Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Phar- macy, Bucharest, RomaniaRomania
Department of General Surgery, Ponderas Hospital, Bucharest, RomaniaRomania
Department of Radiology, Unirea Medical Center, Bucharest, RomaniaRomania
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Background: The early postpartum hematoma represents a rare complication which can appear in the early post-partum period. Its formation and development is favoured by the hypervascularization of the genital area during pregnancy and by the cellular hormone dependent laxity of the tissues which favours its apparition and diffusion. Description of the case: We present a rare situation of a large bilateral Bartholin glands hematoma at a 27-years-old, primiparous female, who had experienced a prolonged labour, ended by a caesarean section. Conclusion: Early postpartum hematoma is a rare condition which might need in selected cases a surgical approach in order to resect the compromised structures.
Keywords: Delivery; Massive hematoma; Bartholin glands
Puerperal hematoma is a rare complication which might develop after delivery and 1,2 which might put the mother’s life in danger if not recognized in time.1,2 Statistically, the in-
cidence of puerperal hematoma widely varies between 1/300 and 1/1500 deliveries while the 3-6 rate of cases necessitating surgical treatment is almost 1/900 cases.3-6 Most often, puerperal
hematomas develop in the peri-vaginal or peri-vulvar spaces, in the lax tissues, tending to
widely dissect the spaces where no anatomical obstacle is present. At this level, due to the
high levels of pregnancy hormones there is a limited possibility of spontaneous haemostasis;
secondarily, the hematoma might dissect the peri-vaginal and peri-rectal spaces, ascending to
the retroperitoneal space.3 The most common localizations are the vaginal, vulvar and pelvic
ones.3 We present the case of a 27-year-old primiparous patient who developed a massive bi-
lateral vulvar hematoma after a prolonged labour followed by a Ceasarian section, associated
with perineal debilitating pain, fever and difficulties in defecation. The hematoma proved to
be entirely developed into the Bartholin glands, which were irreversibly compromised. A total
bilateral resection of Bartholin glands was performed.
th
complete cervical dilation; after a negative labour test the patient was submitted to a Cae-
and very painful when touched (Figure 1). The vaginal examination revealed the presence of
two pseudotumoral lesions located on the lateral vaginal wall.
The perineal MRI showed the presence of two heterogeneous,
hyperintense in T1 hematomas measuring 6/5 cm on the right
side and 4/3 cm on the left side of the outer lips (Figures 2 and
3). The patient was resubmitted to surgery, intra-operatively a
bilateral massive hematoma of the Bartholin glands being found,
with total destruction of the glandular structures. A total bilateral
resection of Bartholin glands was performed (Figures 4, 5 and
6). The postoperative evolution was uneventful, the patient beth ing discharged the 4th postoperative day.
on the left side are located in the outer lips.
Most puerperal hematomas develop due to the lacera-
tions which might appear during labour or due to the instrumen-
tal extractions, especially due to the use of forceps.3 Primiparity
represents a particular risk factor, which, in association with a
prolonged labour, a foetal weight over 4000 gr, coagulation disorders or vulvovaginal varicosities significantly increase the risk
of developing puerperal hematomas.3,7
Unless the puerperal hematomas develop secondarily
to peri-partum traumatisms such as episiotomy or vulvo-vaginal
ruptures, they can be related to a secondary necrosis of the small
calibre arteries which might be compressed by a too slow de-
scend of the foetal head. Once the hematoma appears, it will
have no spontaneous tendency to regress; contrarily it will de-
velop a progressive growth and will compress the surrounding
tissues. For this reason, the secondary vascular necrosis might
affect blood vessels with increasing diameters.3
When it comes to the chronological classification of
puerperal hematomas, they can be considered as early and late
lesions.8 In our case we can consider that the hematoma was an
early one, developed immediately after the decompression of the
perineal region by Caesarean section. In that moment, the small
calibre vessels which had been already compressed by the foetal
head and necrotised developed a bleeding at the level of the Bar-
tholin glands which was recognized and diagnosed in the third
postoperative day.
The second widely recognized classification is the
anatomical one which divides the puerperal hematoma into vag-
inal, vulvar and subperitoneal. In fact, this classification is an
essential one because it creates a net separation between vulvar
and vaginal hematoma on one side and subperitoneal hemato-
mas on the other side, the two groups having totally different
therapeutic strategies.3 The particularity of our case is the atypi-
cal localization, neither vulvar nor perineal but localized sym-
metrically at the level of the Bartholin glands.
When it comes to the most appropriate therapeutic
strategy, it depends on location and dimension of the lesions.
While for vaginal or vulvar hematoma a conservative treatment
might be taken in consideration especially for the small sized
lesions, subperitoneal and retroperitoneal hematomas usually
benefit from surgical treatment, although a conservative therapy
might be also taken in consideration.9
In our case, we decided to perform a surgical ma-
noeuvre consisting of Bartholin glands resection due to the fact
that their structure had been already destroyed by the ischemic
modifications induced by the compressive hematoma.
To the best of our knowledge, no other case of bilat-
eral Bartholin gland hematoma has been described.
The authors declare that they have no conflicts of interest.
The patient has provided written permission for publication of
3,7