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CASE REPORT
Year : 2012  |  Volume : 2  |  Issue : 1  |  Page : 37-38

Vulva hematoma


Department of Obstetrics and Gynaecology, ABU Teaching Hospital, Shika-Zaria, Nigeria

Date of Web Publication22-Sep-2012

Correspondence Address:
Mathew Akpa
Department of Obstetrics and Gynaecology, ABU Teaching Hospital, Shika-Zaria
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.101272

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  Abstract 

Background: Vulva hematoma is a very rare maternal injury that usually presents in the third stage of labor after a normal spontaneous vaginal delivery. Most cases develop insidiously with a sudden collapse and severe groin pain. Causes reported include imperfect repair of episiotomy and rupture of varicose vein of the vulva. We report an interesting case of vulva hematoma.
Case Report: We present a case of a 22-year-old primipara referred from a peripheral hospital, having collapsed at home following an unsupervised spontaneous vaginal delivery at home 6 h earlier. At presentation, the patient was pale and in shock. There was a huge left vulva hematoma with a peri-urethral laceration up to the clitoris. Surgical treatment resulted in a good outcome.
Conclusion: Vulva hematoma is a rare cause of maternal morbidity and mortality. This case reminds an obstetrician to be suspicious of vulva hematoma in a patient in shock postpartum.

Keywords: Shock, unsupervised pregnancy, vulva hematoma


How to cite this article:
Akpa M, Oguntayo AO. Vulva hematoma. Arch Int Surg 2012;2:37-8

How to cite this URL:
Akpa M, Oguntayo AO. Vulva hematoma. Arch Int Surg [serial online] 2012 [cited 2019 Nov 15];2:37-8. Available from: http://www.archintsurg.org/text.asp?2012/2/1/37/101272


  Introduction Top


Vulva hematoma is a very rare maternal injury that usually presents in the third stage of labor, after a normal spontaneous vaginal delivery. [1] Majority of cases develop insidiously with a sudden collapse and severe groin pain. Few cases have been associated with imperfect repair of episiotomy. [2] Some others are often due to rupture of varicose vein of the vulva that consequently collects in the dead space of the surrounding tissues of the labial folds and the perineal body on one side. It could also be due to tear of the mucosal vessels of the lateral wall of the vagina following normal or instrumental delivery. More often than not, they usually present in shock. [1],[2] Otherwise, they present in pains with swelling. Considering the etiological factors of maternal mortality, this case report brings to mind the rare causes of hemorrhage as a factor of maternal mortality. In our environment, adding this remote factor makes it significant, especially where the attending physician is not conversant with its management. The objective of this study is to discuss the presentation and management of vulva hematoma, a rare but life-threatening cause of maternal mortality and morbidity.


  Case Report Top


The case presented here is 22-year-old primipara referred from a peripheral hospital, having collapsed at home following an unsupervised spontaneous vaginal delivery at home 6 h earlier. The pregnancy was unsupervised. Examination at admission revealed a young lady sweating profusely, pale with cold clammy extremities. Her pulse rate was 104/min regular but of small volume, and blood pressure was 100/50 mm Hg (supine). There was no significant finding in the abdomen. There was a huge left vulva hematoma with a peri-urethral laceration up to the clitoris [Figure 1]. A diagnosis of postpartum hemorrhage secondary to vulva hematoma was made. She was resuscitated with intravenous fluids and blood transfusion. She was also placed on antibiotics, tetanus prophylaxis, and analgesics. She had exploratory laparatomy under general anesthesia; no definite bleeder was identified and about 500 ml of blood clot was evacuated. A repair was carried out with a drain in situ to avert further collection. She made satisfactory postoperative recovery having removed the drain after 48 h.
Figure 1: Massive left vulval haematoma

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  Discussion Top


Vulva hematoma is usually a unilateral injury of the vulva with edematous swelling, which is occasionally encountered during the course of labor; it is usually noticed after delivery [1] though it had been reported in literature to occur following coital trauma [3] or sometimes spontaneous. [4] At times, it is so large that it extends up the vagina and occludes it as it was in this patient.

The cases present usually with a huge vulvar swelling that is associated with pain. The pain is usually severe that they sometimes present with neurogenic shock.

Management options are either conservative or definitive depending on the size and the rate of progression of the hematoma. Conservative management is done when it is self limiting (when the haematoma arrest further bleeding and there is no appreciable increase in the swelling. [1]

The index case had exploration and evacuation of the hematoma under general anesthesia. The exploration rarely revealed the bleeding point as it was in this patient.

The repair is usually done to ensure that there is no dead space to avert recurrence and complication of abscess collections. [1],[2]

It is important to cover the patient with broad-spectrum antibiotics to reduce the chances of infection. Vulvar abscess is a notable complication. In some cases, the patient may require blood transfusion.

A recent report by UN and World Bank revealed that 144 women die in Nigeria everyday from pregnancy and childbirth complications. [5] Ignorance, illiteracy, and inadequate facilities are reported to be the prime reasons for the increasing maternal mortality rate in the country. [5] This could actually contribute to maternal mortality under the hemorrhagic causes even though it is rare.

Whatever can be done to reduce maternal mortality in a developing nation like Nigeria is significant and should not be underestimated. Our maternal mortality stands at 59,000 maternal deaths annually in recent United Nations data. [6] The data show that Nigeria has the second highest maternal mortality rate in the world. The country's 59,000 maternal deaths annually rank second to India's 117,000. Locally available statistics also show that the Northwest zone of the country, where we are reporting from, has the second highest mortality rate in Nigeria after the Northeast zone. [6]

It is very important to encourage our patients not only to book for antenatal care but also to ensure that they deliver in the hospitals so as to reduce our maternal mortality and morbidity. Though the period of pregnancy is longer than that of labor and delivery, the latter records more mortality, as such hospital deliveries should be encouraged.

 
  References Top

1.Agboola A. Maternal Injuries. In: Agboola A, Editro, 2 nd ed. Text book of Obstetric and Gynaecology for Medical Students. Lagos: Heinemann Educational Books (Nigeria); 2006. p. 478-9.  Back to cited text no. 1
    
2.Stanley GC. Traumatic Lesions. In: Stanley GC, Lewis TL, Pinker GD, Editors. 4 th ed. Obstetric by Ten Teachers. London: Edward Arnold (pub) Ltd; 1985. p. 282-91.  Back to cited text no. 2
    
3.Machado-Linde F, Capel-Alemán A, Sánchez-Ferrer ML, Cascales-Campos P, Pérez-Carrión A, Ortiz-Vera C. Major post-traumatic non-obstetric large haematoma: Transarterial embolisation. Eur J Obstet Gynecol Reprod Biol 2011;154:118-9.   Back to cited text no. 3
    
4.Nelson EL, Parker AN, Dudley DJ. Spontaneous vulvar haematoma during pregnancy: A case report. J Reprod Med 2012;57:74-6.  Back to cited text no. 4
[PUBMED]    
5.One World International Foundation, 144 maternal deaths in Nigeria in one world South Asia. C-5 Qutab Institutional Area New Delhi-110016. 30 th May 2011.  Back to cited text no. 5
    
6.United Nation Statistics and Indicator on Women and Men data on Maternal Mortality 2008. The worlds Women Report. Available from: http://www.Genderstat@un.org. [Last accessed 2012 Apr 5]  Back to cited text no. 6
    


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