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The Puerperal Hematoma or Genital Thrombosis: A Case Report and Literature Review

Case Report The puerperal hematoma is a dreaded complication of postpartum hemorrhage, caused by a vascular rupture, most often a venous one. The main known risk factors are fetal macrosomia and instrumental extractions. Depending on the location of the puerperal hematoma, a variety of symptoms ranging from vulvar swollen to an abdominal pain can be seen. The diagnosis is often clinical; a CT scan can locate the vessel causing the hematoma. The management of the puerperal hematoma is multidisciplinary with a tendency toward arterial embolization in most cases. Through a clinical observation, we will try to focus on this pathology and especially discuss the different therapeutic options.


INTRODUCTION
The puerperal hematoma (or the genital thrombosis) is a rare dreaded hemorrhagic complication of the postpartum which the maternal prognosis can be engaged. A puerperal hematoma is a special form of postpartum hemorrhage.
The objective of our work is to study the modalities of management of puerperal hematoma in a case in the gynecological and obstetrical department the Souissi maternity hospital Rabat.

CASE REPORT
Mrs. K.F, 25 years old, with was no significant past, obstetric, or surgical history, primitive, gives birth to a newborn male, weighing 3700g by vaginal delivery. An instrumental extraction by Forceps and an episiotomy were necessary for extraction and a lateral vaginal tear occurred during delivery. Two hours after childbirth, the patient claims very intense, unbearable pain in the perineal region with an urge to push.
On examination, we find a patient with a stable hemodynamic state, a good safety globe, with an externalization several blood clots, the blood loss was estimated to be 600 g and a very painful swelling in the vulva of 6 cm, the diagnosis of genital thrombosis was made.
The patient was urgently transferred to the operating room with monitoring, 102bpm, a blood pressure of 110/60 mmHg and the blood count showed an Hb level of 10.7g/dl. Under general anesthesia a wide incision was made with evacuation of the hematoma by cleaning-draining, hemostasis was ensured by the realization of an X stitches, a corrugated blade of delbet was left in place for 24 h to ensure the draining.
The patient left the hospital five days after the operation, and a complete disappearance of the hematoma after 5 weeks. She was followed up after 2 month and she did not have any complaints. The patient's consent and the institutional ethical board's permission were taken for the publication of this case report.

