Pelvic Retroperitoneal Dissection: A Hands-on Primer. Embolization is another management option for an expanding hematoma in a patient whose condition is otherwise stable. Similarly, patients with pressure symptoms resulting in compartment syndrome require surgical intervention. Hemodynamically unstable patients require resuscitation and surgical exploration. Hematomas in the retroperitoneal space can conceal a large volume of blood due to the proximity of well-known and typically avascular areas, namely the perivesical, parametrial (the base of the broad ligament), and perirectal spaces.Įarly recognition, evaluation, and expeditious intervention can be lifesaving in a patient with a hematoma. However, lacerations to the posterior vagina, such as a sulcus tear, can rupture vessels, leading to hemorrhage that dissects into the uterosacral area and expands into the retroperitoneal space. The most common retroperitoneal hematomas associated with childbirth occur as a result of injury to branches of the hypogastric and ovarian vessels.
Retroperitoneal hematomas constitute another category of rare but potentially life-threatening hemorrhage complications. Expansion can also occur cephalad in a concealed manner past the inguinal ligament into the retroperitoneal space and result in considerable blood loss. Hemorrhage in this area can expand medially and occlude the vagina. Bleeding from these vessels can extend into the paravaginal space, which is bound superiorly by the cardinal ligament, medially by the vagina, laterally by the obturator internus muscle, and inferiorly by the muscles of the levator ani. Surgical intervention and evacuation can prevent spontaneous skin rupture.Ĭervical tears, vaginal tears, and large episiotomies can rupture branches of the hypogastric arteries, including the descending branch of the uterine artery, the vaginal artery, and the pudendal artery. These hematomas are generally self-limiting however, they can cause pressure necrosis of the skin. As a result, expanding hematomas in these areas usually present as a blue-purple mass. Similarly, deep extension of a hematoma in the posterior triangle is limited by the presence of perirectal and anal fascia. Deep extension of a vulvar hematoma in the anterior triangle is limited by Colles fascia and the urogenital diaphragm. Vulvar hematomas often occur in the anterior and posterior urogenital triangles in areas bound by strong fascia tissue, which limits their expansion. These hematomas result from laceration or rupture of the pudendal artery and/or its tributaries. Vulvar hematomas are often encountered postnatally. Risk factors include lacerations from operative vaginal delivery/episiotomy and injury to pelvic vasculature from a variety of mechanical events, including uterine evacuation or perforation. Puerperal hematomas occur commonly and may pose life-threatening morbidity.
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