Vulvovaginal Haematoma

Vulvovaginal haematomas, an example of which is shown here, are an uncommon complication of pregnancy; the reported incidence ranges from 1 in 500 to 1 in 12,500 confinements.¹

The trauma of delivery is the major aetiological factor in the development of a postpartum vulvovaginal haematoma. Seemingly, radical stretching of the birth canal with the passage of the foetus during parturition can cause contusion or avulsion of the vascular supply, and hence haematoma formation. These factors seem particularly important in primigravidas. Primiparity is the most commonly associated obstetric factor even though along with most of the other commonly-reported predisposing obstetric factors (e.g. episiotomy, instrumental delivery, genital tract variscosities, etc.) it is a poor predictor of the development of a postpartum vulvovaginal haematoma. Other causes include direct trauma (to the pudendal vessels) with the needle at the time of pudendal nerve block.²

Once a vulvovaginal haematoma has been diagnosed, ready access to an operating theatre and aggressive therapy (i.e. fluid replacement, blood transfusion, indwelling urethral catheter, antibiotics, surgery) is mandatory.¹ The aim of surgery is to stop the pain caused by the haematoma, prevent further bleeding and tissue destruction, and minimise the risk of subsequent infection.¹ The first step is to evacuate clots and ligate individual bleeding vessels (if these can be identified). If, however, bleeding vessels cannot be identified, the haematoma cavity should be tightly packed with gauze and drained, with subsequent removal of the packs and healing by secondary intention. Another approach which has its advocates involves draining the haematoma followed by primary repair. Other techniques that may be necessary include angiographic embolisation of the bleeding internal iliac artery tributaries, and internal iliac artery ligation.

Prompt resolution of the vulvovaginal haematoma results in reduced scarring, postpartum pain, and dyspareunia.

References

1. Morgans D, Chan N, Clark CA. Vulval perineal haematomas in the immediate postpartum period and their management. Aust N Z J Obstet Gynaecol 1999;39:223-227.

2. Postpartum haemorrhage and shock. In: Obstetrics and the newborn (2^nd edn). Beischer NA, Mackay EV (eds). W.B. Saunders, Sydney, Australia, pp 508.

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