Version May 2024
INTRODUCTION — The pregnant uterus, vagina, and vulva have rich vascular supplies that are at risk of trauma during the birth process, and trauma may result in formation of a hematoma. Puerperal hematomas occur in 1:300 to 1:1500 deliveries and, rarely, are a potentially life-threatening complication of childbirth [1,2].
Most puerperal hematomas arise from bleeding lacerations related to operative deliveries or episiotomy; however, a hematoma may also result from injury to a blood vessel in the absence of laceration/incision of the surrounding tissue (eg, pseudoaneurysm, traumatic arteriovenous fistula) [1,3-6]. Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams, preeclampsia, prolonged second stage of labor, operative vaginal delivery, multifetal pregnancy, vulvar varicosities, or clotting disorders [3,7-9]. Each of these risk factors is discussed in more detail individually:
●(See "Preeclampsia: Clinical features and diagnosis".)
●(See "Labor: Diagnosis and management of a prolonged second stage".)
●(See "Neonatal complications of multiple births".)
●(See "Vulvovaginal varicosities and pelvic congestion syndrome".)
●(See "Approach to the adult with a suspected bleeding disorder".)
In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. We encourage the reader to consider the specific counseling and treatment needs of transgender and gender-expansive individuals.
COMMON LOCATIONS — The most common locations for puerperal hematomas are the vulva, vaginal/paravaginal area, and retroperitoneum. While extremely rare, bowel hematoma is also a reported complication of delivery [10].
Vulva — 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 (figure 1) [1,3]. These vessels are typically located in the superficial fascia of the anterior (urogenital) or posterior pelvic triangle (figure 2). 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 [9].
Vaginal/paravaginal area — Vaginal/paravaginal hematomas result from injuries to branches of the uterine artery, mainly the descending branch (figure 3) [1,9]. These hematomas are commonly associated with forceps delivery, but may also occur during spontaneous delivery.
In contrast to the vulva, 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 (figure 4). Most vaginal/paravaginal hematomas also extend into the upper portion of the vaginal canal, and may occlude its lumen. Extension and dissection into the retroperitoneum may occur and form a palpable tumor above Poupart's ligament. Dissection may also extend cephalad, potentially reaching the lower margin of the diaphragm.
Retroperitoneum — Compared with vulvar and vaginal/paravaginal hematomas, retroperitoneal hematomas are a rare complication of childbirth. In peripartum women, retroperitoneal hematomas are typically caused by injury to branches of the hypogastric (ie, internal iliac) artery. The most common childbirth-related causes are (1) laceration of a uterine artery during hysterotomy or from uterine rupture and (2) extension of a paravaginal hematoma. Other causes include trauma, anticoagulation, ruptured ectopic pregnancy, and rupture of an aneurysm in the abdominopelvic vasculature. The resulting hemorrhage can be quite severe and lead to immediate hemodynamic instability.
CLINICAL MANIFESTATIONS AND DIAGNOSIS — The diagnosis of most puerperal hematomas is based upon the presence of characteristic symptoms and findings on physical examination. Symptoms usually develop in the first 24 hours after delivery. The clinical manifestations of puerperal hematomas vary depending upon the location of the hematoma. Although small hematomas may be asymptomatic, most hematomas are associated with pain and mass effects. A large mass may displace the vagina or rectum or both and hemodynamic instability may result from continued significant bleeding.
●Vulvar hematomas usually present with rapid development of a severely painful, tense, compressible mass covered by skin with purplish discoloration [1]. A vulvar hematoma may be an extension of a vaginal hematoma that has dissected through loose subcutaneous tissue into the vulva.
●Vaginal hematomas often present with rectal pressure; however, hemodynamic instability due to bleeding into the ischiorectal fossa and paravaginal space may be the first indication of a vaginal hematoma, and can result in hypovolemic shock. On physical examination, a large mass protruding into the vagina is usually obvious [3].
●Retroperitoneal hematomas extending between the folds of the broad ligament may be asymptomatic initially. Due to the significant amount of blood that can accumulate in the retroperitoneal space, these patients often present with symptoms of hemodynamic instability, including tachycardia, hypotension, or, in the most severe cases, shock. Patients with a retroperitoneal hematoma usually do not present with pain unless the hematoma is associated with trauma. Palpation of an abdominal mass or fever can also be signs of a retroperitoneal hematoma.
