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POGS CLC

Maternal
Conference
Auran Rosanne B. Cortes, MD – MBA
September 28, 2018
VULVOVAGINAL HEMATOMA
WITH COMPLICATIONS
CASE REPORT: Brief History and Findings
General Data
• EA
• 40 y/o Gravida 3 Para 3 (3-0-0-3)
• Married
• Roman Catholic
• Las Piñas
CASE REPORT: Brief History and Findings
Chief Complaint
Routine postpartum follow up
CASE REPORT: Brief History and Findings
> Postpartum
> Admitted Day 7
> Wound
for trial of > Evacuation
dehiscence
labor of hematoma
> Rectovaginal
> Delivered and ligation fistula (?)
of bleeders
via NSD
> Blood
transfusion
(2u pRBC)

> Postpartum
Day 1
> Post-
> Vulvovaginal
hematoma evacuation
Day 1
> Hospital
discharge
CASE REPORT: Brief History and Findings
> Postpartum
> Admitted Day 7
> Wound
for trial of dehiscence
labor 7 days prior > Evacuation > Rectovaginal
> Delivered “Labor pains”of hematoma fistula (?)
via NSD and ligation
Stable vital signs
of bleeders
Good fetal heart tones
IE: 7 cm, 70% effaced, (+) bag of water, cephalic,
station -3 85
Mode of delivery: Normal spontaneous delivery with
perineal support and repair of 2nd degree laceration
> Postpartum
Dayunder
1 local anesthesia
> Post-
Outcome: Baby Boy, 2935 grams
> Vulvovaginal AGA
evacuation
hematoma
Duration of labor: > 3 hours Day 1
Estimated blood loss: 400 ml > Hospital
discharge
CASE REPORT: Brief History and Findings
> Postpartum
> Admitted Voiding freely Day 7
> Wound
for trial of No subjective complaints dehiscence
labor > Evacuation > Rectovaginal
> Delivered
Stable
of hematoma
vital signs fistula (?)
via NSD Pelvic examination:
and ligation
of bleeders
Intact sutures
(+) 8 x 6 cm fluctuant,
tender mass between 85
the 6 & 7 o’clock position
of the perineum
> Postpartum extending to the right
Day 1
> Vulvovaginal
posterior vaginal wall
> Post-
hematoma evacuation
Cervix soft, admits 1 finger
Day 1
Uterus contracted> Hospital
Minimal, non-foul smelling lochial discharge
discharge
CASE REPORT: Brief History and Findings
> Postpartum
> Admitted ASSESSMENT: Day 7
> Wound
for trial of dehiscence
labor > Evacuation3 Para 3 (3003) > Rectovaginal
> Delivered
Gravida
of hematoma fistula (?)
via NSD Status post
and ligation
of bleedersspontaneous delivery
Normal
with repair of
2nd degree laceration85
under local anesthesia,
Vulvovaginal hematoma
> Postpartum
Day 1
> Post-
> Vulvovaginal
hematoma evacuation
Day 1
> Hospital
discharge
CASE REPORT: Brief History and Findings
> Postpartum
> Admitted INTERVENTIONS: Day 7
> Wound
for trial of dehiscence
labor
> Delivered
•of> Evacuation
Hemostasis
hematoma
> Rectovaginal
fistula (?)
via NSD andInsertion
ligation of vaginal pack
• ofVenoclysis
bleeders as double line
for possible fluid
resuscitation 85
• Bladder catheterization
• Medications:
> Postpartum Antibiotic (Ampicillin 2g/IV)
Day 1 and anti-fibrinolytic> Post-
> Vulvovaginal
hematoma (Tranexamic acidevacuation
1g/IV)
• CBC: Hgb 91 | HctDay0.30
1 | WBC 14.2 | Platelet 351
• Stat evacuation>discharge
Hospital
of hematoma with ligation of
bleeders and repair under spinal anesthesia
CASE REPORT: Brief History and Findings
> Postpartum
TECHNIQUE OF REPAIR: Day 7
> Admitted
> Wound
for trial of > Evacuation dehiscence
labor of hematoma • Series of figure-of-eight stitches
> Rectovaginal
> Delivered and ligation of for the deepest layerfistula (?)
bleeders
via NSD > Blood
• Vaginal mucosa
transfusion reapproximated in 2 layers
(2u pRBC) • 1st layer: figure-of-eight
stitches using polyglactin 0
85suture
• 2nd layer: continuous
interlocking stitches using
> Postpartum chromic 2-0 suture
Day 1 • >Skin:
Post-
Inverted T stitches using
> Vulvovaginal chromic 2-0 suture
hematoma evacuation
• Repair
Day 1 followed by perineal
cleansing and Povidone Iodine
> Hospital
application
discharge
CASE REPORT: Brief History and Findings
> Postpartum
OPERATIVE FINDINGS:Day 7
> Admitted
> Wound
for trial of > Evacuation dehiscence
labor of hematoma • (+) 8 x 6 cm fluctuant, tender
> Rectovaginal
> Delivered and ligation of mass between the 6 fistula
& 7 o’clock
(?)
bleeders
via NSD > Blood
position of the perineum
transfusion extending to the right posterior
(2u pRBC) vaginal wall
• 300 ml blood clots were
85
evacuated
• 8 x 8 cm laceration between 6
and 7 o’clock position of the
> Postpartum perineum
Day 1 • >Smooth
Post-
and intact rectal
> Vulvovaginal mucosa with tight sphincteric
hematoma evacuation
tone
Day 1
> Hospital
• discharge
Estimated blood loss: 1 L
CASE REPORT: Brief History and Findings
> Postpartum
> Admitted Day 7
> Wound
for trial of PELVIC EXAMINATION FINDINGS:
DISCHARGE > Evacuation dehiscence
labor of hematoma > Rectovaginal
>External
Deliveredgenitalia: and ligation of fistula (?)
bleeders
via NSD
Intact sutures, no discoloration, no bleeding
> Blood
transfusion
Internal examination: (2u pRBC)
Intact sutures, no masses nor tenderness,
Cervix soft, admits 1 finger
Uterus well contracted
Minimal non-foul smelling lochial discharge

> Postpartum
Repeat CBC: Day 1
Hgb 102 | Hct 0.31> Vulvovaginal
| WBC 17.6 | Platelet 258 > Post-
hematoma evacuation
Day 1
Home medications: > Hospital
Co-amoxiclav, Ferrous sulfate, Mefenamic acid discharge
CASE REPORT: Brief History and Findings
> Postpartum
> Admitted Day 7
Routine postpartum follow-up > Wound
for trial of > Evacuation dehiscence
No subjective complaints
labor of hematoma > Rectovaginal
>Stable
Delivered and ligation of
vital signs fistula (?)
bleeders
via NSD > Blood
PELVIC EXAMINATION FINDINGS: transfusion
(2u pRBC)
(+) Loose sutures with wound gaping at the site of laceration repair, 6
cm in length and 5 cm in depth
85
(+) Minimal yellow, non-foul smelling discharge, necrotic tissues, and
minimal bleeding at the site of laceration repair
(+) 2 cm defect within the right side of the wound dehiscence at the
middle third of the vagina that communicates with the rectal vault, with
> Postpartum
Day 1
fecaloid material upon probing with a cotton pledget > Post-
> Vulvovaginal
hematoma evacuation
Day 1
> