DOI: 10.7860/JCDR/2017/24060.

9777
Original Article

Risk Factors and Incidence of

Obstetrics and Gynaecology

Puerperal Genital Haematomas

Section

Shikha Rani1, Meesha Verma2, Dilpreet Kaur Pandher3, Navneet Takkar4, Anju Huria5

ABSTRACT compared for the evaluation of risk factors for puerperal genital
Introduction: Puerperal genital haematomas although an haematoma.
uncommon entity but is elusive. This painful condition is not Results: During the study period 27,826 vaginal deliveries were
only distressing and dangerous to patient but is embarrassing performed in our institute. Thirty nine haematomas were drained
to the obstetrician who has conducted the delivery. during this period. Incidence of haematomas was one in 1,113
deliveries, in our institute. Among the puerperal haematomas,
Aim: This study has been planned to evaluate the incidence and
vulvovaginal was the most common type. Perineal pain was
risk factors for puerperal genital haematomas.
the most common complaint. To evaluate the risk factors, 77
Materials and Methods: A case control study was done from controls were enrolled. Primigravida, hypertensive disease of
August 2005 to August 2015, of all puerperal genital haematomas. pregnancy and coagulopathy were the significant risk factors
All patients, who had undergone drainage for the puerperal genital with p-value of <0.01, 0.01 and 0.03 respectively. Episiotomy
haematoma, were enrolled as cases. Two controls were chosen too was a risk factor with a p-value of 0.002.
for each case, who had delivered immediately after the case. All Conclusion: Primigravida, hypertensive disease of pregnancy,
the patients were evaluated for the characteristics of haematoma coagulopathy and episiotomy are still the most common risk
and the management of the same. Cases and controls were factors.

Keywords: Perineal haematomas, Traumatic haematomas,

Traumatic postpartum haemorrhage, Vulvovaginal haematomas

INTRODUCTION Details of both cases and controls like baseline characteristics,

Puerperal genital haematomas arise most often due to vascular obstetric and significant medical history were recorded. Details of
injury to lower genital tract. An incidence of 1 in 300 to 1 in 15,000 type of haematoma, its management and complications were also
deliveries has been reported in literature [1,2]. Vulval veins have no recorded.
valves and there is no counter pressure, so continued bleeding from
trauma leads to gross distension of the soft tissues of vagina and Statistical analysis
vulva [3,4]. Multiple underline risk factors like primiparity, episiotomy, Data was entered in Microsoft excel. Statistical of analysis was
instrumental delivery, pudendal nerve block, hypertensive disorders of done with statistical package R. Mean or median was calculated
pregnancy, macrosomia, prolong second stage of labor, vulvovaginal for continuous variables. Significance of risk factors for puerperal
varicosity and any coagulation disorders are responsible for genital haematoma was calculated by Wilcoxon rank sum test and
puerperal genital haematoma formation [5,6]. However, most of Fisher‘s-Exact test.
these haematomas are formed after normal labor and delivery rather
than abnormal labor or delivery [6]. RESULTS
Since very long there has been no change in aetiology and treatment During the study period 27,826 vaginal deliveries were performed
of this potentially serious condition. Also, limited data is available in in our institute. Thirty nine haematomas were drained during the
literature. So, this study was planned to evaluate the risk factors, study period, of which 25 patients were booked in our institute and
management and immediate maternal outcome in patients with 14 patients were referred with haematoma. So, the incidence of
puerperal genital haematoma. puerperal genital haematomas was 1 in 1,113 deliveries.
Seventy seven controls were enrolled during the same time period.
MATERIALS AND METHODS Baseline characteristics and risk factors for puerperal genital
This case control study was done in Department of Obstetrics and haematoma of cases and controls are shown in [Table/Fig-1]. Mean
Gynaecology from August 2005 to August 2015. Study approval age in cases and controls were 23±2.28 years and 26±4.07 years
had been taken from Institutional Ethic Board. Subjects who had respectively. Mean birth weight in cases and controls were 2656±420
puerperal genital haematoma and in whom drainage was done in gm and 2665±585 gm respectively. Four subjects in each group
our institute were enrolled as cases. Subjects who did not have had instrumental delivery. [Table/Fig-2] depicts the characteristic
puerperal genital haematoma were enrolled as controls. of puerperal genital haematomas. Vulvovaginal (35/39) was the
Patients who were managed conservatively or referred without most common type of haematoma. Pain in the episiotomy site was
drainage were excluded. All haematomas were drained vaginally the most common complaint (12/39) followed by tachycardia and
with occlusion of dead space followed by vaginal packing. Vaginal bleeding. Median time to detect haematoma was six hours (0-17).
pack was removed after 12 to 24 hours. Two controls for each Drainage and occlusion of the dead space with vaginal packing for
case were enrolled. Controls were chosen as a subject who had 24 hours was sufficient management for 38 haematomas.
delivered immediately after the case. Records of both cases and Only one case had drainage twice with vaginal packing but still
controls were retrieved from medical record department. developed haematoma. She was referred to another center for

Journal of Clinical and Diagnostic Research. 2017 May, Vol-11(5): QC01-QC03 1

 Shikha Rani et al., Risk Factors and Incidence of Puerperal Genital Haematomas www.jcdr.net