●A bowel hematoma may be diagnosed on the basis of diagnostic imaging performed to evaluate a suspected obstetric hematoma or bowel symptoms such as nausea, vomiting, cramping, abdominal pain and/or obstipation.
Of note, the patient may require analgesia in order to allow a thorough examination, as vulvar and perineal trauma can be associated with pain and discomfort out of proportion to the size of the injury due to the sensitivity of this area.
Diagnostic imaging — Diagnostic imaging of suspected vulvar or vaginal hematomas is unlikely to provide clinically important information unobtainable by a thorough physical examination, and is rarely necessary. However, diagnostic imaging may be useful in the following settings:
●To evaluate the expanding hematoma.
●To identify rare cases of arterial bleeding in patients with a rapidly expanding hematoma.
●To identify nonpalpable hematomas in puerperal women with pain or pressure suggestive of a hematoma, particularly retroperitoneal hematomas [11]. Puerperal hematomas should be suspected in all postpartum patients who demonstrate signs of acute blood loss or hypovolemia, such as unexplained tachycardia or decreased urine output. As with all cases of hemorrhage (both obstetric and nonobstetric), imaging studies should not delay appropriate intervention to stabilize the patient and control bleeding if the patient is hemodynamically unstable.
When imaging is indicated, we suggest ultrasound for initial evaluation, followed by computed tomography if there is a suspicion for a retroperitoneal hematoma that cannot be visualized on ultrasound.
●Ultrasound (sonography) – Ultrasound is generally available, easy to perform, and provides quick diagnostic information. Either transperineal or transabdominal approach can evaluate patients with suspected hematoma, unexplained vulvovaginal pain, or concern for occult bleeding [12]. Transabdominal ultrasound requires the patient have a full bladder while the transperineal approach does not. Perineal ultrasound is discussed elsewhere. (See "Ultrasound examination of the female pelvic floor", section on 'Perineal (pPFUS)'.)
●Computed tomography (CT) – Arteriovenous malformations have been reported in association with hematoma formation. The use of intravenous contrast at the time of computed tomography can aid in diagnosis in these cases [5]. Information obtained from diagnostic imaging can facilitate the decision-making process regarding conservative versus interventional management and the appropriate interventional technique.
●Magnetic resonance imaging (MRI) – Magnetic resonance imaging is more time-consuming, expensive, and less readily available than ultrasound or CT, but not necessarily more useful in this setting. (See "Initial evaluation and management of blunt abdominal trauma in adults", section on 'Imaging studies'.)
INITIAL APPROACH AND PATIENT PREPARATION — Recognition of a hematoma and prompt stabilization of the patient are the initial steps in the management of all hematomas. Thorough physical examination of the abdomen, vulva, vagina, and rectum (including visual inspection of the external genitalia, vagina, and cervix) should be performed to determine the location and size of the hematoma.
Hemodynamically stable patients almost always have venous bleeding; arterial bleeds invariably result in hemodynamic instability. If the patient is hemodynamically stable, we place a large-bore intravenous line to administer crystalloid. If the patient is hemodynamically unstable, we place two large-bore intravenous lines and begin volume resuscitation with crystalloid and blood products (ie, packed red blood cells) as clinically indicated to stabilize the patient as we make preparations for surgical intervention or embolization via interventional radiology.
We also order a complete blood count, fibrinogen level, prothrombin time, and partial thromboplastin time to determine baseline levels and whether a bleeding diathesis is present. It is important to remember that the initial hemoglobin value does not reflect the amount of acute blood loss. In most cases, we have four units of packed red blood cells available for transfusion.
Consultation with an anesthesiologist is important, as repair of large and expanding puerperal hematomas almost always requires regional or general anesthesia to control pain from retraction to expose the surgical field and from extensive suturing. Incision of a vulvar hematoma can be attempted using local anesthesia alone (subcutaneous infiltration with 1% lidocaine); however, the surgical team should be prepared for more aggressive anesthesia if heavy bleeding is encountered or deep suturing becomes necessary. The use of pudendal block is generally not practical, given the physical difficulty of getting around the hematoma to appropriately administer the block.
