What are the common causes of vulvar hematoma. How is vulvar hematoma diagnosed and treated. What are the potential complications of untreated vulvar hematoma.

Understanding Vulvar Hematoma: An Overview

A vulvar hematoma is a collection of blood in the soft tissues of the vulva. While it’s most commonly associated with childbirth, it can occur in non-obstetric settings as well. The vulva, primarily composed of smooth muscle and loose connective tissue, is supplied by branches of the pudendal artery, making it susceptible to hematoma formation.

Prompt recognition and treatment of vulvar hematomas are crucial, as they can potentially be life-threatening if left undiagnosed and untreated. Early intervention can significantly reduce associated morbidity, improve patient outcomes, and shorten hospital stays.

Causes and Risk Factors of Vulvar Hematoma

Vulvar hematomas can result from various causes, both obstetric and non-obstetric. During childbirth, they may occur due to:

• Direct injury from episiotomy, vaginal laceration repairs, or instrumental deliveries
• Indirect injury from extensive stretching of the birth canal during vaginal delivery

Interestingly, most vulvar hematomas form after normal deliveries rather than complicated ones. Risk factors for developing vulvar hematoma during childbirth include:

• Instrumental delivery
• Episiotomy
• Primiparity (first-time pregnancy)
• Prolonged second stage of labor
• Macrosomia (large baby)
• Use of anticoagulants
• Coagulopathy
• Hypertensive disorders of pregnancy
• Vulvovaginal varicosity

In non-obstetric settings, vulvar hematomas can arise from:

• Trauma to the perineum (e.g., saddle injuries, falls)
• Insertion of foreign bodies
• Sexual assault
• Consensual sexual intercourse
• Surgery of the vulva
• Spontaneous vessel rupture (in rare cases)

Post-coital injury is reported to be the most common non-obstetric cause of vulvar hematoma.

Epidemiology of Vulvar Hematoma

Vulvar hematomas are more prevalent in the obstetric population, with an incidence ranging from 1 in 300 to 1 in 1000 deliveries. In non-obstetric settings, they account for approximately 0.8% of gynecological problems.

Non-obstetric vulvar hematomas follow a bimodal age distribution:

1. More common in childhood or early adolescence due to less developed labia majora
2. Increased occurrence in postmenopausal women due to vulvar and vaginal atrophy

Pathophysiology and Presentation of Vulvar Hematoma

A vulvar hematoma presents as a swollen, fluctuant lump beneath intact epidermis. It can be extremely tender to palpation. The rich blood supply of the vulva makes it prone to hematoma formation, with arterial bleeds primarily originating from branches of the pudendal artery.

The most common symptom of a vulvar hematoma is pain, which can be severe enough to interfere with mobility. Patients may describe it as perineal, abdominal, or buttock pain. Other symptoms and signs may include:

• Intermittent bleeding
• Urinary retention or micturition difficulties (due to mechanical urethral obstruction)
• Hemodynamic instability in severe cases

Symptoms typically develop within hours to days of the inciting event, depending on the severity of the condition.

Diagnosis and Evaluation of Vulvar Hematoma

When a vulvar hematoma is suspected, a thorough history and physical examination are essential. The healthcare provider should inquire about potential causes and risk factors, such as recent childbirth, trauma, or sexual activity.

Physical examination may reveal:

• A swollen, discolored, and tender vulvar mass
• Signs of hemodynamic instability in severe cases
• Urinary retention or difficulties with urination

In some cases, additional diagnostic tests may be necessary:

• Complete blood count to assess for anemia
• Coagulation studies to rule out bleeding disorders
• Imaging studies (e.g., ultrasound or CT scan) to determine the extent of the hematoma

Management Options for Vulvar Hematoma

The management of vulvar hematoma depends on its size, the patient’s clinical status, and the presence of ongoing bleeding. Treatment options include:

Conservative Management

For small, stable hematomas (<5 cm), conservative management may be appropriate. This includes:

• Ice packs to reduce swelling and pain
• Analgesics for pain relief
• Bed rest and elevation of the pelvis
• Close monitoring for signs of expansion or infection

Surgical Intervention

Surgical management is indicated for larger hematomas (>5 cm), rapidly expanding hematomas, or those causing significant symptoms. Surgical options include:

• Incision and drainage of the hematoma
• Ligation of bleeding vessels
• Placement of drainage catheters
• In severe cases, angiographic embolization may be necessary

Supportive Care

Regardless of the treatment approach, supportive care is crucial and may include:

• Pain management
• Antibiotics to prevent infection
• Blood transfusion in cases of significant blood loss
• Psychological support, especially in cases of trauma or sexual assault

Potential Complications and Prognosis

If left untreated, vulvar hematomas can lead to several complications:

• Severe pain and discomfort
• Infection and abscess formation
• Necrosis of surrounding tissues
• Rupture and significant blood loss
• Urinary retention or difficulties
• In rare cases, compartment syndrome or hemorrhagic shock

With prompt and appropriate treatment, the prognosis for vulvar hematoma is generally good. Most patients recover fully within a few weeks to months, depending on the severity of the hematoma and the treatment approach.

