Pelvic Haematoma After Delivery

Pelvic haematoma after delivery is a collection of blood in the pelvic retroperitoneal tissues above the levator ani muscles, usually from a tear of uterine, vaginal or pudendal vessels after instrumental delivery, a cervical or lower segment tear, caesarean section or uterine rupture. It matters because it can conceal several litres of blood and cause shock, with a firm uterus and little external bleeding.

• Risk factors: forceps and vacuum, cervical and high vaginal tears, uterine rupture, caesarean section (lateral extension), coagulopathy, preeclampsia, anticoagulants.
• Spread is into the broad ligament, retroperitoneum and sometimes under the diaphragm.
• Delay in diagnosis raises mortality.

Women have lower abdominal or flank pain, back pain, rectal pressure, a rise in pulse and fall in blood pressure within hours of delivery, despite a contracted uterus and minimal vaginal bleeding. The uterus may be pushed to one side.

• Pelvic or flank mass, tenderness and ileus.
• Falling haemoglobin out of proportion to visible loss.
• Differential diagnosis: uterine rupture, broad ligament haematoma, vaginal haematoma, intra-abdominal bleeding, uterine atony, amniotic fluid embolism, ovarian vein thrombosis.
• Complications: haemorrhagic shock, coagulopathy, infection and abscess, ureteric compression, ileus, anaemia, nerve injury, hysterectomy, maternal death.

The diagnosis is made by ultrasound or CT, with continuing assessment of shock.

• Pulse, blood pressure, urine output, uterine tone and fundal height; abdominal and vaginal examination.
• Haemoglobin repeated every 4 to 6 hours, platelets, clotting screen, fibrinogen, creatinine, group and cross-match 4 units.
• Ultrasound for retroperitoneal or paravaginal collection and free fluid; contrast CT for size, spread and active bleeding.
• Do not delay resuscitation for imaging.

The principle is resuscitation, correction of coagulation and haemostasis by embolisation or surgery.

• Supportive: two large-bore cannulae; Ringer's lactate 1 to 2 litres rapidly; blood transfusion early with fresh frozen plasma 15 mL/kg and cryoprecipitate 10 units for fibrinogen below 2 g/L; urinary catheter with hourly output; oxygen; warm the patient; bimanual compression if uterine atony coexists; high dependency care.
• Pharmacological: tranexamic acid 1 g IV over 10 minutes, repeated once after 30 minutes if bleeding continues; oxytocin 10 IU IM and 20 IU in 1 litre Ringer's lactate at 125 mL per hour for 4 hours; calcium gluconate 1 g IV after every 4 units of blood; cefazolin 2 g IV plus metronidazole 500 mg IV before surgery, then amoxicillin-clavulanate 1.2 g IV 8-hourly for 5 days; paracetamol 1 g IV 6-hourly; morphine 2.5 to 5 mg IV titrated for pain; ferrous sulphate 200 mg oral 8-hourly for 3 months.
• Procedures: uterine or internal iliac artery embolisation for a stable woman with active bleeding on CT where available; laparotomy with evacuation of the haematoma, ligation of the uterine and internal iliac arteries, packing and drainage for instability or failed embolisation; hysterectomy for uncontrolled bleeding; ultrasound guided drainage of an infected collection.
• Red flags: shock, falling haemoglobin, flank pain, expanding mass, fibrinogen below 2 g/L, fever above 38 degrees Celsius, oliguria.
• Follow-up: haemoglobin 6-hourly until stable; ultrasound at 1 week and 6 weeks to confirm resolution; review at 6 weeks; contraception and counselling for a later pregnancy.