Puerperal genital haematomas


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Puerperal genital haematomas

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Puerperal genital haematomas

  1. 1. Puerperal genital haematomas Prof Aboubakr Elnashar Benha university HospitalAboubakr Elnashar
  2. 2. Contents  Introduction  Incidence  Types  Etiology  Risk factors  Presentation and DD  Investigations  Management  Prevention  Conclusion Aboubakr Elnashar
  3. 3. Introduction Relatively uncommon  ± serious morbidity and even maternal death.  ± difficult to diagnose {symptoms non-specific and bleeding is often concealed}. Haematoma: localized collection of blood outside of blood vessels > 2.5 cm Aboubakr Elnashar
  4. 4. Incidence 1:300 to 1:1000 deliveries (Thakar and Sultan 2009) >4 cm: 1/1000 deliveries. Supralevator < infralevator Surgical intervention: 1/1000 deliveries Aboubakr Elnashar
  5. 5. Types I. Infralevator: below the levator ani muscle usually around vulva, perineum and lower vagina 1. Vulval: limited to the vulval tissues superficial to the anterior urogenital diaphragm. Haematoma: evident on the vulva. 2. Vulvovaginal Evident on the vulva but extend into the paravaginal tissues. Aboubakr Elnashar
  6. 6. Aboubakr Elnashar
  7. 7. Vulvovaginal Aboubakr Elnashar
  8. 8. 3. Paravaginal confined to the paravaginal tissues in the space bounded inferiorly by the pelvic diaphragm and superiorly by the cardinal ligament. not obvious externally but can be diagnosed by vaginal examination. often occludes the vaginal canal and extends into the ischiorectal fossa. Aboubakr Elnashar
  9. 9. II. Supralevator: Supravaginal=subperitoneal Spread upwards and outwards beneath the broad lig. or downwards to bulge into the wall of the upper vagina, or backwards into the retroperitoneal space. Aboubakr Elnashar
  10. 10. Paravaginal haematoma: Supralevator Aboubakr Elnashar
  11. 11. Aboubakr Elnashar
  12. 12. Aetiology Injury Direct: episiotomy, forceps or Indirect: radial stretching of the birth canal as the fetus passes through. 80 %: failure to achieve haemostasis e.g. at the apex of an episiotomy or tear. 20 %: concealed ruptured vessel with an apparently intact perineum (Thakar and Sultan 2009) 50 %: spontaneous delivery. Coagulopathies: von Willebrand disease, are rarer causes. Aboubakr Elnashar
  13. 13. I. Infralevator Usually associated with vaginal birth 1.Vuval or vulvovagial injury to the branches of the pudendal artery: posterior rectal transverse perineal posterior labial arteries 2. Paravaginal Injury to descending branch of the uterine artery. Aboubakr Elnashar
  14. 14. {‫عمر‬Vulval vulvovaginal Infralevator paravaginal Supralevatolr Aboubakr Elnashar
  15. 15. II. Supralevator Injury to uterine artery branches in the broad ligament. May occur after spontaneous birth More commonly operative vaginal birth difficult CS Due to an extension of a tear of the cervix, vaginal fornix or uterus Aboubakr Elnashar
  16. 16. Risk factors Episiotomy Instrumental delivery Primiparity Prolonged 2nd stage of labour Macrosomia Vulval varicosities Aboubakr Elnashar
  17. 17. Presentation and differential diagnosis Onset usually within a few hours of delivery. Speed of diagnosis depend on extent of the bleeding associated consequences level of awareness of medical staff. Aboubakr Elnashar
  18. 18. Classical symptoms Pain: Excessive perineal pain is a hallmark symptom its presence should prompt pelvic examination. Over a few days in a small haematoma in an Episiotomy Restlessness Rectal tenesmus (constant need to empty bowels) within a few hours after birth Aboubakr Elnashar
  19. 19. Collapse: within a few hours of delivery in large haematoma Bleeding Continued vaginal if a haematoma ruptures into the vagina DD: from other causes of PPH: e.g. atonic uterus. Rare symptoms  Retention of urine  unexplained pyrexia. Aboubakr Elnashar
  20. 20. Vulval and vulvovaginal haematomas Typical symptoms: pain and swelling in the perineum. DD:  abscesses.  pain of an episiotomy  tear or  haemorrhoids: Examination Aboubakr Elnashar
  21. 21. Paravaginal haematomas Typical symptoms: Rectal pain lower abdominal pain (often vague) symptoms of hypovolaemia: often out of proportion to revealed blood loss. These non-specific symptoms can readily be attributed to other causes: delay the correct diagnosis. Aboubakr Elnashar
  22. 22. Supravaginal haematoma Symptoms: Abdominal pain no vaginal symptoms. Signs hypovolaemia: collapse. shock: elevated pulse, decreased BP, pale, sweaty, clammy, dizzy Abdominal examination: uterus is deviated upward and laterally, to the opposite side from the broad ligament haematoma. DD: pelvic mass: abscess intra-abdominal bleeding. Aboubakr Elnashar
  23. 23. Investigations Blood tests CBC Coagulation screen mandatory {determine baseline values} should be repeated as necessary. Cross matching according to the clinical picture. {Transfusion more likely to be necessary with paravaginal and subperitoneal than with vulval haematomas}. . Aboubakr Elnashar
  24. 24. Imaging US, CT and MRI diagnosing haematomas above pelvic diaphragm assess any extension into the pelvis MRI location, size and extent of a haematoma monitoring progress or resolution. DD between other causes of a pelvic mass: abscess or endometrioma. Aboubakr Elnashar
  25. 25. Management Aims prevent further blood loss, minimise tissue damage, relieve pain reduce the risk of infection. Prompt resolution: reduced Scarring postpartum pain dyspareunia. Aboubakr Elnashar