Prevention and Patient Education

While not all vulvar hematomas can be prevented, certain measures can reduce the risk, especially in obstetric settings:

• Careful perineal management during childbirth
• Judicious use of instrumental delivery
• Proper repair of episiotomies and lacerations
• Management of underlying conditions that may increase bleeding risk

Patient education is crucial for early recognition and treatment. Healthcare providers should counsel patients about:

• Signs and symptoms to watch for after childbirth or perineal trauma
• The importance of seeking prompt medical attention if symptoms develop
• Proper perineal care and hygiene to prevent complications

Are vulvar hematomas always related to childbirth? No, while vulvar hematomas are most commonly associated with childbirth, they can occur in non-obstetric settings as well. Trauma, sexual activity, and certain medical conditions can also lead to vulvar hematoma formation.

Can vulvar hematomas resolve on their own? Small vulvar hematomas (<5 cm) may resolve spontaneously with conservative management. However, larger hematomas or those causing significant symptoms often require surgical intervention for proper resolution and to prevent complications.

How long does it take for a vulvar hematoma to heal? The healing time for a vulvar hematoma can vary depending on its size and the treatment approach. With appropriate management, most patients recover within a few weeks to months. However, complete resolution of symptoms and any residual swelling may take longer in some cases.

Is follow-up care necessary after treatment for vulvar hematoma? Yes, follow-up care is important to ensure proper healing and to address any potential complications. Patients should be monitored for signs of infection, recurrence, or persistent symptoms. In some cases, additional interventions or supportive care may be necessary during the recovery period.

The management of vulvar hematoma requires a multidisciplinary approach, involving obstetricians, gynecologists, emergency physicians, and sometimes interventional radiologists. Effective communication and collaboration among healthcare providers are essential for optimal patient outcomes. By understanding the causes, recognizing the symptoms, and implementing appropriate treatment strategies, healthcare professionals can significantly reduce the morbidity associated with vulvar hematomas and improve patient care.

Vulvar Hematoma – StatPearls – NCBI Bookshelf

Continuing Education Activity

Vulvar hematoma is a rare but potentially fatal condition if left undiagnosed and untreated. Hence, prompt recognition of this condition is important. This activity outlines the evaluation and management of vulvar hematoma and explains the role of the interprofessional team in the care of patients with this condition.

Objectives:

• Identify the etiology of a vulvar hematoma.

• Explain the common presentation of a patient with vulvar hematoma.

• Outline the management options available for vulvar hematoma.

• Summarize the importance of collaboration and communication amongst the interprofessional team to enhance care coordination for patients affected by vulvar hematoma.

Access free multiple choice questions on this topic.

Introduction

A vulvar hematoma is a collection of blood in the vulva. The vulva is soft tissue mainly composed of smooth muscle and loose connective tissue and is supplied by branches of the pudendal artery. [1] Although it is a common obstetric complication, a vulvar hematoma can occur in non-obstetric settings too. Other types of puerperal genital hematomas include paravaginal, vulvovaginal, or subperitoneal hematomas. Perineal pain is the hallmark symptom that should prompt clinicians to examine the patient for a suspected puerperal genital hematoma.[2] Early recognition is paramount in reducing the associated morbidity, improving patient outcomes, and shortening the length of hospital stay.[3]

Etiology

During labor, a vulvar hematoma can result from either direct or indirect injury to the soft tissue. Examples of causes of direct injuries include episiotomy, vaginal laceration repairs, or instrumental deliveries, while indirect injury can result from extensive stretching of the birth canal during vaginal delivery.[4] Interestingly, most vulvar hematomas are formed after a normal delivery instead of complicated deliveries.[2][5] Risk factors for developing vulvar hematoma include instrumental delivery, episiotomy, primiparity, prolonged second stage of labor, macrosomia, use of anticoagulants, coagulopathy, hypertensive disorders of pregnancy, and vulvovaginal varicosity. [6][7]

Non-obstetric vulvar hematomas can arise from any form of trauma to the perineum, such as a saddle injury,[8] falling from a height,[3] insertion of a foreign body, sexual assault,[9] consensual coitus,[1] or surgery of the vulva.[10][11] If there is no associated trauma, spontaneous vessel rupture is a possible cause.[12] It is reported that post-coital injury is the most common non-obstetric cause of vulvar hematoma.[1]

Epidemiology

Vulvar hematomas are more common in the obstetric population, with an incidence ranging from 1:300 to 1:1000 deliveries.[12] Outside the obstetric population, it can make up about 0.8% of gynecological problems.[1]

