Angiographic Embolization of a Postpartum Vulvovaginal Hematoma in a Patient with Situs Inversus Totalis: An Effective Second-Line Treatment

Aim Post‐partum hematomas are a serious obstetrical complication. Choosing treatments for post‐partum hematomas is difficult, and the application of transcatheter arterial embolization remains unclear. We aimed to clarify the clinical characteristics, identify the treatment indications and create a treatment algorithm for post‐partum hematomas. Methods Fifty‐four patients with post‐partum hematomas were enrolled. Hematomas were categorized according to location: upper vaginal, lower vaginal and vulvar. Blood loss, treatment methods and other clinical data were collected from the patients’ medical records and analyzed retrospectively. Results Five, 19 and 30 patients had upper vaginal wall, lower vaginal wall and vulvar hematomas, respectively. All upper vaginal wall hematomas required transcatheter arterial embolization to control bleeding, and the average blood loss was 2473 ± 1689 mL. Most lower vaginal wall hematomas were treated surgically; however, two patients required transcatheter arterial embolization, and the average blood loss in these patients was much higher (2010 ± 1145 mL) than that in patients with lower vaginal wall hematomas (395 ± 316 mL). No patient with vulvar hematomas was treated with transcatheter arterial embolization. Two and four patients with vulvar and lower vaginal wall hematomas, respectively, were managed with observation. Conclusion We created an algorithm for post‐partum hematoma management. Post‐partum hematoma location should guide treatment selection. Transcatheter arterial embolization should be selected for upper vaginal wall hematomas. Most lower vaginal wall hematomas are treatable with surgery, but transcatheter arterial embolization should be considered for hemostasis in difficult cases. Management with observation may also be possible for lower vaginal wall and vulvar hematomas.

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“…Dahdouh et al have suggested TAE as a second-line treatment for postpartum hematomas 11. In our experience, all patients…”

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confidence: 52%

“…Dahdouh et al . have suggested TAE as a second‐line treatment for post‐partum hematomas . In our experience, all patients with upper vaginal wall hematomas that formed in the supralevator space required TAE; therefore, TAE might be the first choice of treatment for these patients.…”

Section: Discussionmentioning

confidence: 89%

Clinical characteristics, treatment indications and treatment algorithm for post‐partum hematomas

Tsumagari

Ohara

Mayumi

et al. 2019

J of Obstet and Gynaecol

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“…Kehila et al reported two cases of postpartum vaginal hematomas managed by arterial embolization [ 7 ]. Dahdouh et al reported a case of postpartum vulvovaginal hematoma which was managed by angiographic embolization [ 8 ].…”

Section: Discussionmentioning

confidence: 99%

Large Vaginal Hematoma in a Puerperium Patient: Treating a Delayed Diagnosis & Management Caused by an Incomplete Clinical Examination

Sinha¹,

Agarwal²,

Singh³

2023

Cureus

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Here, we report a case where the lack of pelvic examination in a puerperium patient led to a delay in diagnosis and appropriate management of a large posterior vaginal wall hematoma for about a month. The patient had a history of difficult vaginal breech delivery of a macrosomic asphyxiated baby 28 days prior, following which, she started having gradually increasing distension of the abdomen, inability to void urine and pass stools by herself, and a history of fever on and off. Her family members took her to a private hospital for a consultation, where she was examined and assessed. However, a pelvic examination was not done. A CT scan of the abdomen and pelvis showed a large organized hematoma of size 13.6cm×11.1cm×10.5cm with a volume of 802 ml in the pouch of Douglas. Following this report, diagnostic laparoscopy was done on day 10 of puerperium where a large hematoma was seen beneath the peritoneum in the pouch of Douglas without any intraperitoneal collection. As the hematoma was not seen to be expanding, conservative management was done with 5 units of blood transfusion and antibiotic coverage, and the patient was discharged. However, the patient's symptoms were not relieved due to which she presented to us on day 28 of puerperium with the same symptoms. On pelvic examination, purulent, foulsmelling discharge was present in the vagina, and a huge tense bluish bulge was seen in the posterior vaginal wall more towards the right side obliterating the whole vagina. After taking informed consent and with proper pre-operative preparations of laparotomy, the hematoma was drained vaginally, and approximately 1300 ml of blood and clots were removed, following which, the patient had a speedy recovery and relief of her symptoms.

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“…We searched the keywords “vulvovaginal hematoma”, “embolization”, and “genital tract injury (trauma)” in PubMed [ 5 , 19 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 ]. Among them, we found papers that describe embolic materials ( Table 2 ).…”

Section: Discussionmentioning

confidence: 99%

Transcatheter Arterial Embolization (TAE) Using N-Butyl-2-cyanoacrylate (NBCA) as the First Choice for Postpartum Vulvovaginal Hematoma; Case Series and Reviews of the Literature

et al. 2022

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Transcatheter arterial embolization (TAE) has long been reported to be safe, effective, and to have a high clinical and technical success rate for vulvovaginal hematoma. We used a permanent embolic material, diluted N-butyl-2-cyanoacrylate (NBCA), for the first choice intervention for six cases of vulvovaginal hematoma, in order to confirm the effectiveness of NBCA. Regarding post-embolization adverse events, we did not observe any fever nor necrosis or pain in the vaginal wall or vulva, in all cases. The use of NBCA as a first-line treatment for TAE of vulvovaginal hematoma is considered to be effective, in the following two ways: First, hemostasis can be achieved by adjusting the mixing ratio of NBCA and lipiodol, according to the distance between the tip of the catheter and the site of injury. Second, NBCA does not cause complications such as pain, necrosis, or infection, and it can be used safely. There are no reports clearly recommending NBCA as the first choice in the treatment of TAE for vulvovaginal hematoma. This is the first report to examine the efficacy and safety of NBCA as the first-line intervention for such cases.

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Angiographic Embolization of a Postpartum Vulvovaginal Hematoma in a Patient with Situs Inversus Totalis: An Effective Second-Line Treatment

Cited by 5 publications

References 11 publications

Clinical characteristics, treatment indications and treatment algorithm for post‐partum hematomas

Clinical characteristics, treatment indications and treatment algorithm for post‐partum hematomas

Large Vaginal Hematoma in a Puerperium Patient: Treating a Delayed Diagnosis & Management Caused by an Incomplete Clinical Examination

Transcatheter Arterial Embolization (TAE) Using N-Butyl-2-cyanoacrylate (NBCA) as the First Choice for Postpartum Vulvovaginal Hematoma; Case Series and Reviews of the Literature

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