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

Abstract

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.

Large vulvar hematoma secondary to obturator artery pseudoaneurysm following uncomplicated vaginal delivery: A case report and review of the literature

“…Surgical evacuation of puerperal hematoma was the mainstay of treatment until around 1980, when reports of selective arterial embolization started to arise [2]. However, determining one route of management versus the other can be challenging.…”

“…Tsumagari et al created an algorithm for management of puerperal hematoma, stating that location should determine treatment. Vulvovaginal hematomas should be observed versus surgically evacuated, whereas upper vaginal hematomas should undergo CT angiography for assessment of selective arterial embolization [2].…”

“…Puerperal hematoma is a rare but serious obstetrical complication that occurs in 1 in 300-1500 deliveries [2]. Risk factors for the development of postpartum vulvovaginal hematomas include laceration, episiotomy, operative delivery, nulliparity, macrosomia, increasing maternal age and maternal coagulation abnormalities [2][3][4]. Vulvovaginal hematomas result from lacerated vessels in the superficial fascia of the anterior or posterior pelvic triangle.…”

Uterine Artery Laceration after Vacuum Delivery

“…Post-partum hematomas, particularly intra-abdominal hematoma, are an unusual presentation of post-partum hemorrhage and can be caused by collapse of blood vessels following laceration, episiotomy or an operative delivery. 8 Spontaneous uterine artery rupture is also a rare complication. 9 Post-partum hemorrhage is an unpredictable emergency usually controlled by uterine massage, uterotonic agents or by surgical intervention in the event of persistent bleeding.…”

Laparoscopic hemostasis and drainage for postpartum retroperitoneal hematoma complicated with an infection: A case report and surgical video

“…Delivery-related injuries to the blood vessels surrounding the birth canal can result in the formation of retroperitoneal hematomas. Such hematomas can spread throughout the retroperitoneum, resulting in hypovolemic shock, and hemostatic therapy via interventional radiology (IVR) and surgery has been reported [ 1 ]. Furthermore, such hematomas can lead to refractory infections, for which the optimal management strategies are unclear.…”