Non-obstetric vulvar hematoma follows a bimodal age distribution. It is more common during childhood or early adolescence because the labia majora, which is composed of fat for its protective functionality, is less developed in young pre-pubertal females.[3] At the other end of the spectrum, hypoestrogenism in postmenopausal women results in atrophy and loss of elasticity of the vulva and vagina epithelium. The increased friability of the tissue makes the vulva more prone to injury, hence, vulvar hematoma formation.[3]

Pathophysiology

A hematoma is described as a collection of blood beneath an intact epidermis that presents as a swollen fluctuant lump. It can be extremely tender on palpation.[3] Due to its rich blood supply, the vulva is highly vulnerable and prone to hematoma formation. Although venous bleeding is possible, arterial bleeds mainly originate from one of the branches of the pudendal artery.[1] Vulvar hematoma, rarely, might be secondary to operative laparoscopy (especially adnexal surgery), spontaneous rupture of the internal iliac artery, or spontaneous rupture of a pseudoaneurysm of the pudendal artery.[12][13]

History and Physical

Pain is the most common symptom of a vulvar hematoma. Patients can describe it as perineal, abdominal, or buttock pain.[12] The intensity of the pain can be severe enough to interfere with mobility.[3] There may also be intermittent bleeding. Depending on the size and location of the vulvar hematoma, urological or neurological signs and symptoms may be present. Due to mechanical urethral obstruction, patients may present with urinary retention or micturition difficulties.[12] In severe cases, the patient can be hemodynamically unstable and will require urgent fluid resuscitation or blood transfusion. Symptoms usually develop within a few hours to days of delivery, depending on the severity of the condition.

If a vulvar hematoma is suspected, a detailed history should be taken to elicit possible causes associated with it. They include preceding coitus, accidents involving injury to their perineum, and recent deliveries or operations. It is also important to inquire about sexual assault in a sensitive manner. 

As bleeding into the vulva is largely restricted only by the Colles fascia and the urogenital diaphragm, a hematoma in this area will be visible on physical examination.[12] This is seen as a tender fluctuant lump of variable size. Since the Colles fascia exerts little resistance, vulvar hematomas can grow to become 15cm in diameter or more.[14] The observation of a lump or swelling in the groin may be offered by the patient if asked during the consultation. Although there is no anatomical explanation, it is discovered that the right side appears to be more commonly affected.[3][15]

During the examination, a thorough inspection should be performed for pelvic fractures and genital lacerations, especially if there is a history of significant trauma.[15] In addition, basic observations such as the patient’s heart rate, respiratory rate, and blood pressure should be measured and recorded to provide baseline values for monitoring. A urinary catheter may also be inserted if clinically indicated.

Evaluation

Complete blood count (CBC), type and screen, and if deemed necessary, coagulation screening should be performed. If there is a likelihood of the need for a blood transfusion, blood should also be taken for cross-matching.

Ultrasound, computed tomography (CT), or magnetic resonance imaging (MRI) of the pelvis can be done to evaluate the size, site, and growth of the hematoma. MRI angiography of the pelvis may help in the detection of any aneurysms. Transperineal sonography is also a simple, non-invasive technique that can be useful for the follow-up and monitoring of patients undergoing expectant management of a vulvar hematoma.[8]

In addition, further investigations can be done to evaluate for causes of hematoma formation, such as the presence of connective tissue disorders or coagulopathies. In cases associated with severe trauma or sexual assault, the extent of injury to the perineum and pelvis must also be assessed adequately. Additional investigations, such as a pelvic X-ray for pelvic bone fractures in cases of pelvic trauma, should be done.[9]

Treatment / Management

The majority of vulvar hematomas are small and can be managed conservatively. However, large (>10 cm in diameter) or progressively enlarging hematomas causing intense pain and distress to the patient require surgical intervention. Urgent surgical management is also warranted if the hematoma is large enough to cause hemodynamic instability, or urological or neurological signs and symptoms.[3][13] A catheter may be inserted if the patient experiences difficulty urinating.

Conservative management usually involves the use of ice packs, local compressions, bed rest, and analgesics. In the event that conservative management has not been effective, surgery may be performed. In fact, conservative management of large hematomas has been found to be associated with a longer period of hospitalization, greater need for antibiotics, and blood transfusion[14]. A conservative approach is also not advisable for hematomas that are expanding acutely.[16]

Surgical management includes surgical drainage of the hematoma, evacuation of any clots present, ligation of bleeding points, and the assessment for signs of pressure necrosis (a complication of vulva hematoma).[1] These can be done under local anesthesia. As further blood loss during surgery is anticipated, the necessary investigations such as cross-matching and preparations for a possible blood transfusion should be done. An intravaginal approach for incision and evacuation of hematoma produces better cosmetic results.[17]

Alternatively, selective arterial embolization may be performed. This procedure was first described by Brown et al. for the treatment of postpartum hemorrhage.[18] Subsequently, this approach has been used successfully for the treatment of bleeding in several obstetric and gynecological conditions.[19] Pelvic angiography is done prior to selective embolization to investigate and locate bleeding vessels. Surgeons may choose angiographic embolization if bleeding continues post-operatively, or if the vulvar hematoma reforms after surgical management. It may also be the choice of treatment in situations where surgery is not possible, such as in patients who are hemodynamically unstable and not fit for surgical ligation procedures.[20] A case of successful transarterial embolization after a failed conservative treatment for an expanding non-obstetrical vulvar hematoma has also been reported. [21]

Differential Diagnosis

There are a few more frequently diagnosed vulvar conditions that can present similarly to a vulvar hematoma. These include Bartholin’s gland cysts and abscesses, vulvar varicosities, and folliculitis.[1][22] In addition, as with any conditions presenting as a growth, vulvar cancer must also be considered on the list of differential diagnoses.