An obstetrician/gynecologist with expertise in the management of patients with expanding hematomas should be available, as first line therapy is usually surgical intervention and control of bleeding can be difficult. Consultation with an interventional radiologist is another option, especially for retroperitoneal hematomas (see 'Management' below). Percutaneous transcatheter interventional procedures (ie, angiographic embolization) have been used in the management of vulvovaginal hematomas and for retroperitoneal bleeding as a first-line therapy.
There are no data regarding the value of placing all patients with hematomas on antibiotics. We generally administer antibiotics (for surgical site prophylaxis) to patients undergoing surgical intervention. If signs of infection are present, treatment with broad spectrum antibiotics is initiated and continued until resolution of the infection. Generally, endocarditis prophylaxis is not indicated for minor vaginal or vulvar procedures in the absence of clinical infection.
MANAGEMENT — The management of puerperal hematomas is based on practice patterns established over the years, rather than clinical trials with clearly defined outcomes. The three primary approaches for managing puerperal hematomas are (1) conservative management with observation and supportive care, (2) surgical intervention, and (3) selective arterial embolization. The literature is inconclusive regarding the benefits of conservative treatment versus surgical intervention [13].
In general, patients who are conservatively managed should be observed closely. It is essential to monitor for signs of hypovolemia, suggestive of persistent and severe hemorrhage. Monitoring should be undertaken in an acute care area, such as an obstetric unit recovery area where vital signs (including urinary output) can be monitored at least hourly.
It is important to keep in mind the usual hemodynamic changes that occur in the postpartum period. Patients can experience significant blood loss without changes in blood pressure. Therefore, signs of decreased end-organ perfusion (such as lethargy and decreased urinary output) should prompt reexamination of the patient.
Most patients will require administration of analgesia (including narcotics) since hematomas can be quite painful. While the effects of these medications need to be taken into account when assessing overall status, changes in mental status should not automatically be attributed to these medications, especially when other signs point toward continued blood loss.
Laboratory studies may be needed every four to six hours, depending upon the clinical presentation of the patient. Imaging modalities, such as ultrasound, are performed serially, as needed, to help determine if there is expansion of the hematoma. The advantage of ultrasound over CT is that ultrasound allows rapid bedside evaluation of the patient and makes serial imaging examination more feasible.
In any case, since the clinical presentation of obstetric hematomas can be variable, it is important for the physician to continually assess the overall status of the patient taking into account all available data, rather than focusing on any particular endpoint. If the decision is made to surgically evacuate the hematoma, the procedure should be performed in an operating room to optimize positioning, visualization, and access to other resources that may not be immediately available in a labor and delivery room or procedure room (such as electrocautery, suction device, and surgical retractors).
Vulvar hematomas — Small, nonexpanding vulvar hematomas will often resolve with conservative management, including analgesia and application of cold packs. They are best left undisturbed to avoid introducing bacteria and undertaking a potentially difficult and unnecessary surgical procedure. The rationale for conservative management is that soft tissue swelling and space limitations will result in tamponade of bleeding vessels. Patients may be uncomfortable with such swelling, but they should be reassured the body will naturally reabsorb the blood and edema over time. Some hematomas may rupture spontaneously.
Ice packs applied to the perineum for the first 24 hours help to minimize swelling, and narcotic or nonnarcotic analgesia should be administered to manage pain. Large vulvar hematomas often interfere with urination so a Foley catheter should be placed upon initial evaluation. Placement after obstruction has occurred may not be possible without sedation or anesthesia. These patients should be monitored closely (as described above), otherwise bleeding that tracks posteriorly, vaginally, or into the retroperitoneum may not be recognized promptly.
There are no proven criteria that can be used to select vulva hematomas likely to have a better outcome with surgical intervention rather than supportive care [1,4,14,15]. One group suggested surgical intervention when the patient had significant pain or expansion of the hematoma, or if the hematoma was >5 cm or had estimated volume >200 mL [15]. Another group advised surgical intervention if the product of the longitudinal dimension and transverse dimension is ≥15 cm2 [13]. There is a general consensus that prompt surgical intervention is necessary if there is expansion of the hematoma on physical examination or imaging studies or a falling hematocrit, as persistent hemorrhage can lead to hemodynamic instability or put the tissue at risk of necrosis.
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.
We reapproximate the space created by the hematoma 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 sandbag or a one liter bag of intravenous fluid 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.
