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Laparoscopic treatment of postpartum pre-sacral haematoma


1 Department of Gastrointestinal Surgery, Synergy Institute of Medical Sciences, Dehradun, Uttarakhand, India
2 Department of Radiology, Synergy Institute of Medical Sciences, Dehradun, Uttarakhand, India
3 Department of Anaesthesia, Synergy Institute of Medical Sciences, Dehradun, Uttarakhand, India
4 Department of Digestive Surgery, Sahloul Hospital, University of Sousse, Sousse, Tunisia

Date of Submission29-Jul-2020
Date of Acceptance06-Sep-2020
Date of Web Publication07-Nov-2020

Correspondence Address:
Rahul Gupta,
Department of Gastrointestinal Surgery, Synergy Institute of Medical Sciences, Dehradun - 248 001, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmas.JMAS_153_20

  Abstract 

Postpartum retroperitoneal or pelvic haematomas are rare after vaginal delivery. The clinical presentation can vary from being an incidental finding to the development of life-threatening bleeding. Due to their rarity, there are no established guidelines for the management of these postpartum haematomas. The reported treatments vary from watchful observation to emergent laparotomy. We report a case of postpartum pre-sacral haematoma after uneventful vaginal delivery managed successfully by laparoscopic drainage after the failure of conservative treatment.


Keywords: Laparoscopy, postpartum, pre-sacral haematoma, puerperal, retrorectal lesion



How to cite this URL:
Gupta R, Pokharia P, Daspal U, Ammar H. Laparoscopic treatment of postpartum pre-sacral haematoma. J Min Access Surg [Epub ahead of print] [cited 2020 Dec 5]. Available from: https://www.journalofmas.com/preprintarticle.asp?id=300302



  Introduction Top


Pelvic haematomas are commonly encountered in clinical practice secondary to trauma, iatrogenic injuries or anticoagulation therapy. However, they can rarely occur in patients after vaginal delivery. The symptoms can vary from pelvic pain or fullness to the development of overt haemodynamic instability.[1] Early detection and timely treatment of the haematoma is important especially in patients with haemodynamic instability. We present an unusual case of puerperal pre-sacral haematoma treated by laparoscopy after failed conservative treatment.


  Case Report Top


A 26-year-old female developed urinary retention 2 days following uncomplicated full-term vaginal delivery. The treating obstetrician noticed a retro-rectal swelling on per-rectal examination. On pelvic ultrasound, a predominantly hypoechoic lesion was found in the pre-sacral space measuring 8.2 cm × 7 cm × 8.4 cm with no evidence of septation or calcification [Figure 1]. The patient was haemodynamically stable with no significant fall in haemoglobin. Hence, the patient was treated conservatively. Repeat pelvic ultrasound performed after 3 days revealed reduction in the size of the haematoma to 7 cm × 5.7 cm × 8.7 cm. Hence, the patient was discharged and asked to maintain close follow-up. Repeat pelvic ultrasound after 1 month of vaginal delivery revealed no change in the size of the haematoma. Contrast-enhanced computed tomography (CT) of the abdomen and pelvis showed a well-defined, round-to-oval, heterogeneous lesion in the pre-sacral space measuring 7.9 cm × 9.3 cm × 8.9 cm with an enhancing wall [Figure 1]. The lesion was displacing the rectum anteriorly. There was no obvious communication with the bowel lumen. In view of the CT findings showing no signs of resolution, the plan for laparoscopic drainage of the haematoma was made.
Figure 1: Abdominal ultrasound showing a heterogeneous, round-to-oval lesion (a) in the pre-sacral space pushing the rectum anteriorly (b). Contrast-enhanced computed tomography of the abdomen and pelvis showing a large well-defined lesion (arrow) in the pre-sacral region pushing the rectum anteriorly on the axial (c) and sagittal (d) images. The haematoma was confirmed at laparoscopy after rectal mobilisation (e) (arrow) and needle aspiration

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Intraoperatively, the rectum was mobilised anteriorly and the pre-sacral space was entered. After gradual caudal dissection, the haematoma was identified [Figure 1]. The lesion was confirmed by needle aspiration and opened. About 300 ml of altered blood and blood clots were evacuated and the cavity was cleaned with warm normal saline. The postoperative course was uneventful with hospital stay of 4 days.