The Bartholin’s glands are two pea-sized glands located symmetrically at the vaginal opening. These glands function by lubricating the vagina through mucus production.[23] A Bartholin’s gland cyst forms as a result of a blocked duct, which leads to a collection of secretions. This can subsequently develop into a Bartholin’s gland abscess when infected. While the former can be asymptomatic, Bartholin’s gland abscesses usually present with surrounding cellulitis.[23] A non-obstetric vulvar hematoma has been reported to be misdiagnosed as a Bartholin’s gland duct abscess.[15] Such a misdiagnosis is possible as extravasated blood of a vulvar hematoma can trigger an inflammatory reaction similar to an abscess.

Vulvar varicosities can also be a differential diagnosis. However, it is important to note that there have been case reports of postoperative vulvar hematoma following surgical management for vulvar varicose veins.[10] Unlike vulvar hematomas, vulvar varicosities are much more common, especially in multigravid females. In addition, they are often asymptomatic, with only a minority of cases causing mild discomfort.[24]

Vulvar folliculitis arises due to inflammation of the hair follicles and often resembles acne in the genital region. Patients with vulvar folliculitis may present to the clinic with genital pain or itchiness. However, on examination, it is usually seen as small papules or pustules uniformly distributed over the vulva.[25]

Finally, although vulvar carcinoma can present as a fleshy lump or mass, most cases have a history of pruritus and do not usually present with pain. In addition, vulvar carcinoma can also be described as ulcerated, leukoplakic, or warty. [26] Metastatic choriocarcinoma is a highly vascularized trophoblastic tumor which should also be suspected in patients with trophoblastic disease. In a case report by Bhattacharyya SK et al., vulvovaginal metastasis of choriocarcinoma was initially misdiagnosed and managed as an old infected vulvar hematoma.[27]

Prognosis

Vulvar hematomas may cause serious morbidity but rarely leads to mortality. A complete recovery is often seen. For small vulvar hematomas, most resolve spontaneously under conservative management.[28] Management with surgical intervention or selective arterial embolization is also effective, with most patients being able to mobilize within a day or two, and discharged home without any complication.[13][21]

Complications

Necrosis is a complication that will necessitate surgical debridement. This complication arises due to the pressure applied by the large or growing hematoma on surrounding tissues.[1] Pressure necrosis can be prevented with the prompt surgical evacuation of blood clots. [12][29] In situations where there is increasing pain and necrosis on presentation, urgent surgical intervention will be necessary.

As with any condition managed operatively, the risk of infection is a potential complication, and patients should follow up shortly after discharge from the hospital to check for recurrence of hematoma or infection. Prophylactic antibiotics may be prescribed if clinically indicated.

Selective pelvic arterial embolization, although not readily available, is an effective procedure in competent hands.[30] Reported post-procedural complications include muscle pain, guidewire perforation, and vaginal fistula.[31] Low-grade fever, pelvic infection, and temporary foot drop are also possible. Pelvic arterial embolization means some degree of exposure to ionizing radiation.[32]

Postoperative and Rehabilitation Care

Early mobilization has been shown to have inherent benefits in minimizing the risk of venous thromboembolism.[33] However, there remains much controversy over the recommended period of bed rest before encouraging mobilization after vulvar surgery. [34] Other routine postoperative care relevant to patients receiving vulvar operations include attentive wound care, postoperative analgesics, and antibiotics if indicated. In addition, as hematomas can recur after surgery, continued monitoring of the patient’s vital signs is important.

Deterrence and Patient Education

Vulvar hematoma can be prevented by adopting measures to avoid the preceding causes, as mentioned above, whenever possible. Maintaining a safe home environment, such as through the use of non-slip floor material and having adequate illumination, especially at night. To minimize the risk of traumatic damage to a friable vulval epithelium in postmenopausal women, estrogen gels and other methods of therapy for vulvar and vaginal atrophy may be prescribed.[35] In the obstetric population, reducing episiotomy and operative vaginal procedures will reduce the incidence of obstetrical vulvar hematomas.