DISCUSSION
The incidence of genital hematomas is of the order of 4/5132 or 1/1283 deliveries [1]. Due to a vascular rupture a blood collection is formed within the cellular tissues of the vulva, the vagina, or the parameter and tending to diffuse towards the pelvis or towards the perineum. The vascular rupture is most often venous. Formed in the thickness of the vaginal walls after the rolling of the tissues undoubtedly related to the rotation of the fetal head and the instrumental extractions. A forced cleavage is formed and very often the rupture of the visceral fascia. The hematoma continu it's spreading along the various fasciae and progressively dissect the vaginal wall. It can also extend below the levator ani muscle, distend the perineum and push back the rectum, the anus, and extend above, upward into the broad ligament base and retroperitoneum [2][3][4] Vascular wounds within tissue detachment have no tendency to hemostasis and the hemorrhage will be complicated by DIC very quickly [5].
There are four main types of genital hematoma according to an anatomical classification: [6]  Vulvar hematoma,  the vaginal hematoma itself  vulvovaginal hematoma  pelvi-abdominal hematoma A chronological classification describes: [5] Immediate hematoma: occurs immediately after delivery and directly secondary to obstetric trauma. The bleeding is often of venous origin, cannot be collected as long as the fetal head is still not expelled compressing the virtual cavity. This hematoma only becomes apparent after delivery. If the bleeding is arterial, it will collect very quickly, which may interfere with the delivery of the placenta.
Delayed hematoma: it is most often discovered a few days, even a few weeks after childbirth, probably secondary to necrosis by hyperpressure of the pelvic vessels, which can be the evolution of an immediate hematoma not previously recognized.
The main risk factors are primiparity, instrumental extractions, toxemia of pregnancy, fetal macrosomia, prolonged labor, difficult or insufficient hemostasis mainly by inadequate repair, or a vascular wound during a pudental block, multiple pregnancies and vulvar vaginal varicose veins [7,8].
The role of episiotomy is controversial, protective for some [9] promoting for others [7]. Vulvar vaginal hematomas often develop on the ipsilateral side of the episiotomy site. However, hematomas can also be formed on the contralateral side of the episiotomy [10] In the 2006 CNGOF recommendations on the practice of episiotomy, the restrictive practice of episiotomies does not modify the rate of perineal hematomas [5].
In our patient, the risk factors are represented by primiparity and instrumental extraction. The symptoms vary depending on the location of the hematoma, its size and whether it is extensive or not, immediate or delayed, an externalized hemorrhages or not. The pain is the master symptom; it is often very intense, throbbing and unbearable. It is usually associated with a tenesmus, a urge to push, Its unusual exacerbated character, with agitation contrasting with the usual lull of postpartum and must quickly alert to perform an immediate examination [1]. These symptoms are accompanied by more or less marked signs of internal bleeding up to hypovolemic shock [5].
The Inspection shows a very painful swelling in case of vulvar hematoma, and the large lip is rapidly oedemated, tense, hyperalgic to the touch and purplish. In case of vaginal hematoma, the diagnosis is less easy, the external examination is normal appearance, it is the internal vaginal examination that will authenticate the swelling and its volume. Examination reveals swelling of the side wall of the vagina [11]. Concerning the hematoma under peritoneal, the clinical picture is that of an unexplained internal bleeding, it is often underestimated [11]. We find a defense, a deviated uterus, a voussure above the crural arcade.
The management must be rapid taking into account the prognosis, the intensity of the pain, and the blood loss with the risk of consumption coagulopathy.
Once the postpartum hematoma is diagnosed, it is necessary to stabilize the hemodynamic state of the patient, the search for secondary anemia due to the hemorrhage, and choose an adequate treatment as soon as possible. At the start, the therapeutic management of puerperal hematoma was carried out according to its size: If the hematoma is less than 3-5 cm, an expectation can be performed with local application of ice, prescription of analgesics, and careful monitoring. If the hematoma has remained stable for several hours and without maternal repercussions, nothing else will be offered [5].
In the event of a medium-sized hematoma 5 to 10cm in diameter, the incision-cleaning-draining appears to be the best compromise; embolization may come to the aid of a resumption of bleeding [8].
When the hematoma is large, in particular more than 10 cm long, rapidly extensive or recurrent, elective embolization appears to be the most appropriate technique. In the event of failure of embolization, conventional surgery must be performed, especially the ligation of the hypogastric arteries [8].

Currently other strategies have been proposed depending on the authors
Takaji et al. proposed to perform, if the patient is hemodynamically stable, as a first-line CT scan to identify the type of hematoma and determine the origin of the bleeding, if an actively bleeding vessel is confirmed, emergency arterial embolization should be selected as the first-line treatment to obtain hemostasis. After hemostasis has been obtained, the hematoma should be opened and drained [10].
Tsumagari et al. created an algorithm for the management of postpartum hematoma by taking into account the anatomical location of the hematoma and proposing several treatment options. They therefore insisted on the fact that the location of the puerperal hematoma must constitute the basis for the choice of treatment. Specifically, TAE (Transcatheter Arterial Embolization) (TAE) should be the first treatment offered for hematoma of the upper vaginal wall. Hematomas of the lower vaginal wall can be treated using surgery, but when it is difficult to achieve hemostasis, TAE should be considered. For hematomas of the lower vaginal wall or vulva, abstention from therapy may be considered if the patient's hemodynamic state is stable [12].

CONCLUSION
The puerperal hematoma is a serious complication of the immediate post-partum that should not be ignored, the management must be fast and adapted according to the location of the hematoma and the hemodynamic state of the patient, the use of Transcatheter arterial embolization should be the first treatment offered for hematoma of the upper vaginal wall.

Guarantor of Submission
The corresponding author is the guarantor of submission.

Availability of data and materials
Supporting material is available if further analysis is needed.