Optimal approach for management of postpartum vulva hematoma: Report of three cases

Computed Tomography Findings in Non-Obstetric Vulvar Hematoma: A Case Report

Non-obstetric vulvar hematoma is a rare but clinically important diagnosis in the emergency department for which there is no consensus on optimal diagnosis or management. We present a case of non-obstetric vulvar hematoma that occurred after minimal trauma in a young, otherwise healthy woman who presented with labial swelling after consensual digital penetration, initially managed conservatively but ultimately requiring surgical drainage. Although a rare presentation in the emergency department, prompt identification, diagnosis, and management of vulvar hematoma is crucial to appropriately treat complications including pain, hemodynamically significant hemorrhage, urinary obstruction, and soft tissue necrosis.

Topics

Vulvar hematoma, pelvic trauma, women's health, CT (computed tomography) angiography.

Delayed presentation of a non-resorbing postpartum vulvar hematoma: A case report

Vulvar hematomas are more common in the obstetric population, and usually present within 24 h of delivery. Small, nonexpanding vulvar hematomas will often resolve with conservative management. In a rural setting in the USA, a 35-year-old woman, G3P3, presented to clinic 26 days after a home vaginal delivery attended by a midwife, which was complicated by postpartum hemorrhage secondary to retained placenta. Ten days after her delivery she developed intense pressure in her inferior right vulva. On examination a 4-5 cm well defined right vulvar mass was observed. Incision and drainage were performed and the mass was determined to be a hematoma that had not resorbed. Four days later, the patient returned to clinic as the mass had reformed. Computerized tomography did not show extravasation of contrast. As examination showed the mass was now 1 cm smaller, no intervention was undertaken and after one month the hematoma had completely resolved. This case provides a rare example of the delayed development of a vulvar hematoma. In the literature, the vast majority are reported to present within 24 h of delivery. Smaller hematomas, such as this one, which was 4-5 cm, are treated conservatively, as they typically absorb. This hematoma was present for approximately two weeks without resorbing.

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

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, foul-smelling 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.

Postpartum spontaneous vulvar hematoma as a cause of maternal near miss: a case report and review of the literature

Background

Postpartum spontaneous vulvar hematoma is a rare complication of childbirth that can potentially cause maternal death if not managed properly and in a timely manner.

Case summary

We present the case of maternal near miss secondary to postpartum hemorrhage secondary to vulvar hematoma after home delivery in a 28-year-old para IV mother from rural Ethiopia. The case was surgically managed under spinal analgesia. The mother and her newborn were discharged on the fourth postprocedure day.

Conclusion

Neglected and inappropriately managed postpartum vulvar hematoma can cause significant maternal morbidity; therefore, timely surgical exploration, ligation of bleeding vessels, and obliteration of dead space can avert severe maternal complications