Vulvar Hematomas: Symptoms, Causes, Treatment

Introduction

The vulva is not a common site of injuries due to its location and the protective effects of the spontaneous adduction of the thighs which prevents direct trauma to the vulva. Howbeit some cases of both obstetric and non obstetric vulva haematomas have been reported, but the actual incidence is not known. Obstetric vulva haematomas are usually seen following delivery as a result of soft tissue injuries or iatrogenic injuries from episiotomies1,2. Non-obstetric vulva haematomas on the other hand are usually due to direct trauma to the perineum1,3, sexual intercourse (forceful or consensual)4. The clinical features usually include severe pain in the vulva, vulva swelling which may be rapidly increasing with or without bleeding or laceration.Options for treatment can be either conservative (for small non-progressing haematomas)5 or surgical (for huge or rapidly progressing haematomas which require prompt evacuation)6. The outcomes of either management options are good6,7, although Some authors have reported that conservative management is associated with increased need for antibiotics, blood and longer hospital stays8.This case report is that of a rapidly evolving vulva haematoma following blunt trauma in a pregnant woman in the early third trimester who after surgical intervention successfully carried the pregnancy to term and had a normal vaginal delivery.

Case Report

A 27yr old unbooked G5P4+0 (4 living children) at 32weeks gestational age who presented to the emergency unit with complains of vulva pain and mild bleeding following a road traffic accident in which she sat astride on a motor bike. She was said to have bounced repeatedly on the motor bike during the course of the accident. There was no bleeding from any other body site or orifice. No abdominal pain, no drainage of liquor and she still felt adequate fetal movement.On examination she was in obvious painful distress, afebrile (T 36.80C), not pale, anicteric, not dehydrated and no pedal edema. Her respiratory rate was 20 cycles per minute, the chest was clear clinically, her pulse rate was 72 beats per minute and her blood pressure was 120/80mmhg. There was no abdominal or uterine tenderness and there was no uterine contraction. The Symphysiofundal height was 30cm which was compatible with her gestational age of 32weeks. There was no area of tenderness. A single intrauterine foetus was palpated in longitudinal lie and cephalic presentation. The fetal heart rate was 144beats per minute and it was regular. The vulva was smeared with blood but there was no active bleeding. A left vulva haematoma of about 4cm in diameter was noticed.

There was no obvious laceration in the vulva or vagina. The cervical os was closed and there was no liquor drainage. Her packed cell volume was 33%, urgent abdominal ultra sound scan revealed a normal cyesis at 32weeks + 4days gestational age and ruled out broad ligament haematoma. She was admitted for close observation, given analgesics and haematinics and counselled to report to the nurses if the pain worsened or swelling increased. About 30 into the admission she was in severe pain and the haematoma had increased significantly but the fetomaternal vital signs were normal. She subsequently had examination under anaesthesia, haematoma evacuation and application of haemostatic stitches. Intraoperatively, there was a huge left vulva haematoma of about 10x10cm that contained about 300ml of clotted blood which was evacuated through an incision on its most bulging aspect in the vagina. After the evacuation diffuse bleeding points from the wall of the haematoma were ligated with chromic 2-0 sutures. The haematoma cavity was closed with chromic 2-0. The total blood loss was about 400ml. An indwelling urinary catheter as well as a vagina packing was Left insitu for 12hours. She was placed on analgesics, antibiotics tocolytics and haematinics. Vulva swelling resolved and she was discharged after 48hours on admission with a packed cell volume of 32%. She subsequently presented at term in spontaneous labour and had a successful vaginal delivery of a live male neonate that weighed 2.9kg without any episiotomy, vulval or perineal tear.

Discussion

This was a 32week pregnant woman who developed acute vulva haematoma following repeated trauma to the vulva while riding on a commercial motorcycle.The loose connective tissue and smooth muscles of the vulva is richly supplied by branches of the pudendal artery; a significant branch of the internal iliac artery9. It drains into the labial veins, which are tributaries of the internal pudendal veins. 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 significant vulvar hematomas10.The factors that contributed to the development of the haematoma in this case include the loose areola connective tissue in the vulva that permits room for expansion, increased blood flow to the vulva and perineum in pregnancy and the repeated blunt trauma that led to rupture of the blood vessels in the vulva. With uncontrolled extravasation of blood and room to expand, a worsening haematoma was inevitable.The incidence of vulvar hematomas including those in pregnancy and delivery is not known as there are very few reports of the same 10,11.

A similar case of traumatic vulva haematoma was reported by Ekweani et al in a 36week pregnant unbooked multipara who was managed conservatively and subsequently had a spontaneous vaginal delivery3In addition to trauma3, vulva haematomas have been linked to sexual intercourse4 consensual or forced, child birth12 and in some cases it may be spontaneous10.Risk factors for development of obstetric vulva hematoma include nulliparity, age > 29 years, birth weight of the baby >4 kg, instrumental vaginal delivery, prolonged labor, preeclampsia and bleeding diathesis1,11. About 87% of the hematomas occur following repair of episiotomies or vaginal lacerations2.Obstetric hematomas can be vulval/vulvovaginal, paravaginal, pelvic/subperitoneal13. In vulval/vulvovaginal hematomas, bleeding is obvious on the external surface with or without vaginal extension, limited above by the anterior urogenital diaphragm. Both types arise from injury to the branches of the pudendal artery (the posterior rectal, transverse perineal and posterior labial arteries).

Paravaginal hematomas are not seen externally and can be detected only on vaginal examination. They result from damage to the descending branch of the uterine artery. The haematoma is confined to the paravaginal tissues in the space bounded inferiorly by the pelvic diaphragm and superiorly by the cardinal ligament. Subperitoneal hematomas are the result of damage to the uterine artery branches in the broad ligament. The hematoma develops within the broad ligament and can dissect retroperitoneally. It can be clinically occult despite significant blood loss. A high index of suspicion is required to diagnose and manage these haematomas promptly before signs of cardiovascular collapse develop14.Vulva haematomas can be managed either conservatively or surgically. For rapidly expanding life-threatening haematomas, surgical treatment is advocated15 and it remains the gold standard not just for relief of symptoms but for its life saving potential.

Surgical options include EUA, evacuation7,15 and haemostatic stitch application as performed in the index case, as well as arterial embolization16. Conservative management has been supported by some authors as the outcome is said to favourable7. However, it is reserved for small non-progressing haematomas in haemodynamically stable patients5. In the case discussed, the patient was initially being managed conservatively but with the rapidly increasing haematoma she was quickly offered surgical treatment. Proper care during the procedure obviates the need for premature deliveries, shortens hospital stay and improves patient satisfaction. These include adequate analgesia, antibiotics, transfusion where indicated as well as administration of tocolytics to prevent uterine contractions which may progress to preterm labour and delivery.

Conclusion

Vulvar haematomas, although not very common may occur during and outside pregnancy from a variety of causes like blunt trauma as in the case discussed. Occasionally these haematomas may be potentially life threatening and may require urgent surgical intervention for haematoma evacuation and to secure haemostasis which will in turn reduce hospital stay, reduce the risk of complications and improve overall outcome and patient satisfaction.

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