Pearls and Other Issues

In conclusion, the main presentation of vulvar hematoma is perineal pain and unilateral swelling of the vulva. If the hematoma is not large or acutely expanding, conservative management can be considered. A serious case of vulvar hematoma can lead to hemodynamic instability and should be recognized and treated early. Surgical intervention may be necessary when the hematoma is expanding, larger than 10 cm in size, causing pressure necrosis, hemodynamic instability, or suspicion for another associated pelvic injury.

Enhancing Healthcare Team Outcomes

Obstetric vulvar hematoma is a concern for the obstetrician, but non-obstetric vulvar hematoma may present to the emergency clinician and primary clinicians. In the case of a small vulvar hematoma, expectant management is appropriate. Although the gynecologist is the primary clinician involved in the care of patients with a vulvar hematoma, if surgery or selective arterial embolization is necessary, an interprofessional team consisting of gynecologists, interventional radiologists, and vascular surgeons may be required. Therefore, it is important for healthcare workers in these fields to be familiar with the recognition and management of vulvar hematoma and to work together so as to provide optimal care for these patients, improve patient outcomes and reduce morbidity.

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References

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Disclosure: Ginny Oong declares no relevant financial relationships with ineligible companies.

Disclosure: Frederick Eruo declares no relevant financial relationships with ineligible companies.

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

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J Med Case Rep. 2022; 16: 85.

Published online 2022 Feb 28. doi: 10.1186/s13256-022-03281-2

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Data Availability Statement

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

Keywords: Vulvar hematoma, Postpartum, Severe anemia, Maternal near miss

According to the World Health Organization (WHO), maternal near miss (MNM) is defined as “a woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy” [1]. In Ethiopia, for every woman who dies from pregnancy-related causes, 12–21 others experience maternal near miss (MNM) [1–3]. One of the causes of MNM is postpartum hemorrhage (PPH) [1, 4, 5]. The major causes of PPH are uterine atony, genital tract laceration, retained tissues (placenta and membranes), and coagulopathy [4, 5]. Vulvar hematoma is among genital tract traumas that cause PPH [5, 6].

A vulvar hematoma is a collection of blood in the vulva [6]. The vulva is soft tissue mainly composed of smooth muscle and loose connective tissue and is supplied by branches of the pudendal artery [7, 8]. The venous drainage is provided by labial veins, and labial veins drain into the external and internal pudendal veins [8, 9]. This vulvar vasculature commonly develops varicosities during pregnancy, especially in parous women, due to increased venous pressure created by the increasing weight of the uterus [8]. Damage to labial branches of the internal pudendal artery in this vascular network easily initiates hematoma development [7–9].

Postpartum vulvar hematomas cause maternal morbidities such as anemia, postpartum hemorrhage, superinfection, necrotizing fasciitis, prolonged hospitalization, and need for transfusion [5–7]. Here we present, a case of postpartum vulvar hematoma as the cause of MNM.

This is a 28-year-old para IV mother from rural Ethiopia who gave birth to an alive female neonate weighing 3000 g at home 24 hours before presentation. She did not remember her last normal menstrual period (LNMP) but claimed to be amenorrheic for 9 months. She had antenatal care (ANC) at a nearby health center where she had routine investigations and care during pregnancy. During the last antenatal visit, she was told to come to the health center when she feels labor pains. However, her labor advanced within 6 hours of the onset of labor pain. She gave birth normally at home with the assistance of traditional birth attendants. The mother reported that there was neither difficulty with delivery of the placenta nor excessive bleeding during and after delivery. She noticed gradual swelling of her right vulva that was associated with vulvar pain. Due to the worsening of these complaints, the family took her to nearby hospital. At this hospital, evacuation of vulvar hematoma (6 cm × 8 cm) was done. The managing team evacuated 500 ml of hematoma and referred the patient to Wollega University Referral Hospital (WURH) for blood transfusion.

Upon arrival to WURH, the patient was re-evaluated by the charge resident physician and consultant gynecologist, and obstetrician. The mother reported vaginal bleeding from the vulva on her way to WURH, significant swelling of the vulva, and vulvar pain. She had difficulty with micturition. She also complained of palpitation, easy fatigability, vertigo, and headache. The patient had no history of hypertension, diabetes mellitus, or bleeding tendency.

On examination, she was acutely sick-looking. Her vital signs were blood pressure (BP) 90/60 mmHg, pulse rate (PR) 136 beats per minute, respiratory rate (RR) 22 breaths per minute, and temperature 37. 1 °C. She had dry buccal mucosa and pale conjunctivae. Lymph glandular system, chest, and cardiovascular system were normal. Abdominal examination showed a 20-week-sized uterus that was well contracted and nontender, and the bladder was distended. There were no signs of fluid collection or organomegaly. On genital examination, there was a 12 × 20 cm right-sided vulvar mass extending to the mons pubis and posteriorly to the right buttock (Fig. ). The mass was tender and fluctuant. There were two stitches applied to it. However, there was bleeding from this site. There was no active vaginal bleeding or vaginal and cervical tear. She exhibited palmar pallor. On neurologic examination, she was oriented to time, person, and place. She had normal reflexes and no neurologic deficits. With the final diagnosis of severe anemia secondary to postpartum hemorrhage secondary to a vulvar hematoma, she was admitted to the obstetric ward. At admission, she was investigated and the results were as indicated in Table .

