolemia (tachycardia, drop in hemoglobin level, decreased urinary output) and/or infection (fever, leukocytosis) (2-5). In the present case, we introduce a patient who presented with an extraordinary sign of bladder flap hematoma. Case PresentationA 25-year-old nulliparous, 40 weeks and 5 days pregnant woman presented to Suleymaniye Maternity, Research and Education Hospital in labor. Transabdominal ultrasonography showed 3490 g fetus in cephalic presentation. She had regular contractions on non-stress test. Her cervical examination revealed a dilatation of 4 cm and an effacement of 80%. She was hospitalized in order to perform vaginal delivery. The woman had neither obstetric risk factors nor systemic diseases. Prenatal screening of the fetus was unremarkable. The patient underwent cesarean delivery due to persistent late decelerations during active labor. Cesarean delivery was performed with the technique of traditional method. The visceral peritoneum was sutured as in the traditional technique. The newborn's weight was 3220 g with an Apgar score of 7 at 1 minute and 9 at 5 minutes. On the first postoperative hour, the patient developed postpartum hemorrhage due to uterine atony. She had severe anemia and tachycardia. Transvaginal ultrasonography revealed the presence of 86×77 mm solid mass interposed between lower uterine segment and bladder (Figure 1). Preoperative hemoglobin level was 11 mg/dL and postoperative drop in hemoglobin was 5 mg/dL. Although bleeding time (2 minutes), platelet count (165.000/mcL), and fibrinogen level (310 mg/dL) were normal, slow-onset hematuria was noticed in the previously clear urinary discharge. She was transfused with 4 units of erythrocyte suspension and 4 units of fresh frozen plasma. The follow ups of the patient were performed using serial transabdominal ultrasounds. The bladder flap hematoma was stable in dimension and the patient was clinically asymptomatic. Intravenous antibiotic therapy with ampicillin/sulbactam (4 g/day) was ordered. Urinary catheter was not removed until gross hematuria was resolved. She had no fever or leukocytosis during the follow-up period. Transvaginal ultrasonography on seventh post-operative day showed an obvious reduction in hematoma size (32×33 mm) (Figure 2). The patient was discharged with oral ampicillin/ sulbactam (1.5 g/day) on the seventh post-operative day AbstractObjective...

May the Systemic Immune-Inflammation Index be an Indicator of Premature Ovarian Insufficiency?

“…Some studies have evaluated the value of some blood cell count indices, especially NLR and PLR, and reported that these biomarkers may be related to POI (3,13).…”

Post-Supravaginal Hysterectomy for Bladder Flap Hematoma in P3A0 Preterm Delivery by Cesarean Section due to Fetal Distress

“…It is crucial to use the most effective and safe surgical technique. Standard and evidence-based techniques are essential to minimize surgical complications [8]. Misgav Ladach was chosen for the cesarean section in this case.…”

“…ultrasonography shows a well-circumferenced complex collection between the bladder and uterus, causing posterior shading [17]. During the following hours, the fusion of blood through the bladder is the reason for the hematuria [8]. The scientific literature does not have a clear protocol regarding BFH management or its surgical treatment.…”

“…Uterine atony is the most common cause and the leading cause of maternal mortality worldwide [18]. According to Ilhan et al [8], the decrease in uterine contractions has caused bleeding at the laparotomy incision site and resulted in a bladder flap hematoma. Carvalho et al [19] reported that, of 13 emergency hysterectomies performed (< 24 hours after delivery), 8 were performed after cesarean section and 5 after vaginal delivery.…”

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“…Usual presentations include a palpable mass, suprapubic pain, signs of hypovolemia and fever [5]. No standardized protocols exist for management of post CS BFH [6].…”