Abstract
Objective: To evaluate the characteristics and risk factors of puerperal hematoma.
Materials and Methods: Data from the medical records of 2,776 women, who delivered vaginally between January 2008 and December 2017 in the authors’ hospital, were analyzed retrospectively.
Results: Primigravida status was considered to be a significant risk factor. Among women with multigravida status, maternal age, instrumental delivery, and episiotomy were considered to be statistically significant risk factors. Regarding characteristics, hematoma occurred on the right side in 61.5% of cases, 53.8% were ≥50 mm in size, 61.5% were detected within 2 h of delivery, 46.2% were associated with severe pain, and 61.5% required surgical treatment.
Conclusion: Primigravida status a risk factor for puerperal hematoma, and maternal age, instrumental delivery, and episiotomy were risk factors for puerperal hematoma in women with multigravida status. Puerperal hematomas occurred more frequently on the right side than the left reflected by the number of episiotomies performed on the right side. Approximately one-half of the hematomas were associated with severe pain, and many were detected within 2 h after delivery. Many hematomas, especially those associated with severe pain, required surgical removal.
Keywords: puerperal hematomas, vulvar hematomas, vaginal hematomas, risk factors, characteristics
Introduction
Puerperal hematoma is considered to be a serious postpartum complication, with a reported morbidity rate of 1 in 300 to 1 in 1,500 deliveries1). Most puerperal hematomas are small and are associated with mild symptoms; however, some are large and associated with more serious symptoms and complications.
Puerperal hematomas are classified as vulvar, vaginal, or retroperitoneal2). In particular, retroperitoneal hematomas are serious disorders requiring emergent measures. The cause is believed to be vascular injury to the genital tract during vaginal delivery. Reported risk factors include primigravida status, episiotomy, instrumental delivery, macrosomia, vulvovaginal varicosity, and coagulation disorders, among others3). In particular, it has been reported that primigravida status, episiotomy, and instrumental delivery are the most commonly associated risk factors4). Accordingly, the present analysis aimed to evaluate the characteristics of and risk factors for puerperal hematoma that occurred in our hospital.
Materials and Methods
Data from medical records of 2,776 women, who delivered vaginally between January 2008 and December 2017 in the authors’ hospital, were analyzed retrospectively. Thirteen patients (10 primigravida, 3 multigravida) experienced puerperal hematoma and 2,763 (1,086 primigravida, 1,677 multigravida) did not.
Patients who experienced puerperal hematoma and those who did not were separated according to primigravida or multigravida status. Potential risk factors for puerperal hematoma included parity, maternal age, maternal body mass index, gestational age at delivery, neonatal birth weight, instrumental delivery, and episiotomy.
Risk factors were compared between the two groups using the Wilcoxon signed-rank test and Fisher’s exact probability test. Statistical analysis was performed using StatView version 5.0 (Hulinks Inc., Tokyo, Japan) for Windows (Microsoft Corporation, Redmond, WA, USA).
Among the 13 patients who experienced puerperal hematoma, type, laterality, corresponding with episiotomy, size, time of detection, symptoms, and treatments were analyzed.
All patients provided informed consent for publication of anonymized case details, and privacy was protected. This study was approved by the research ethics committee of the authors’ hospital (approved numbers: R 2-002).
Results
The morbidity rate of puerperal hematoma was 0.47%. Vulvar and vaginal hematomas accounted for the puerperal hematomas among the cases studied; no retroperitoneal hematomas were documented.
The ratio of primigravida status with puerperal hematomas is shown in Table 1. These data demonstrated that primigravida status was a significant risk factor for puerperal hematoma.
Table 1. Comparison of parity.
| Group with hematoma | Group without hematoma | P value | |
|---|---|---|---|
| Primigravida | 10 | 1,086 | <0.01 |
| Multigravida | 3 | 1,677 |
Fisher’s exact probability test.
A comparison between the groups with and without hematoma and primigravida status is shown in Table 2. These six parameters were not considered to be risk factors for puerperal hematoma. A comparison between patients who experienced hematoma and those who did not in multigravida status is shown in Table 3. Three characteristics were considered to be statistically significant risk factors for puerperal hematoma in those with multigravida status: maternal age, instrumental delivery, and episiotomy.
Table 2. Comparison among women with primigravida status.
| Group with hematoma (n: 10) | Group without hematoma (n: 1,086) | P value | |
|---|---|---|---|
| Age (years) | 29.1 ± 4.73 (19–35) | 28.2 ± 4.67 (16–42) | N.S. |
| Maternal body mass index (kg/m2) | 19.7 ± 1.74 (15.9–22.0) | 20.8 ± 2.84 (14.2–35.9) | N.S. |
| Gestational week (weeks) | 39.9 ± 0.55 (38.71–40.71) | 39.5 ± 1.15 (29.14–41.71) | N.S. |
| Neonatal birth weight (g) | 3,080 ± 329.9 (2,394–3,536) | 3,014 ± 350.2 (1,454–4,200) | N.S. |
| Instrumental delivery | 1 | 101 | N.S.* |
| Episiotomy | 9 | 867 | N.S.* |
Data presented as mean ± standard deviation (range). Mann-Whitney U test, Fisher’s exact probability test*.
Table 3. Comparison among women with multigravida status.
| Group with hematoma (n: 3) | Group without hematoma (n: 1,677) | P value | |
|---|---|---|---|
| Age (years) | 37.3 ± 1.53 (36–39) | 31.3 ± 4.56 (17–44) | <0.05 |
| Maternal body mass index (kg/m2) | 20.8 ± 1.72 (19.2–22.6) | 21.1 ± 3.07 (13.6–36.5) | N.S. |
| Gestational week (weeks) | 39.9 ± 0.50 (39.43–40.43) | 39.4 ± 1.03 (32.29–41.71) | N.S. |
| Neonatal birth weight (g) | 3,119 ± 610.6 (2,748–3,824) | 3,105 ± 364.9 (1,552–4,166) | N.S. |
| Instrumental delivery | 2 | 37 | <0.01* |
| Episiotomy | 3 | 213 | <0.01* |
Data presented as mean ± standard deviation (range). Mann-Whitney U test, Fisher’s exact probability test*.