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Postpartum spontaneous vulvar hematoma managed at Wollega University Referral Hospital, Western Ethiopia, 2021

Table 1

Summary of laboratory investigations of the case of postpartum spontaneous vulvar hematoma managed at Wollega University Referral Hospital, Western Ethiopia, 2021

Time of investigations	Laboratory tests	Results
At admission	CBC count	WBC count 1760 cells/μl; RBC count 1.1 million cells/μL; hematocrit 10.3%a; platelet count 189,000 cells/μl; MCV 92.2 fL; MCH 30.6 picograms(pg)
	Urinalysis	Nonrevealing
	RBG	145 mg/dl
	Blood group	B+
	Abdominopelvic ultrasound	Empty uterus, no peritoneal collection
	VDRL	Nonreactive
	HBsAg	Nonreactive
After procedure	CBC count	WBC count 1971 cells/μl; RBC count 1. 4 million cells/μl; platelet count 177,000 cells/μl; MCV 92.1 fL; MCH 30.7 picograms(pg)
		Hematocrit 12.9%b
		Hematocrit 17.2%c

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CBC complete blood count, WBC white blood cell, RBC red blood cell, VDRL Venereal Disease Research Laboratory, HBsAg hepatitis B surface antigen, RBG random blood glucose, MCV mean corpuscular volume, MCH mean corpuscular hemoglobin

^aAt admission

^bAfter the first transfusion

^cAfter the second transfusion

The patient was prepared and taken to the operation room. Under spinal analgesia, through a previous incision made at referring hospital, about 700 ml of clotted blood was evacuated from vulvar hematoma. The actively bleeding vessels were identified and ligated. Then, the wound was sutured in three layers. The site was observed for bleeding and vulvar swelling. A hemostatic gauze was used for further compression and removed after 12 hours. The patient was transferred to ward where she was transfused with two units of compatible blood. On the fourth postprocedure day, the patient was discharged with ferrous sulfate and appropriate advice on vulvar care.

This is the case of maternal near miss in rural Ethiopia. The major causes of maternal near-miss events are obstetric hemorrhages, hypertensive disorders of pregnancy, difficult labor and delivery, sepsis, complications of abortion, and uterine rupture [1, 5]. This patient presented with postpartum hemorrhage (PPH) secondary to spontaneous vulvar hematoma. It is an unusual cause of PPH [5, 6]. The other causes of PPH such as uterine atony retained tissue, coagulopathy, and genital tract laceration were excluded from patient history, physical examination, and laboratory investigation. A huge postpartum vulvar hematoma explained the patient’s condition. The hematoma was severe enough to cause maternal shock and severe anemia. This patient could have died had she not been aggressively managed with intravenous fluid, blood transfusion, and surgical intervention.

Postpartum vulvar hematomas are rare events in modern obstetrics. Their magnitude varies from 1 per 300 to 1 per 15,000 deliveries. It can be classified into obstetric and non-obstetric vulvar hematomas [6, 8, 10, 11]. Postpartum vulvar hematomas most frequently result from genital tract laceration [8] or improper hemostasis during the repair of perineal tears or an episiotomy wound. Failure to take precautions while suturing the apex of the episiotomy may result in a large vulvovaginal hematoma due to the distensible nature of the tissue [12, 13].

Postpartum spontaneous vulvar hematomas are rare events. They result from injury to blood vessels in the absence of laceration or incision of the surrounding tissue (such as pseudoaneurysm and traumatic arteriovenous fistula) [10, 13]. They usually follow precipitate labor, macrosomic babies, prolonged second stage of labor, hypertensive disorders of pregnancy, coagulopathy, or vulvar varicosities [2, 10, 11, 14]. In our case, the total duration of labor was only 6 hours, which might have been the triggering factor. It occurred spontaneously after home vaginal delivery. It is observed that most spontaneous vulvar hematomas are right-sided vulvar hematomas [11] as in our case. This may be due to dextrorotation of the uterus, which might cause vulvar varicosities.

The pathogenesis of vulvar hematomas is due to iatrogenic injury to blood vessels and/or spontaneous rupture resulting in various symptoms such as vulvar swelling, vulvar pain, and urologic symptoms [6, 8, 10, 15]. Our patient presented with vulvar swelling, vulvar pain, and difficulty with urination. As bleeding into the vulva is largely restricted only by the Colles fascia and the urogenital diaphragm, a hematoma in this area is visible as tender fluctuant mass [15] as in our case.

Vulvar hematomas may develop within hours after delivery or be initially misdiagnosed as vulva swelling or edema until the delayed formation of the hematoma [8, 14]. Early recognition is paramount in reducing the associated morbidity, improving patient outcomes, and shortening the length of hospital stay. Delay in recognition and management may result in adverse consequences and increase maternal morbidity [7, 11, 14] as in our case.