Variable Cases (n=39) Controls (n=77) 1113, which is same as reported in the literature [1,2]. We also found
that primigravida, hypertensive disease of pregnancy, coagulopathy
Age(yrs)a 23±2.28 26±4.07
and episiotomy are significant risk factor for these haematoma with
Gravida b
1(1-3) 2(1-6)
a p-value of <0.01, 0.01, 0.03 and 0.002 respectively. Saleem Z et
Risk factorsc al., did a population based study of vulvar haematoma in 1,76,1156
Primigravida 29 30
Episiotomy 39 63 deliveries from 1987-2000. They found 1418 haematoma during
Hypertensive disease of pregnancy 13 9 this period. They reported nulliparity was a strong risk factor with
Obstetric cholestasis 6 4
Anaemia 6 1 OR 3.63; (95% CI 3.25–4.08), birth-weight ≥ 4500 g OR 1.51; (95%
Instrumental delivery 4 4 CI 1.15–1.99) and age > 29 years was an independent risk factor.
Coagulopathy 3 0 On an average each patient had two days extra hospital stay [7]. We
Type of deliveryc found a median duration of hospital stay of five days, which is four
Normal vaginal 35 73
Instrumental
days more than average hospital stay after normal delivery. Mc ET et
Forceps 4 4 al., too reported episiotomy as the most common risk factor 85%-
Ventouse 0 0 93% of haematomas [8]. Sotto LS et al., studied 47 consecutive
Birth weight (gm)a 2656±420 2665±585 haematomas. They reported, 85% of patients had episiotomy and
[Table/Fig-1]: Baseline characteristics and risk factors for puerperal genital hematoma six of 47 of them had improperly repaired episiotomy. Improper
among cases and controls.
repair of episiotomy was also reported as a major risk factor of
Values in a are mean± SD, b is median,c are numbers
these haematomas [9,10].
Variable Number of cases (n=39) Pedowitz P et al., analysed 112 cases of puerperal haematoma.
They found that only half of the haematomas were on the
Symptoms a

Pain 19 episiotomy site and suggested probably episiotomy was not the
Bleeding 10 major reason of puerperal haematomas [10]. In our study, we found
Shock 01
Rectal pressure 01
four haematomas on the site different from episiotomy. Iskender C
Tachycardia 12 et al., did a retrospective analysis of 47 cases of puerperal genital
Time of detection of haematoma (hr)b 6(0-17) haematomas [11]. They reported nulliparity, instrumental delivery and
Site of haematomaa
mediolateral episiotomy as the main risk factors for haematomas.
At episiotomy 35 Since long, there has not been any change in risk factors and the
Other than episiotomy 04 management of vulval haematomas. Few cases have been reported
Size of haematoma (cm)c 6.2±1.6 in literature regarding the use of selective arterial embolization and
Type of haematomaa tissel for the management of vulval haematomas [4,12].
Vulval 00
Vaginal 04 Among all the risk factors for these haematomas episiotomy is
Vulvovaginal 35 one of the modifiable risk factor. Episiotomy is also associated
Retroperitoneal 00 with increased risk of anal incontinence and perineal lacerations.
Drainage of haematomaa American College of Obstetrics and Gynecology (ACOG) do not
Once 38
More than once 01
support the routine or liberal use of episiotomy except in certain
situations in view of best available data [13]. WHO too recommend
Referreda 01
an episiotomy rate of 10% a good goal to pursue [14]. But,
Blood transfusion a
32
whether restricted use of episiotomy will decrease the incidence of
Duration of Hospital stay (days) b 5(2-11) haematoma is not known.
[Table/Fig-2]: Characteristic of puerperal genital haematoma.
Values in a are numbers, b is median, c are mean± SD
Due to the retrospective nature of study the relationship between
the experience of obstetrician conducting delivery and incidence of
haematomas solely due to improperly repaired episiotomy could not
Cases Controls
Risk Factors p-value be calculated. We have evaluated the incidence and risk factors of
(n=39) (n=77)
Primigravida 29 30 <0.01
puerperal genital haematomas after such a long time (over 10 years)
which is the strength of our study.
Hypertensive disease of pregnancy 13 9 0.01
Obstetrics cholestasis 6 4 0.08
CONCLUSION
Aanemia 6 1 0.005 Primigravida, hypertensive disease of pregnancy, coagulopathy
Coagulopathy 3 0 0.03 and episiotomy are significant risk factor for puerperal genital
Instrumental delivery 4 4 0.44 haematoma.
Episiotomy 63 39 0.002

[Table/Fig-3]: Risk factors for puerperal genital hematomas.

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PARTICULARS OF CONTRIBUTORS:
1. Antenatal Medical Officer Cum Lecturer, Department of Obstetrics and Gynaecology, Government Medical College and Hospital, Chandigarh, India.
2. Junior Resident, Department of Obstetrics and Gynaecology, Government Medical College and Hospital, Chandigarh, India.
3. Assistant Professor, Department of Obstetrics and Gynaecology, Government Medical College and Hospital, Chandigarh, India.
4. Associate Professor, Department of Obstetrics and Gynaecology, Government Medical College and Hospital, Chandigarh, India.
5. Professor, Department of Obstetrics and Gynaecology, Government Medical College and Hospital, Chandigarh, India.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Shikha Rani,
Junior Resident, Department of Obstetrics and Gynaecology,
Government Medical College and Hospital, Chandigarh-160030, India. Date of Submission: Sep 11, 2016
E-mail: shikhataneja2000@yahoo.co.in Date of Peer Review: Oct 14, 2016
Date of Acceptance: Dec 28, 2016
Financial OR OTHER COMPETING INTERESTS: None. Date of Publishing: May 01, 2017

Journal of Clinical and Diagnostic Research. 2017 May, Vol-11(5): QC01-QC03 3