Vulvovaginal hematoma - Dr Mitra Saxena

This presentation has a complete description of Vulvo-Vaginal hematoma, its causes , clinical features and management strategy. Hematoma can happen in case of episiotomy given during childbirth

1. Greetings 04-09-2021 HIGHGRAD E3 1

2. Vulvovaginal Hematoma Dr Mitra Saxena MD,DNB,FICOG,FICMH Chairperson Practical Obstetrics Committee FOGSI

3. ANTICIPATE,PREVENT And MANAGE ,Mantra for SAFE OBSTETRICS 20/08/2021 Obstetric Update Bhagalpur 3

4. 20/08/2021 Obstetric Update Bhagalpur 4 Tackling the bugbear Vulvovaginal hematoma

5. WHAT IS UNIQUE TO VULVOVAGINAL HEMATOMA Insidious in Onset, From Innocuous to Devastating Will happen in VIPs COMPLICATE an already exhausted obstetrician’s life…..

6. Pregnant uterus, Vagina, Vulva have rich vascular supplies that are at risk of Trauma during the birth process ~Hematoma Puerperal hematomas occur 1:300 to 1:1500 deliveries a potential life threatening complication of childbirth .

7. Classification Vulvar hematoma Vaginal hematoma Vulvovaginal hematoma Broad ligament hematoma Retroperitoneal hematoma

8. WHO ARE AT RISK FOR PUERPERAL HEMATOMAS Primiparas OVD, Episiotomy (85-90%) Big babies Over 4kg PIH , Prolonged second stage Multifetal preg Precipitate labour Other reasons Vulvar Varicosities Clotting Disorder Injury to BV, Pseudo Aneurysm , Traumatic AV fistula Saleem Z, Rydhstrom H. Vaginal hematoma during parturition: a population-based study. Acta Obstet Gynecol Scand 2004;83:560–2

9. Detrimental to VVH DELAYED DIAGNOSIS INCOMPLETE ,INAPPROPRIATE MANAGEMENT DO IT RIGHT THE FIRST TIME 20/08/2021 Obstetric Update Bhagalpur 12

10. Vaginal venous plexus surrounds the vagina Entire venous pool becomes tremendously engorged during the latter months of pregnancy WHAT WILL BLEED

11. What will bleed?!? 20/08/2021 Obstetric Update Bhagalpur 15 Vulva  — Most vulval hematomas result from injuries to branches of the pudendal artery (inferior rectal, perineal, posterior labial, and urethral arteries; the artery of the vestibule; and the deep and dorsal arteries of the clitoris) that occur during episiotomy or from perineal lacerations Vaginal/paravaginal hematomas result from injuries to branches of the uterine artery, mainly the descending branch ,vaginal. AND THE RICH VENOUS PLEXUS

12.  Most vulvar hematomas result from injuries to branches of the pudendal artery (inferior rectal, perineal, posterior labial, and urethral arteries; the artery of the vestibule; and the deep and dorsal arteries of the clitoris) that occur during episiotomy or from perineal lacerations These vessels are typically located in the superficial fascia of the anterior (urogenital) or posterior pelvic triangle The superficial compartment of the anterior triangle communicates with the subfascial space of the lower abdomen below the inguinal ligament. Extension of bleeding in the anterior triangle is limited by Colles ' fascia and the urogenital diaphragm, while the anal fascia limits extension of bleeding in the posterior triangle. As a result, bleeding is directed toward the skin where the loose subcutaneous tissues afford little resistance to hematoma formation. Superficial hematomas can extend from the posterior margin of the anterior triangle (at the level of the transverse perineal muscle) anteriorly over the mons to the fusion of fascia at the inguinal ligament. Necrosis caused by pressure and rupture of the tissue surrounding the hematoma may lead to external hemorrhage

13. Vessels in the vagina are surrounded by soft tissue and do not lie in the superficial fascia; therefore, trauma to these vessels can lead to a large accumulation of blood in the paravaginal space or ischiorectal fossa