The management of vulvar hematomas depends on the size of the hematoma, hemodynamic stability of the patient, availability of medical resources, and duration of the hematoma [9, 10, 14, 16]. Smaller and chronic vulvar hematomas can be conservatively managed [9] including the use of sitz baths, ice packs, empiric antibiotics, pain medication, and/or blood transfusion [12, 14]. However, large and rapidly expanding hematomas, as in this case, are managed by surgical techniques [9, 11]. The surgical management can be surgical exploration or selective arterial embolization [9, 10]. The surgical exploration consists of incision and drainage of the hematoma, ligation of the bleeding vessels, and packing or placement of drainage tube [9–11]. Our patient was managed by a similar approach. However, the primary treating hospital did not place a vaginal pack or drainage tube. As a result, the patient was having ongoing active bleeding from the incision site on the way to the referral hospital. This made the patient develop a recurrent huge hematoma. Therefore, optimal management of vulvar hematomas includes surgical exploration, ligation of bleeding vessels, obliteration of the dead space and placing pack in the vagina, placing drainage tube, or applying pressure over it [9, 10, 14]. The surgical exploration also prevents pressure necrosis of the surrounding tissue and decreases the risk of infection and necrotizing fasciitis [6, 8]. Sometimes, however, a surgical repair may fail or a recurrent hematoma can be formed, as in our case. In such cases, selective arterial embolization is the treatment of choice [10, 17].

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 maternal complications

We thank the patient for allowing the publication of this case report.

Authors’ details

TT is Associate Professor of obstetrics and gynecology, Institute of Health Sciences, Wollega University; AW is Assistant Professor of obstetrics and gynecology, Institute of Health Sciences, Wollega University; AL is medical doctor and first-year resident of obstetrics and gynecology, Institute of Health Sciences, Wollega University; RO is lecturer in the department of public health, Institute of Health Sciences, Wollega University.

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis, and interpretation, or in all these areas; took part in drafting, revising, or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work. All authors read and approved the final manuscript.

No funding source

The datasets used during the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

Wollega University Referral Hospital has approved the publication of this case. The study protocol is performed per the relevant guidelines.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interests

The authors report no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Consequences of birth cephalohematoma in the future – important information for parents – clinic “Dobrobut”

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Medical Library Dobrobut
Publication date: 2020-01-22

Cephalohematoma in newborns on the head – symptoms, treatment

Cephalohematoma is a birth injury characterized by the formation of a hematoma. Pathology is diagnosed in 3% of babies, regardless of gender. Cephalhematoma in newborns on the head can be accompanied by various complications: deformation of the bones of the skull, suppuration, anemia and jaundice. Formations come in various sizes and depend primarily on the volume of accumulated blood. Due to the failure of the hemostasis system in the baby’s body, blood can accumulate for several days after childbirth, contributing to an increase in the size of the hematoma.

Causes of cephalohematoma during childbirth:

• large fruit;
• rapid delivery;
• abnormal position of the fetus;
• premature or prolonged labor;
• cord entanglement;
• discrepancy between the size of the pelvis of the mother and the head of the fetus;
• pathology of intrauterine development;
• use during childbirth forceps.

Classification of cephalohematoma

As noted above, external cephalohematoma is a hemorrhage between the periosteum and the surface of the bones of the skull, which disappears by the end of the second month of a baby’s life.

Depending on the location, the hemorrhage can be frontal, occipital, parietal and temporal. According to the severity, cephalohematoma of I degree (hematoma volume 3-4 cm), II (4-9 cm) and III (hemorrhage more than 9 cm) are distinguished. The consequences of a generic cephalohematoma in the future depend on the size of the formation and the general condition of the newborn. Given the localization of the hemorrhage, cephalohematoma can be left-sided, right-sided and bilateral. In some cases, the pathology is accompanied by concomitant injuries in the form of a fracture (crack) of the skull bones.

Signs of an ossified cephalohematoma

A cephalohematoma occurs within a few hours after the baby is born. The next 2-3 days, the formation increases in size, after which a period of regression begins. Complete resorption of the hematoma occurs by the end of 8 weeks.

Main symptoms:

• education has clear boundaries;
• on day 2-3, the growth of the hematoma stops;
• the color of the skin in the area of ​​cephalohematoma is unchanged;
• hematoma soft to the touch;
• the general condition of the baby is unchanged.

On our website Dobrobut.com you can make an appointment with a specialist and get an answer to any question. The doctor will tell you about the main signs of ossified cephalohematoma and about the methods of treating the pathology.

Diagnosis

The diagnosis is made after a thorough examination of the baby. Differentiate cephalohematoma from cerebral hernia, birth tumor, coagulopathy, congenital mycoplasmosis and hemorrhage under the aponeurosis will help research: ultrasound, CT, neurosonography and craniogram.

