Pelvic Haematoma Requiring Angioembolisation Following Operative Vaginal Delivery: A Case Study.

Abstract

Background: Puerperal haematomas affecting the vulva, vagina and paravaginal spaces can present complex management challenges and cause significant morbidity for postpartum women. Aim(s): This case aims to illustrate the multidisciplinary management of a pelvic haematoma where traditional conservative and surgical management strategies were unsuccessful. Case: A 36-year- old primipara underwent a forceps delivery for obstructed labour. A vaginal haematoma was initially diagnosed several hours postpartum and managed conservatively with observation and analgesia. However, surgical management of the haematoma became indicated due to suspected ongoing bleeding with falling haemoglobin levels (121 g/L to 63 g/L), tachycardia and increasing pain. Operative vaginal evacuation of the haematoma and ligation of the bleeding vessel was unsuccessful due to massive soft tissue swelling obstructing the vagina and inhibiting the surgeons' ability to identify and treat the source of bleeding. Result(s): A CT angiogram post-operatively demonstrated active bleeding from a small artery arising from the pubic branch of the right inferior epigastric artery. Radiological embolisation was successfully performed eight hours following her return to theatre, with no further extravasation confirmed on follow-up CT two days later. Transfusion of six units of packed red blood cells achieved haemoglobin stability at 91 g/L. The patient and her baby were discharged home well on day six postpartum with no clinical concerns at a six-week postnatal review. Discussion(s): Puerperal haematomas are an uncommon but potentially significant complication of birth due to associated maternal morbidity. This case demonstrates the benefits of timely collaboration with interventional radiology where usual conservative and surgical strategies are unsuccessful.