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KEY QUESTIONS
How does the location of an obstetric hematoma affect management?
Can adequate examination be performed bedside, or is examination under anesthesia in the operating room required?
When is conservative management versus evacuation and repair or embolization appropriate?
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CASE 70-1
A 28-y.o. G1P1 is two hours status post vacuum assisted delivery of a 4100 g, occiput posterior infant at 40 weeks gestation. There was a 2nd degree laceration that was repaired, and estimated blood loss was 300cc. The patient seemed to be recovering appropriately, and epidural was removed 30 minutes ago. She currently complains of 9/10 rectal pain, and upon standing with assistance, became lightheaded. Heart rate is 100 bpm, and blood pressure is 90/60. On examination, the fundus is firm at the level of the umbilicus and there is normal lochia on the pad. The nurse calls you to the bedside. What are the next steps in your evaluation of the patient?
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Vulvar and vaginal hematomas can require immediate attention and management from an obstetric and gynecologic (OB/GYN) hospitalist. Hematomas can be the result of obstetric delivery, complications of gynecologic surgery, or the result of trauma. According to a large population–based study, vaginal hematoma occurs in 1 of every 1218 singleton vaginal deliveries.1 Obstetric hematomas more commonly present in those who are primiparous, delivered an infant greater >4500 g, underwent instrumental delivery, or have comorbidities such as preeclampsia, vulvar varicosities, or coagulopathy.2 This chapter reviews the diagnosis and management of vulvar and vaginal hematoma in patients hospitalized following vaginal delivery or gynecologic surgery.
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ANATOMY AND PATHOPHYSIOLOGY
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Branches of the pudendal artery injured during delivery are responsible for the majority of vulvar hematomas, whereas injury to the descending branch of the uterine artery accounts for the majority of vaginal hematomas. Although spontaneous hematoma formation is possible in the uncomplicated delivery, episiotomy and the use of vacuum or forceps to facilitate delivery both increase the risk of hematoma.
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Vulvar hematomas are collections of blood that are bounded from extension of bleeding, thereby causing an obvious collection of blood protruding to the vulvar skin. These may be located in one of two anatomic areas, often referred to as the anterior and posterior triangles (Fig. 70-1). When the hematoma occurs anterior to the superficial transverse perineal muscles, the perineal membrane (previously called the urogenital diaphragm) and Colles’ fascia prevent the extension of bleeding. Figure 70-2 depicts the anterior triangle as an enclosed space. When posterior to the superficial transverse perineal muscles, it is the anal fascia that prevents extension, although it is possible for these to dissect into the ischiorectal fossa. Figure 70-3 shows a hematoma in this compartment.
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