Treatment of cephalohematoma in a child

Hemorrhage is treated by a neonatologist or pediatric surgeon. With a small hematoma, special treatment is not necessary. The baby is prescribed calcium and vitamin K preparations for 5-7 days. The course of therapy for uncomplicated pathology is 7–10 days. It will take at least a month to treat a cephalohematoma in a child with complications. A baby with such a pathology must be registered with a surgeon and a neurologist.

Neonatologists recommend using Troxerutin to speed up the healing of the mass. The gel is applied to the hematoma area twice a day. The drug increases vascular tone and prevents further penetration of blood.

In case of extensive hemorrhage (more than 9 cm in volume), the doctor will prescribe surgery. Puncture of cephalohematoma of the parietal bone is a safe procedure for the health of the baby, the duration of which takes no more than 10 minutes. The child’s skin at the site of hematoma formation is pierced with a special needle, the accumulated blood is sucked off, after which the puncture site is disinfected and a pressure bandage is applied. Surgical removal of cephalohematoma is indicated in the presence of purulent contents of the cavity, as well as in the III degree of development of the pathology.

Doctor’s recommendations after the puncture:

• parents must strictly follow the specialist’s instructions;
• in no case should you self-medicate;
• protect the newborn’s head from injury;
• use a cap one size larger;
• closely monitor the general condition of the baby.

Consequences and prognosis

In most cases, the prognosis is favorable. Serious consequences occur in a small percentage of babies due to the displacement of brain structures under the pressure of a hematoma and the accumulation of blood under the periosteum.

Most severe consequences:

• infection of the meninges;
• anemia;
• compression of the optic (auditory) nerves;
• suppuration;
• ossification of cephalohematoma with irreversible deformity of the skull bones.

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Cephalhematoma in newborns – GBUZ YNAO

It only seems that when the baby is born, the baby slowly and leisurely leaves the mother’s womb. In fact, in order to be born, the child has to make corkscrew, pendulum and other active movements of the body. Therefore, in the process of passing through the birth canal, the baby often gets injured.

Neonatal cephalohematoma refers to birth trauma to the head and is a small tumor that occurs as a result of rupture of blood vessels. This leads to the fact that between the bones of the skull and the periosteum begins to accumulate blood. Since the blood of newborns is characterized by low coagulability, the formation continues to increase in size within 2-3 days after birth.

Cephalhematoma occurs in 0.1 to 1.8% of newborns. Causes of cephalohematoma in newborns As a result, the brain is compressed, and the child’s head is slightly deformed. However, you should not worry about this – within a few days after the birth, the bones of the cranium return to their places.

Meanwhile, the scalp is displaced along with the periosteum, thereby provoking vascular rupture. Most often this happens if the newborn suffers from a deficiency of vitamins K, C, PP. The blood flowing from the damaged capillaries begins to accumulate in the pocket between the flat bone of the skull and the periosteum, forming a tumor.

Other causes of cephalohematoma in newborns:

Large fetus with narrow birth canal;

Breech, parietal or facial presentation;

Rapid or, conversely, too slow delivery;

Postterm pregnancy;

Malformations and pathologies of fetal development;

A woman’s narrow pelvis or past trauma that deformed the pelvic bones.

Also among the factors contributing to the formation of cephalohematoma in newborns, one can name chronic intrauterine fetal hypoxia. It can occur as a result of entanglement or squeezing of the umbilical cord. In addition, hemorrhages can be the result of the actions of obstetricians if forceps or vacuum are used in complicated births.

Treatment of cephalohematoma in newborns

A cephalohematoma can be located in different parts of the head, but most often it occurs in the region of the crown, less often in the occipital, frontal or temporal regions. The borders of the tumor usually do not go beyond the sutures of the skull, where the periosteum is tightly fused with the bones. The blood in the cephalohematoma remains liquid for a long time, does not clot, so the formation is initially elastic in consistency. On palpation, you can feel the movement of fluid inside.

If the amount of blood in the cephalohematoma in newborns is small, then after a few days it begins to decrease in size and dissolve. The tumor disappears completely in about one and a half to two months without any intervention. If there was a significant hemorrhage, then resorption may take a longer period of time.

Small cephalohematomas in newborns usually do not require treatment. Doctors observe the child, sometimes they prescribe vitamin K, which increases blood clotting. This is done in order to stop the leakage of blood and the increase in the size of the tumor. To avoid complications, it is recommended to feed the baby with breast milk, which contains maternal antibodies and contributes to the formation of his own immunity.

If the size of the hemorrhage is significant, a puncture of the cephalohematoma is performed, but not earlier than 10 days of life, due to the high probability of rebleeding. Punctures are made in the periosteum with a special needle, through which the contents of the formation are sucked out. Then a pressure bandage is applied to the damaged area.

If there is inflammation of the cephalohematoma, its redness, swelling, increase in body temperature, then there is infection and suppuration.