The characteristics of puerperal hematoma in the 13 patients who experienced is shown Table 4, with the vulvar type occurring in 7 (53.8%) and the vaginal type in 6. Puerperal hematoma occurred on the right side in 8 (61.5%) patients, and on the left in 5. Four (30.8%) cases were associated with episiotomy.
Table 4. Characteristics of puerperal hematomas.
| Tyre | Vulva: 7 | Vagina: 6 | |
| Laterality | Right: 8 | Left: 5 | |
| Matching with episiotomy | 4 | ||
| Size (mm) | 10 ≤ <30 : 2 | 30 ≤ <50 : 4 | 50 ≤ : 7 |
| Time of detection (h) | 0 ≤ <1 : 6 | 1 ≤ <2 : 2 | 2 ≤ : 5 |
| Symptoms | Severe pain and swelling: 6 | Only swelling: 7 | |
| Treatment | Surgery: 8 | Conservative: 5 |
Hematomas ≤10 mm to <30 mm in size were found in 2 patients, 30 mm to <50 mm in 4, and >50 mm in 7 (53.8%). The time to detection of hematoma was 0 h to ≤1 h in 6 patients, 1 h to ≤2 h in 2, and >2 h 5 in 5. The proportion of hematomas detected within 2 h was 61.5%.
Symptoms included severe pain and swelling in 6 patients and swelling only in 7. All patients experienced swelling, with 46.2% experiencing severe pain. Eight (61.5%) patients required surgery for hematoma removal, while 5 received conservative treatment(s).
Discussion
The morbidity rate of puerperal hematoma has been reported to be 1 in 300 to 1 in 1,500 deliveries1), corresponding to percentages of 0.33% to 0.067%. The morbidity of puerperal hematomas was 0.47% in our study. Although morbidity in our study was higher, we believe this can be explained by the fact that we investigated a smaller number of hematomas.
Puerperal hematomas may be classified as vulvar, vaginal, or retroperitoneal2). In our study, no retroperitoneal hematomas were documented. Primiparity, episiotomy, instrumental delivery, macrosomia, vulvovaginal varicosity, coagulation disorders, and others have been proposed as risk factors3). We investigated six risk factors (maternal age, maternal body mass index, gestational age of delivery, neonatal birth weight, instrumental delivery, and episiotomy), separated according to primigravida or multigravida status.
Primigravida status was a statistically significant risk factor for puerperal hematoma. We speculate that the extensibility of the vaginal wall and vulvar tissue is limited in those with primigravida compared with multigravida status.
In the primigravida group, we did not observe a significant difference among the six risk factors. On the other hand, in the multigravida group, we identified three statistically significant factors: maternal age, instrumental delivery, and episiotomy.
In general, maternal age is a risk factor for some obstetric complications. Instrumental delivery is initiated in most cases involving prolonged delivery, and injuries to the vaginal wall and vulvar tissue often occur. Episiotomy is reported to be associated with puerperal hematoma. In a previous study, episiotomy was performed in 85% to 95% of cases in which puerperal hematoma occurred5). Approximately 50% of puerperal hematomas were associated with episiotomy6).
We considered primigravida status to be a risk factor for puerperal hematoma, while maternal age, instrumental delivery, and episiotomy were risk factors for puerperal hematoma in multigravida patients.
We analyzed the characteristics of puerperal hematoma. There were no retroperitoneal hematomas documented, and vulvar and vaginal hematomas occurred at approximately the same rate. Hematoma laterality was greater on the right than the left; as such, we considered hematoma to be related to episiotomy performed on the right side, and was approximately to the same degree with regard to size (<50 mm and ≥50 mm). There were many small hematomas in this study.
Many puerperal hematomas were detected within 2 h after delivery. Therefore, puerperants should be carefully monitored for at least 2 h after delivery. No serious disorders were detected >2 h, and symptoms were not severe. However, approximately one-half of the hematomas were associated with severe pain, especially vulvar hematomas.
Many hematomas require surgical removal. All hematomas associated with severe pain in this study were surgically removed, and those with non-severe symptoms were observed. For especially severe or large hematomas, such as retroperitoneal hematomas, angiographic embolization has become the first-line management strategy7).
Puerperal hematomas occurred on the right side more than the left, reflected by the number of episiotomies performed on the right side. Approximately one-half of the hematomas were associated with severe pain, and many were detected within 2 h after delivery. Many hematomas, especially those associated with severe pain, require surgical removal. As one preventive measure for hematoma, it is important to comply with adaptations in the enforcement of episiotomy and instrumental delivery.
Conclusion
Results of the present study suggest that primigravida status was a risk factor for puerperal hematoma, and maternal age, instrumental delivery, and episiotomy were risk factors for puerperal hematoma in women with multigravida status. Puerperal hematomas occurred on the right side more than left, reflected by the number episiotomies performed on the right side. Approximately one-half of the hematomas were associated with severe pain, and many were detected within 2 h after delivery. Many hematomas, especially those associated with severe pain, require surgical removal. As one preventive method, it is important that we comply with adaptations to the enforcement of episiotomy and instrumental delivery.
Conflicts of interest
The authors have no potential conflicts of interest to declare.
Acknowledgment
The authors extend special thanks to the Department of Obstetrics and Gynecology, Kochi Medical School, for their technical support and to the patients who participated in this study.
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