Suturing near the clitoris or on the labia may result in more postoperative discomfort than if the area of the evacuated hematoma is left to heal by secondary intention; therefore, these areas are sutured only if there is persistent bleeding or the defect is large.
Vaginal hematomas — The approach to vaginal hematomas is similar to that for vulvar hematomas. As with vulvar hematomas, vaginal hematomas larger than approximately 4 cm may need to be evacuated [13,15]. Patients conservatively managed are followed with the approach described above (see 'Vulvar hematomas' above). If surgical intervention is required, good surgical exposure is important, as these hematomas are less accessible than vulvar hematomas. Evacuation usually needs to be done under general or regional anesthesia in an operating room (rather than a labor or procedure room), where good lighting, appropriate surgical instruments, and a surgical assistant should be available.
If the hematoma is at the site of a laceration that has been repaired, the repair should be taken down to evacuate the hematoma. The hematoma cavity is inspected to determine the extent of the injury and identify bleeding vessels, which are individually ligated. Usually diffuse oozing is noted, rather than bleeding from a single vessel. Most clinicians close the defect in layers using a fine, rapidly absorbable synthetic suture. Closure by secondary intention offers the advantage of direct visualization of any ongoing bleeding, but data on the risks of infection or continued bleeding with this approach are limited.
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. If electrocautery is used to achieve hemostasis, it is important to avoid deep or widespread thermal injury because of the vagina's proximity to the bowel and bladder, as well as risk of infection in the resulting necrotic tissue. We close the vaginal epithelium with a running locked absorbable suture. The anchoring stitch is placed above the apex of the laceration, and each stitch extends to the base of the opening to avoid creating pockets for hematoma/seroma formation.
Vaginal packing with gauze or a balloon (eg, Bakri, Sengstaken-Blakemore, balloon rectal tube) [16,17] for 12 to 24 hours may aid in tamponade. We do not routinely place drains in the absence of infection, although others may use a closed system drainage [15]. A Foley catheter is necessary to drain the bladder in the presence of a vaginal pack or significant edema.
As discussed above, the possibility of retroperitoneal bleeding from torn and retracted vessels should also be considered if the patient becomes hemodynamically unstable.
Retroperitoneal hematomas — There are no large or randomized trials comparing surgical versus angiographic approaches to management of retroperitoneal hematomas. Because the retroperitoneal space is large, many patients with a retroperitoneal hematoma require either surgical or angiographic intervention. However, since it is a confined space, conservative management may suffice because the hematoma tamponades slowly bleeding vessels.
●Surgery – Laparotomy is required in virtually all cases of puerperal retroperitoneal bleeding. Most of these patients are hemodynamically unstable and most cases are associated with uterine rupture or cesarean delivery, both of which require laparotomy for repair of the uterus.
•Surgical ligation – Hemostasis can be achieved after opening the retroperitoneal space by identifying and ligating the lacerated blood vessel or by ligating the hypogastric artery. As with the other types of puerperal hematomas, identification of a bleeding vessel may be difficult. Ligation of the ipsilateral hypogastric artery usually stops the bleeding and avoids the delay associated with searching for the discrete source of bleeding. If bleeding does not respond to ipsilateral hypogastric artery ligation, then bilateral hypogastric artery ligation should be performed. Although hypogastric artery ligation reduces pelvic blood flow by approximately one-half, it has a greater impact on pulse pressure distal to the ligation (85 percent reduction), reducing pulse pressures to that of the venous circuit which promotes hemostasis [18]. The procedure is described separately. (See "Management of hemorrhage in gynecologic surgery", section on 'Strategies for persistent bleeding'.)
•Retroperitoneal packing – Retroperitoneal packing is a technique used by trauma surgeons to tamponade retroperitoneal hemorrhage related to pelvic fracture; it can also be useful to control retroperitoneal bleeding in obstetric patients. Through a midline incision just above the symphysis pubis, the fascia is divided and the space of Retzius accessed, with care to avoid cystotomy. Two to three laparotomy sponges are placed sequentially in the retroperitoneal space, beginning at the sacroiliac joint and staying deep to the pelvic brim [19]. The same procedure is then performed on the opposite side. The resulting tamponade generally leads to prompt cessation of blood loss. The packs are removed or exchanged 24 to 48 hours later, with care to avoid disruption of clot. (See "Peripartum hysterectomy for management of hemorrhage", section on 'Pelvic packing'.)
