According to the American College of Obstetricians and Gynecologists, early postpartum hemorrhage is at least 1,000 mL total blood loss or loss of blood coinciding with signs and symptoms of hypovolemia within 24 hours after delivery of the fetus or intrapartum loss [1,2]. PPH is the one of the most common cause of maternal mortality especially in low-income countries and is responsible for nearly one quarter of all maternal deaths globally [3]^. The four T's mnemonic used to identify possible causes of PPH is uterine atony (Tone), laceration, hematoma, rupture (Trauma), retained tissue (Tissue); and coagulopathy (Thrombus) [4]. Puerperal genital haematomas though less common causes of PPH but can cause maternal morbidity and mortality [5]^. Case series estimate incidence of puerperal genital haematomas 1 in 500 to 1 in 12,500 deliveries, with surgical intervention required in approximately 1 in 1000 deliveries [6,7]^. Risk factors include: nulliparity, prolonged second stage of labour, instrumental delivery, baby weight >4 kg, genital tract varicosities and maternal age >29 years [8].

We report the case of a 22-year-old primigravida patient, with no specific medical or surgical history. Patient was referred to our hospital with history of massive uncontrolled bleeding per vaginum after vaginal delivery of healthy male neonate of 4.4 kg 6 hours back. On admission patient was unconscious, pale, with a feeble pulse at 140 beats per minute and a blood pressure of 90/40 mmHg, SpO2 95% on room air. The gynecological examination found a well retracted uterus and a huge vulval hematoma of 15cm*15cm (Figure 1) involving left side of labia majora along with vaginal bleeding. Ultra sonographic assessment of abdomen and pelvis was normal. The laboratory findings of the patient on admission were as follows: haemoglobin 8.1 gm/dL; hematocrit 31.2%; WBC 20.3×10³/uLand platelets were 160×10³/uL. The patient’s other laboratory values were within normal limits. Two units of packed red blood cells were arranged. Patient was shifted to operation theatre for hematoma drainage along with cervical and vaginal exploration under anaesthesia. Hematoma was drained, all clots removed and bleeding points ligated. Wound was closed with primary suturing. 3 Para urethral tears were also found and repaired. On exploration right sided cervical tear of 3-4 cm and vaginal tear of 6-8cms were found and repaired. Tight vaginal packing was done with compressive wound  dressing.  The  patient  was  given  second generation cephalosporin and metronidazole and pain killers.

Figure 1: large vulval hematoma

Figure 2: on Day 3 of hematoma drainage

Six hours later, the packing was removed with no signs of active bleeding. The patient was discharged from hospital after 3 days (Figure 2). She was called for follow up at two weeks and six weeks after discharge. Both follow ups were uneventful.

Puerperal genital haematomas can be anatomically classified as infralevator or supralevator. Infralevator haematomas occur below the levator ani muscle, example around vulva, perineum and lower vagina. They are associated with vaginal birth. Supralevator haematomas usually form in the broad ligament. They can be an extension of a cervical, vaginal or uterine tear. They are less common than infralevator haematomas. Supralevator haematomas may occur after spontaneous birth, but more commonly occur following operative vaginal birth or a difficult caesarean section [9].

Vulva is supplied from external pudendal and internal pudendal artery. The injury to labial branches of the internal pudendal artery, which is located in the superficial fascia of the anterior and posterior pelvic triangle, can cause vulval hematoma [10].

Excessive perineal pain is a classical symptom and it should prompt examination. The most important factor in correct diagnosis is clinical awareness. Delay in diagnosis and thus management may result in adverse maternal outcome.

Management of vulval hematomas depend on maternal hemodynamic stability, hematoma size and availability of medical resources. Resuscitative measures should be considered the first line of treatment. The extent of the blood loss is often underestimated and a high index of suspicion is required. Aggressive fluid replacement and assessment of coagulation status is essential if there is heavy bleeding or signs of hypovolaemia. Blood should be available for transfusion. A urinary catheter is generally advocated to monitor fluid balance and to avoid possible urinary retention resulting from pain, oedema or the pressure of a vaginal pack [10].

Small, static haematomas (<5 cm in diameter) can be managed conservatively (ice packing, empiric antibiotics, pain medication and blood transfusion when deemed necessary) [ 11].

Large (>5 cm) vulval haematomas are best managed with surgical evacuation, primary closure and compression for 12–24 hours. Adequate anaesthesia is mandatory. The clot should be evacuated and any apparent bleeding points ligated [10]. 

In an era of safe motherhood much emphasis is laid on institutional delivery/delivery by trained ANM’s but home deliveries or by untrained personnel are still prevalent. This leads to many postpartum complications e.g. puerperal haematomas and increase in maternal morbidity and mortality. Small nursing homes or community hospitals usually do not have adequately trained staff or availability of blood components, ICU facility. This delays timely diagnosis and adequate management of puerperal hematomas.

High index of suspicion by proper trained staff can lead to prompt identification and immediate referral to higher center for proper management and improved prognosis.

1. Menard, M.K. et al. "Executive Summary of the reVITALize Initiative: Standardizing Obstetric Data Definitions." Obstetrics and Gynecology, vol. 124, no. 1, 2014, pp. 150–153.

2. American College of Obstetricians and Gynecologists. Obstetric Data Definitions (Version 1.0). Revitalize, https://www.acog.org/-/media/Departments/Patient-Safety-and-Quality-Improvement/2014reVITALizeObstetricDataDefinitionsV10.pdf. Accessed October 2016.

3. Say, L. et al. "Global Causes of Maternal Death: A WHO Systematic Analysis." Lancet Global Health, vol. 2, no. 6, 2014, pp. e323–e333. doi:10.1016/S2214-109X(14)70227-X

4. Evensen, A. et al. "Postpartum Hemorrhage: Prevention and Treatment." American Family Physician, vol. 95, 2017, pp. 442–449.

5. Chin, H.G. et al. "Angiographic Embolization of Intractable Puerperal Haematomas." American Journal of Obstetrics and Gynecology, vol. 160, 1989, pp. 434–438.

6. Morgans, D. et al. "Vulval Perineal Haematomas in the Immediate Postpartum Period and Their Management." Australian and New Zealand Journal of Obstetrics and Gynaecology, vol. 39, 1999, pp. 223–227.

7. Resnik, R. "Vaginal and Vulval Hematoma." Contemporary OB/GYN, vol. 41, 1996, pp. 19–23.

8. Saleem, Z. et al. "Vaginal Hematoma during Parturition: A Population-Based Study." Acta Obstetricia et Gynecologica Scandinavica, vol. 83, 2004, pp. 560–562. DOI: 10.1111/j.1600-0412.2004.00535.x.

9. South Australian Perinatal Practice Guidelines Workgroup. cywhs.perinatalprotocol@health.sa.gov.au.

10. Mawhinney, S. et al. "Puerperal Genital Haematoma: A Commonly Missed Diagnosis." The Obstetrician & Gynaecologist, vol. 9, 2007, pp. 195–200.

11. Key Obgyn. "Genital Tract Laceration and Puerperal Hematomas." https://obgynkey.com/genital-tract-lacerations-and-puerperal-hematomas/. Accessed February 2020