14. Infra levator : vulval or vulvo vaginal 2 ,3 Supra levator : Paravaginal or supravaginal / subperitoneal 1

15. Vulvovaginal haematoma injury to br of Pudendal art… Broad ligament haematoma Uterine ,Cervical ,vaginal art 20/08/2021 Obstetric Update Bhagalpur 19

16. Pathogenesis Two thirds due to failure to achieve hemostasis particularly at the upper end of incision / tear deep ext of episiotomy Can occur without perineal laceration / incision due to stretching and avulsion of vessels during delivery Sheikh GN. Perinatal genital hematomas. Obstet Gynecol 1971; 3: 571–5

17. CLINICAL FEATURES AND DIAGNOSIS Symptoms develop insidiously in first 24 hrs Manifest according to the Location PAIN and MASS effect Displacement of Vagina, Rectum ,Uterus HEMODYNAMIC INSTABILITY

18. Presenting Symptoms and Signs Cardiovascular collapse Upward and lateral displacement of uterus Palpable bladder Rectal pressure Rectal or vaginal mass Vaginal or vulval swelling Continued vaginal bleeding Severe rectal/ vaginal / perineal pain TENESMUS Discoloration and swelling Urinary retention

19. Do we need any diagnostic modality ? Diagnosis is Clinical USG ,CT in Silent SL hematomas

20. Thorough physical examination of the abdomen, vulva, vagina, and rectum (including visual inspection of the external genitalia, vagina, and cervix)  location and size of the hematoma Recognition of a hematoma prompt stabilization of the patient  

21. Hemodynamically stable patients almost always have venous bleeding Arterial bleeds invariably result in hemodynamic instability

22. Surgical management: Preoperative considerations General Measures Maternal resuscitation Assessment of blood loss and replacement CBC, platelet count, coagulation profile Informed consents Antibiotics Analgesics OT Adequate anesthesia, lighting and assistance

23. Management (Vulvar) Conservative Small nonexpanding haematoma < 3 cm (5 cm) ice packs, analgesia ,frequent reassesments .(Grade2C) Prompt Surgical for expanding Hematoma - Evacuation hemostasis and repair - Evacuation hemostasis closed suction and vaginal packing - Cervical and vaginal exploration for any tears, repair by combined abdominal and vaginal approach - Internal artery ligation - Arterial embolization

24. The skin over the hematoma is incised and the clot evacuated. A suction/irrigation device may be helpful in clearing the clot and debris. Detectable bleeding points should be ligated if identified; however, in most cases, the lacerated vessel cannot be identified. Bleeding leading to a vulvar hematoma is often venous and from multiple sites. The specific vessels may be difficult to isolate to control the bleeding surgically.  the space created by the hematoma is approximated using interrupted or figure-of-eight stitches of a fine, rapidly absorbable, synthetic suture such as monocryl or polyglactin 910. It is important to avoid putting extra foreign material into the wound, as this increases the risk of infection. Pressure is maintained by placing a pad and T bandage over the area for 12 hours. These maneuvers usually prevent recurrence of the hematoma, even though a causative vessel was not identified and ligated. We do not pack or drain the hematoma cavity.

25. Surgical management: Supralevator More complicated due to extension into retroperitoneal space / broad ligament Exploration of cervix and upper vagina and repair of tears Full thickness Interrupted sutures Ensure identification of apex If apex not identified then a combined vaginal and abdominal approach for evacuation, hemostasis and repair The proximity of the bladder anteriorly, small bowel and rectum posteriorly, and the ureters and uterine vessels deep in the lateral vaginal fornices are important to consider when closing the defect, as they can be included in placement of large deep sutures Internal artery ligation U/L or B/L Hysterectomy