●Selective arterial embolization – Selective arterial embolization is an effective technique for control of postpartum uterine hemorrhage and hemorrhage related to pelvic soft tissue and/or vascular trauma. Case reports have also described successful percutaneous transcatheter identification and embolization of bleeding retroperitoneal vessels in postpartum women, generally after conventional suture and packing methods had failed [2,20-26]. A case report has also described the use of selective arterial embolization in the setting of pelvic hematoma due to traumatic arteriovenous fistula [5]. We consider this procedure for the hemodynamically stable patient who (1) has evidence of continued bleeding during recovery from delivery and in whom there is a high suspicion of retroperitoneal bleeding or (2) has failed surgical intervention. There is minimal information on subsequent pregnancy outcome after this procedure. (See "Initial evaluation and management of blunt abdominal trauma in adults".)
●Resuscitative endovascular balloon occlusion – Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a temporizing measure to limit blood loss in cases of obstetrical hemorrhage while hysterectomy or selective arterial embolization is being performed. For the hemodynamically unstable patient, use of the REBOA can assist in preparing the patient for the operating room and/or intraoperative evaluation and treatment of a retroperitoneal hematoma. While data on use of REBOA for this indication are limited to case series, it has the potential to be life-saving in cases of catastrophic obstetrical hemorrhage [27,28].
●(See "Postpartum hemorrhage: Management approaches requiring laparotomy".)
●(See "Postpartum hemorrhage: Medical and minimally invasive management".)
Bowel hematomas — There are insufficient data on bowel hematomas after delivery to guide management. Treatment should be guided by whether the bowel hematoma is an isolated finding or is found in the setting of a retroperitoneal hematoma. If the bowel hematoma is an isolated finding, is nonexpanding, and was diagnosed during an evaluation for suspected bowel obstruction, we recommend managing the patient according to tenets of management of mechanical small bowel or colorectal obstruction. (See "Management of small bowel obstruction in adults".)
POSTOPERATIVE CARE — Perineal hygiene with Sitz baths and gentle cleansing with saline rinse are encouraged after vulvar surgery. Adequate analgesia should be prescribed. We suggest pelvic rest (no vaginal coitus or placement of tampons or vaginal medications) for four to six weeks, depending upon the extent of the injury, to avoid disruption of healing tissues. Pressure necrosis of the swollen external genitalia may be prevented by having patients rest primarily on their side or back. At discharge, patients should be counseled to call their provider promptly if they develop fever, new or worsening pain, or bleeding.
SUMMARY AND RECOMMENDATIONS
●Etiology – Most puerperal hematomas arise from bleeding lacerations related to operative deliveries or episiotomy; however, a hematoma may result from spontaneous injury to a blood vessel in the absence of laceration/incision of the surrounding tissue. (See 'Introduction' above.)
●Anatomic location – The most common locations for puerperal hematomas are the vulva, vagina/paravaginal area, and retroperitoneum. (See 'Common locations' above.)
●Diagnosis – The diagnosis of most puerperal hematomas is based upon the presence of characteristic symptoms and findings on physical examination. (See 'Clinical manifestations and diagnosis' above.)
●Clinical presentation – Most hematomas present with pain within 24 hours of delivery. A mass or rectal pressure are other common signs and symptoms. Hemodynamic instability secondary to blood loss into the abdomen and pelvis is usually the first sign of a retroperitoneal hematoma. (See 'Clinical manifestations and diagnosis' above.)
●Treatment – Treatment depends on the size and location of the hematoma.
•Nonexpanding – We suggest conservative management (ice packs, analgesia) of small nonexpanding hematomas (Grade 2C).
•Expanding – We suggest prompt surgical intervention of expanding hematomas (Grade 2C).
•Retroperitoneal bleeding – Laparotomy is required in virtually all cases of puerperal retroperitoneal bleeding, as most of these patients are hemodynamically unstable and most cases are associated with uterine rupture or cesarean delivery, both of which require laparotomy for repair of the uterus. (See 'Retroperitoneal hematomas' above.)
•Selective arterial embolization – We suggest using selective arterial embolization as an alternative to surgical intervention in the hemodynamically stable patient or when surgical intervention fails to control the bleeding from a puerperal hematoma (Grade 2C). (See 'Management' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Daniel Kiefer, MD, who contributed to an earlier version of this topic review.
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