Vulval hematoma

-            In vulval hematomas bleeding is limited to the vulval tissues superficial to the anterior urogenital diaphragm. The hematoma will be evident on the vulva.

-            Vulvovaginal hematomas are also evident on the vulva but they extend into the   paravaginal tissues.

-            Both types arise from injury to the branches of the pudendal artery (the posterior rectal, transverse perineal and posterior labial arteries)

Vaginal hematoma

-            Vaginal or Paravaginal hematomas arise from damage to the descending branch of the uterine artery.

-            The hematoma is confined to the paravaginal tissues in the space bounded inferiorly by the pelvic diaphragm and superiorly by the cardinal ligament.

-            Rectal pain, vague lower abdominal pain but hematoma will not be obvious externally but can be diagnosed by vaginal examination.

-            The mass often occludes the vaginal canal and extends into the ischiorectal fossa.

Diagnosis of hematomas

-            severe perineal pain and usually rapid appearance of a tense, fluctuant, and sensitive tumor of varying size covered by discolored skin

-            Symptoms of pressure, if not pain or inability to void, should prompt a vaginal examination with discovery of a round, fluctuant tumor encroaching on the lumen

Management of hematomas (Vulval& Vaginal)

-            Smaller vulvar hematomas(≤ 5cm) maybe treated expectantly with analgesics, observation and icepacks.

-            If the pain is severe or the hematoma continues to enlarge, the best treatment is prompt incision

-            done at the point of maximal distention along with evacuation of blood and clots and ligation of bleeding points

-            The cavity may then be obliterated with mattress sutures. Often, no sites of bleeding are identified after the hematoma has been drained.

-            In such cases, the vagina, not the hematoma cavity, is packed for 12 to 24 hours

-            With hematomasof the genital tract, blood loss is nearly always considerably more than the clinical estimate

-            Hypovolemia and severe anemia should be prevented by adequate blood replacement

Broad ligament and retroperitoneal hematoma

-            These occur when a vessel ruptures above the urogenital diaphragm

-            The bleeding extends into the supravaginal space between the leaves of broad ligament and maytrack retroperitoneally even as high as the kidneys.

•            They occur most commonly following operative delivery, trauma, or surgery, but if may also occur following spontaneous vaginal delivery.

•            These can be dangerous as they may be silent and not cause obvious vaginal bleeding.

•            Most patients report back pain, fullness or pressure in the rectoanal area, or an urge to push, or they complain of dizziness

•            Large broad ligament haematomas may be felt on bimanual examination and push the uterus to one side

•            Extensive broad ligament and retroperitnealhaemafomas may cause profound hypovolumic shock and may rupture into peritoneal cavity

•            Diagnosis may be aided by USG or MRI if available

•            Broad ligament hemafoma may be treated either conservatively with blood transfusion, fluid resuscitation, and observation

•            Or it may be successfully treated by uterine artery embolization if facilities are available

•            Or with surgical exploration and evacuation followed by ligature of bleeding points

•            A careful check should be made to confirm or deny uterine rupture as source of haematoma