Vulvar Haematoma

A vulvar haematoma is a collection of blood in the vulval soft tissues from rupture of a vessel, most often from childbirth, straddle injury, sexual trauma or surgery.

• Obstetric haematomas follow spontaneous or operative vaginal delivery and may track into the paravaginal and retroperitoneal space.
• Straddle injury is a common cause in girls.
• Expanding haematomas cause major blood loss and urinary retention.

Sudden painful, tense, bluish-purple vulval swelling after trauma or delivery.

• Severe pain, urinary retention, rectal pressure, asymmetric labial swelling, and signs of blood loss such as tachycardia and hypotension in large haematomas.
• Differential diagnosis: Bartholin abscess, vulval abscess, vulval varicosity, cyst, tumour, vaginal laceration, uterine rupture.
• Complications: haemorrhagic shock, infection, abscess, pressure necrosis, retroperitoneal extension.

Diagnosis is clinical, with assessment of blood loss and the extent of the haematoma.

• Clinical diagnosis with examination under anaesthesia when painful.
• Pulse, blood pressure and haemoglobin; group and cross-match.
• Pelvic ultrasound or CT scan to define extension above the pelvic floor.
• Urinalysis; examine for urethral, vaginal and rectal injury, especially in girls.
• Clotting profile if on anticoagulants or the bleeding is excessive.

Treat small stable haematomas conservatively and evacuate large or expanding ones, with resuscitation as needed.

• Supportive: ice packs wrapped in cloth for 20 minutes every 2 to 4 hours for the first 24 hours; compression with a firm perineal pad; bed rest; bladder catheter if the woman cannot pass urine; IV access and crystalloid for hypovolaemia.
• Pharmacological: analgesia with paracetamol 1 g oral or IV 6-hourly (maximum 4 g in 24 hours) and, if needed, morphine 2.5 to 5 mg IV titrated every 5 minutes (child 0.05 to 0.1 mg/kg IV). Avoid ibuprofen in the first 48 hours because of bleeding risk. Prophylactic antibiotic after surgery: amoxicillin-clavulanate 1.2 g IV 8-hourly for 24 hours then 625 mg oral 8-hourly for 5 days (child 15 mg/kg amoxicillin component 8-hourly, maximum 500 mg per dose). Transfuse when haemoglobin is below 7 g/dL or shock is present. Tranexamic acid 1 g IV over 10 minutes may be given in postpartum bleeding.
• Procedures: conservative management for haematoma below 5 cm that is not expanding. Surgical evacuation for haematoma above 5 cm, expanding, infected or causing retention: incise over the most prominent part under adequate anaesthesia, evacuate clots, ligate bleeding vessels with absorbable 2-0 suture, close dead space in layers, and leave a drain or pack for 24 hours. Selective arterial embolisation when the bleeding point is deep and cannot be reached.
• Special groups: in girls examine under anaesthesia to exclude hymenal, urethral and rectal injury, and consider abuse. In women on warfarin check INR and give vitamin K 5 mg slow IV if INR is above 4 with active bleeding. In postpartum haematoma exclude retroperitoneal extension.
• Red flags: expanding swelling, hypotension, heart rate above 110 per minute, falling haemoglobin, retention, signs of retroperitoneal bleeding.
• Follow-up: review at 24 hours, 1 week and 6 weeks; check haemoglobin; advise on iron: ferrous sulphate 200 mg oral 8-hourly for 3 months if anaemic (child 3 mg/kg elemental iron daily).