26. Arterial embolization Usually indicated in haematomas with intractable bleeding usually supralevator Bloom AI et al Arterial embolisation for persistent primary postpartum haemorrhage: before or after hysterectomy? BJOG 2004;111:880–4. Pelvic Packing for Intractable Obstetric Hemorrhage After Emergency Peripartum Hysterectomy: A Review Omar Touhami   1 ,  Arij Bouzid   2 ,  Sofiene Ben Marzouk   3 ,  Mahdi Kehila   4 ,  Mohamed Badis Channoufi   5 ,  Hayen El Magherbi   6 O obstet gynecol 2018 Pelvic packing should be part of the armamentarium available to the obstetrician whenever intractable pelvic hemorrhage is encountered .  2018 .  2018

27. Quoting a case of Dr Girija Shared in ICOG PPH Panel of TRAUMATIC PPH A pt who had RECURRENT VV H ,Twice managed in Periphery prior to referral Pt needed CT ,AP approach and IIL finally

28. Postoperative considerations Adequate replacement of blood and blood components Careful observation in a high dependency ward for 12-24 hrs Observe for recurrence Antibiotics Analgesics Measures to reduce thromboembolism Compression stockings, leg exercises SRC for 24 hrs

29. Prevention Ensure complete hemostasis SLOW & STEADY ,EPI Early detection( Post delivery I hr later PV) Vitals Pain Correct assessment of blood loss and replacement Early recourse to surgery DO IT RIGHT FIRST Antibiotics Documentation

30. Complications Hemorrhage Ureteric injury Sepsis Thromboembolism Maternal death Medicolegal litigation

31. LESSONS LEARNT The most important factor in correct diagnosis is clinical awareness and high index of suspicion Excessive perineal pain is a hallmark symptom: its presence should prompt examination Aggressive fluid resuscitation/blood transfusion may be required Coagulation status should be monitored Treatment should be carried out in an operating theatre

32. A urinary catheter should be used to prevent urinary retention and monitor fluid balance The threshold for using antibiotics should be low There is no evidence to support best management, which can be primary repair or packing, with or without insertion of a drain Vigilance should be maintained after primary repair / packing, as recurrence is common Proper documentation and communication can reduce the chances of litigation LESSONS LEARNT

33. HAVE YOU MANAGED A HEMATOMA OF YOURS OR OF A COLLEAGUE CAN YOU EVER FORGET THE PATIENTS? MY TWO PENCE , Delay the suturing but don’t delay the diagnosis Be a bit slow ..not too fast ..we are the best person to diagnose the hematoma …So if it’s a big episiotomy more reason not to rush … DEEP EPISIOTOMY, Close Muscle in two layers, PR,…Post Delivery Assessment Don’t ignore vessels or blood filling up..a bleeding vessel doesn’t disappear ..it will cause havoc if its ignored .Layer by layer HEMOSTASIS. POST OP PERIOD ..If Pt is C/O unbearable pain Pressure in rectum this could be a vaginal hematoma HONEST OPINION POLL

34. An Rh Negative booked G3P0A2 Full term preg delivered normally with episiotomy Was living at a distance, Pt complained of Pain unrelentlessly NOD gave injectable Voveran two times and dismissed the complaints Perineal care done Morning round at 8am Pt very uncomfortable though Happy at having delivered Vaginally and a healthy baby, Not ok with pain PV done Barely could put my finger ….. OT, Anaesthetist, Blood Transfusion Drained the hematoma, Ensured Hemostasis ….. A horror story …..20 years ago Pt always came back to me but to remind me would mention ..Main Wo HEMATOMA waali pt …

35. Primi FTP last minute conversion Platelets 80000 Counselled ,advised referral ,admitted on 27 th July Induced by cerviprime gel ,very fast progress,Took her in OT for Section Fetal distress ,Bearing down ,Delivered in OT by vacuum and Episiotomy . Despite Careful ,meticulous suturing ,Hematoma diagnosed within 2 hours Investigations sent hemogram ,Coagulation profile ,Consent ,In OT again ,Under Spinal anesthesia ,with a colleague ,Drained the hematoma ,and closed dead space ensuring hemostasis . I was mentally ,Physically ,Medicolegally prepared for NEXT PROCEDURE IIAL in this case

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