Managing vulvovaginal hematoma by arterial embolization as first-line hemostatic therapy

Aim Post‐partum hematomas are a serious obstetrical complication. Choosing treatments for post‐partum hematomas is difficult, and the application of transcatheter arterial embolization remains unclear. We aimed to clarify the clinical characteristics, identify the treatment indications and create a treatment algorithm for post‐partum hematomas. Methods Fifty‐four patients with post‐partum hematomas were enrolled. Hematomas were categorized according to location: upper vaginal, lower vaginal and vulvar. Blood loss, treatment methods and other clinical data were collected from the patients’ medical records and analyzed retrospectively. Results Five, 19 and 30 patients had upper vaginal wall, lower vaginal wall and vulvar hematomas, respectively. All upper vaginal wall hematomas required transcatheter arterial embolization to control bleeding, and the average blood loss was 2473 ± 1689 mL. Most lower vaginal wall hematomas were treated surgically; however, two patients required transcatheter arterial embolization, and the average blood loss in these patients was much higher (2010 ± 1145 mL) than that in patients with lower vaginal wall hematomas (395 ± 316 mL). No patient with vulvar hematomas was treated with transcatheter arterial embolization. Two and four patients with vulvar and lower vaginal wall hematomas, respectively, were managed with observation. Conclusion We created an algorithm for post‐partum hematoma management. Post‐partum hematoma location should guide treatment selection. Transcatheter arterial embolization should be selected for upper vaginal wall hematomas. Most lower vaginal wall hematomas are treatable with surgery, but transcatheter arterial embolization should be considered for hemostasis in difficult cases. Management with observation may also be possible for lower vaginal wall and vulvar hematomas.

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“…Takagi et al . also reported TAE as a first‐line hemostatic therapy, followed by removal of the hematoma and re‐suturing . Dahdouh et al .…”

Section: Discussionmentioning

confidence: 98%

“…1 Takagi et al also reported TAE as a first-line hemostatic therapy, followed by removal of the hematoma and re-suturing. 10 with upper vaginal wall hematomas that formed in the supralevator space required TAE; therefore, TAE might be the first choice of treatment for these patients.…”

Section: Discussionmentioning

confidence: 99%

Clinical characteristics, treatment indications and treatment algorithm for post‐partum hematomas

Tsumagari

Ohara

Mayumi

et al. 2019

J of Obstet and Gynaecol

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“…The supravaginal or subperitoneal type is clinically occult despite significant blood loss, and a high index of suspicion is required to diagnose and manage these hematomas promptly before signs of cardiovascular collapse develop (Mawhinney and Holman 2007). Effective management strategies have been reported for PGHA, including CM (Propst and Thorp 1998;Palmer and Knudstson 2008), SURG (Abbott et al 1965;Heffner et al 1985;Zahn et al 1996), a balloon tamponade device (Ghirardini et al 2012), and AEM (Hsu and Wan 1998;Villella et al 2001;Distefano et al 2013;Baruch et al 2015;Takagi et al 2017); but many of these have been described only in case reports. In deciding the treatment modality, it is necessary to identify the most reliable clinical findings; however, no prospective clinical trials or retrospective studies have been conducted in this regard.…”

Section: Discussionmentioning

confidence: 99%

“…AEM has been reported as a reliable therapeutic option for PPH, especially for cases of PGHA in which hemostasis cannot be achieved by CM or SURG (Hsu and Wan 1998;Pelage et al 1998;Villella et al 2001;Banovac et al 2007;Baruch et al 2015;Soyer et al 2015;Koganemaru et al 2016; Committee on Practice Bulletins-Obstetrics 2017; Lee et al 2018). Moreover, the efficacy of AEM as the initial treatment for PGHA has recently been reported (Distefano et al 2013;Takagi et al 2017). Although these studies emphasized the high reliability of AEM regarding identification of the bleeding vessels and the high hemostasis success rate (Hsu and Wan 1998;Villella et al 2001;Distefano et al 2013;Baruch et al 2015;Takagi et al 2017), most of these articles are case reports that did not record the specific critical indications for AEM as the initial treatment for PGHA.…”

Section: Discussionmentioning

confidence: 99%

“…However, the lack of scientific data to strongly support any single management approach has prevented a consensus regarding the optimal management (Zahn et al 1996;Mawhinney and Holman 2007). AEM has received particular recognition as an alternative to SURG, and has been proposed as the firstline treatment for PGHA (Distefano et al 2013;Takagi et al 2017). However, the patients who are good candidates for this treatment have not been identified, and AEM is not always available in all institutions where deliveries occur.…”

Section: Introductionmentioning

confidence: 99%

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Establishing a Treatment Algorithm for Puerperal Genital Hematoma Based on the Clinical Findings

Soeda

Kyozuka

Kato

et al. 2019

Tohoku J. Exp. Med.

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Postpartum hemorrhage within 24 hours after delivery remains the leading cause of maternal mortality worldwide. Puerperal genital hematoma (PGHA) is a rare complication of postpartum hemorrhage, and PGHA can be life-threatening if hemostasis is not properly achieved. However, a reliable management algorithm for PGHA based on the clinical findings has not been developed. The objectives were to evaluate the management strategies for PGHA and identify the clinical findings that help select the treatment for PGHA. The medical records of women who were treated for PGHA in our department were reviewed, and data regarding the clinical findings and the treatment strategy for PGHA were analyzed. Thirty-four women who underwent treatment for PGHA were identified and divided into three groups according to the final procedure that achieved hemostasis: conservative management (CM) (n = 9), surgical management (SURG) (n = 15), and arterial embolization management (AEM) (n = 10). Regarding the clinical findings on initial evaluation, the shock index was significantly higher in the AEM group than in the CM or SURG group; and initial platelet count and fibrinogen level were significantly lower in the AEM group than in the CM group. There was no significant difference in any computed tomography (CT) finding among the three groups. In conclusion, this study clearly shows the difference in clinical findings among treatment strategies for PGHA. We suggest that the clinical findings of shock index, platelet count, and fibrinogen level together with CT findings are helpful and valuable for selecting the treatment strategy for PGHA.

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Vulvar Hematomas

Sharma

Singh

2023

Labour and Delivery

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Managing vulvovaginal hematoma by arterial embolization as first-line hemostatic therapy

Abstract: We successfully managed two cases of puerperal vulvovaginal hematoma by arterial embolization based on the evaluation of an enhanced CT scan. In conclusion, we suggest arterial embolization to be a viable option for first-line treatment in the management of vulvovaginal hematomas.

Cited by 18 publications

References 4 publications

Clinical characteristics, treatment indications and treatment algorithm for post‐partum hematomas

Clinical characteristics, treatment indications and treatment algorithm for post‐partum hematomas

Establishing a Treatment Algorithm for Puerperal Genital Hematoma Based on the Clinical Findings

Vulvar Hematomas

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