Vaginal Haematoma

Vaginal haematoma is a collection of blood in the paravaginal tissue, from a torn vessel in the vaginal wall, usually after instrumental delivery, a vaginal tear or an episiotomy. Supralevator haematomas spread into the pelvis and retroperitoneum, and infralevator haematomas bulge into the vagina and vulva. It matters because a large haematoma causes severe pain, urinary retention and hypovolaemic shock with little or no visible bleeding.

• Risk factors: forceps, vacuum, macrosomia, first labour, precipitate labour, coagulopathy, vulvar varices, preeclampsia with low platelets.
• Hidden loss can reach 1 litre or more.
• Prompt recognition prevents shock.

Women have severe perineal or vaginal pain after delivery, rectal pressure, difficulty passing urine, and a tense tender mass in the vagina. Shock may appear with only small visible blood loss.

• Bulging purple vaginal wall mass.
• Rising pulse and falling blood pressure.
• Differential diagnosis: vulvar haematoma, pelvic haematoma, broad ligament haematoma, uterine rupture, retained products, vaginal laceration, abscess.
• Complications: haemorrhagic shock, urinary retention, infection and abscess, pressure necrosis, pelvic haematoma extension, anaemia, dyspareunia.

The diagnosis is made by vaginal examination and imaging for large or high lesions.

• Inspect and palpate the vagina for a tense bulging mass; measure its size and note spread into the vulva or pelvis.
• Pulse, blood pressure, urine output, uterine tone and fundal height.
• Haemoglobin and repeat at 6 hours, platelets, clotting screen, group and cross-match 2 to 4 units.
• Ultrasound or CT for supralevator extension.

The principle is observation for small stable haematomas and drainage with haemostasis for large or expanding ones.

• Supportive: bladder catheter; ice packs to the perineum for 24 hours; vaginal pack (a roll of gauze) for 12 to 24 hours; two cannulae; Ringer's lactate 1 litre IV over 30 minutes if shocked; transfuse for haemoglobin below 7 g/dL or shock; mark the haematoma and check hourly for 6 hours.
• Pharmacological: paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours); morphine 2.5 to 5 mg IV titrated for severe pain; tranexamic acid 1 g IV over 10 minutes if bleeding continues; cefazolin 2 g IV as a single dose before drainage, then amoxicillin-clavulanate 625 mg oral 8-hourly for 5 days; ferrous sulphate 200 mg oral 8-hourly for 3 months; correct coagulopathy with fresh frozen plasma 15 mL/kg and cryoprecipitate 10 units.
• Procedures: conservative care for a haematoma below 5 cm that is not expanding; incision and drainage in theatre for one above 5 cm or expanding, with evacuation of clot, ligation of the bleeding vessel with 2/0 polyglactin, closure of the cavity in layers with a drain or pack; uterine or internal iliac artery embolisation or laparotomy for a haematoma extending into the pelvis.
• Red flags: expanding mass, shock, inability to pass urine, fever above 38 degrees Celsius, flank pain, falling haemoglobin.
• Follow-up: haemoglobin at 24 hours; wound review at 1 week; ultrasound at 2 weeks if large; review at 6 weeks.