  Discussion Top


Puerperal retroperitoneal haematomas after vaginal delivery are rare [Table 1].[1],[2],[3],[4],[5] They occur due to the injury to the branches of internal iliac artery or pre-sacral venous plexus during the labour.[2] The risk factors for postpartum haemorrhage such as multiparity, preeclampsia and prolonged second stage of labour can contribute to the development of haematoma. In the index case, none of these risk factors were present. The most common complaints are abdominal pain, per-vaginal or per-rectal bleeding and perineal swelling. In the current case, the patient had an unusual presentation of urinary retention. The clinical signs depend on the extent of bleeding. In mild cases, the patient may not have any signs. In severe cases, the patients can develop hypotension and shock.
Table 1: A brief review of reported cases of retroperitoneal haematoma after vaginal delivery

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Ultrasonography can detect large retroperitoneal or pelvic haematomas, as seen in the present case. However, the haematoma can mimic a tumour on ultrasound. Moreover, small haematomas can be missed on ultrasound. In such cases, CT and magnetic resonance imaging (MRI) can be helpful in detecting the haematomas, differentiating them from other lesions and planning the treatment. On CT, haematomas appear as heterogeneous, hyperdense lesions, similar to the present case.[2] On MRI, recent haematomas appear hypointense on T1-weighted and T2-weighted images, whereas old haematomas (>2 weeks) are hyperintense with low signal rim on T1-weighted and T2-weighted images.[1]

Treatment of postpartum pelvic haematoma depends on the condition of the patient and the extent of the haematoma. Patients with small haematomas and those with haemodynamic stability can be managed non-operatively.[3] Most of the haematomas resolve without any sequelae. Surgical intervention is required in patients with haemodynamic instability, significant fall in haemoglobin not responding to blood transfusion and failure of conservative treatment [Table 1]. Surgical drainage of haematoma and haemostasis can be achieved by laparotomy, perineal approach and laparoscopy, depending on the location of the haematoma.[1],[4],[5] Along with haematoma evacuation, patients may require hysterectomy or internal ligation artery ligation, if required.[4],[5] In selected cases with stable haemodynamics, transarterial embolisation of the bleeding vessels can be performed to avoid surgery as seen in patients with postpartum haemorrhage or paravaginal haematoma. The index case is the first reported case of laparoscopic treatment of postpartum pre-sacral haematoma.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initial will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Jain KA, Olcott EW. Magnetic resonance imaging of postpartum pelvic hematomas: Early experience in diagnosis and treatment planning. Magn Reson Imaging 1999;17:973-7.  Back to cited text no. 1
    
2.
Alturki F, Ponette V, Boucher LM. Spontaneous Retroperitoneal Hematomas Following Uncomplicated Vaginal Deliveries: A Case Report and Literature Review. J Obstet Gynaecol Can 2018;40:712-5.  Back to cited text no. 2
    
3.
Rafi J, Muppala H. Conservative management of massive puerperal spontaneous onset retroperitoneal psoas muscle haematoma following normal vaginal delivery. J Obstet Gynaecol 2008;28:105-6.  Back to cited text no. 3
    
4.
Kaya B. Paravesical and broad ligament hematoma after vaginal delivery. Case Rep Perinatal Med 2015;4:17-20.  Back to cited text no. 4
    
5.
Park M, Han SS. A case of secondary postpartum hemorrhage with shock followed by rupture of progressive retroperitoneal hematoma through left upper vaginal wall. Korean J Obstet Gynecol 2011;54:314-6.  Back to cited text no. 5
    


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2004 Journal of Minimal Access Surgery
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Online since 15th August '04