  26. 26. Assessment: high index of suspicion is required.  Prompt examination of vulva, perineum, vagina: Identify site of haematoma Whether it is still expanding Estimate blood loss Monitor ongoing blood loss: often underestimated Aboubakr Elnashar
  27. 27. 1. Resuscitative measures first line of treatment.  Fluid replacement: crystalloids/colloids: Hartmann’s, sodium chloride 0.9 %, Gelafusine  Assessment of coagulation status: essential if heavy bleeding or signs of hypovolaemia.  Blood should be available for transfusion.  Urinary catheter monitor fluid balance avoid possible urinary retention resulting from pain, oedema or the pressure of a vaginal pack. Aboubakr Elnashar
  28. 28. 2. Conservative management  Indication Small (5 cm), static haematomas  Not for  Larger haematomas: longer stays in hospital An increased need for antibiotics and blood transfusion and greater subsequent operative intervention.  Haematoma that expands acutely is unlikely to settle with conservative measures}. Aboubakr Elnashar
  29. 29.  Steps  Broad spectrum antibiotics  Ice packs  Analgesia: 1. Regular paracetamol 2. NSAID: diclofenac [Voltaren®] 50 mg tds), contraindications: pp hge, PET, renal disease, concurrent use of other NSAIDs, aspirin, digoxin 3. intramuscular opioid 4. Avoid rectal administration of analgesics  Regular review {ensure that bleeding has settled and haematoma has resolved}. Aboubakr Elnashar
  30. 30. 3. Surgical  Indication Large (5 cm) vulval haematomas  Steps:  Adequate anaesthesia  Evacuation: Incisions should be placed to minimise scarring (this is often medially). Clot should be evacuated Any apparent bleeding points ligated. Aboubakr Elnashar
  31. 31.  Primary closure The exact origin of the bleeding is rarely identified The space should be closed with deep mattress sutures and the overlying skin reapproximated without tension. Care must be taken to avoid damage to contiguous structures (such as the ureters, bowel and bladder) during repair procedures.  Compression The vagina should be packed tightly for 12–24 h. Aboubakr Elnashar
  32. 32.  Drains: usually brought through a separate site distant from the repair. useful to highlight ongoing or recurrent bleeding. defeat the object of packing, which is to tamponade bleeding vessels.  What is optimal management ? primary repair (with or without drains) primary repair with packing, and packing alone have all been advocated. Aboubakr Elnashar
  33. 33. Subperitoneal haematomas  1. Small, stable: conservative. 2. Larger:  Surgical abdominal approach: identification and ligation of bleeding vessels.  Arterial embolisation under radiological control is now an alternative  Broad spectrum antibiotic  Regular review {ensure that bleeding has settled and haematoma has resolved}. Aboubakr Elnashar
  34. 34. Persistent bleeding  {Haematomas can recur after surgical management}.  Continued monitoring for signs of blood loss: essential.  If first line management fails:  further surgical intervention  The haematoma cavity should be explored again.  Ligation of the internal iliac artery, or even hysterectomy, may be necessary. or  occlusion of the internal iliac artery/ies by balloon catheter or embolisation Aboubakr Elnashar
  35. 35. 4. Pelvic arteriography and arterial embolisation Success rate: over 90%. Steps: Pelvic circulation is accessed via the femoral a Angiography is used to identify bleeding vessels before selective embolisation. Embolic agents temporary: absorbable, gelatin-impregnated sponges permanent: metal coils. Performed under light sedation take 1–2 h Aboubakr Elnashar
  36. 36. Complications Uncommon: 9% low grade fever pelvic infection ischaemic buttock pain temporary foot drop groin haematoma Vessel perforation. Use of temporary embolic agents: reduces the risk of ischaemic problems. Aboubakr Elnashar
  37. 37. Advantages: preserve fertility (despite exposure of the ovaries to ionising radiation) most women continue to menstruate. avoid the risks of laparotomy, although the option of surgery is retained. limitation experience equipment. Indication first line treatment for persistent bleeding Aboubakr Elnashar
  38. 38. (a) Digital subtraction angiography (DSA) image of left internal iliac artery runs showing contrast extravasation (arrows) from the inferior vesicle branch (arrowheads) indicating an active bleed. (b) An oblique view showing more extravascular contrast accumulation in the delayed phase (arrows). Aboubakr Elnashar
  39. 39. Post embolisation image showed blockage of the inferior vesicle artery and the bleeding was successfully arrested. Aboubakr Elnashar
  40. 40. Prevention Good surgical technique, with attention to haemostasis in the repair of lacerations and episiotomies However, haematomas are not unavoidable. Aboubakr Elnashar
  41. 41. Conclusion  Genital tract haematomas are uncommon and can cause diagnostic confusion.  Clinicians must be alert to haematomas as a dd of postpartum pain and bleeding. Aboubakr Elnashar
  42. 42.  Key elements of management of puerperal genital haematoma  The most important factor in correct diagnosis is clinical awareness  Excessive perineal pain is a hallmark symptom: its presence should prompt examination  Aggressive fluid resuscitation/blood transfusion may be required Aboubakr Elnashar
  43. 43.  Coagulation status should be monitored  Treatment should be carried out in an operating theatre  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  Awareness should be maintained after primary repair/packing, as recurrence is common Aboubakr Elnashar
  44. 44. Aboubakr Elnashar
  45. 45. Thank You Aboubakr Elnashar Aboubakr Elnashar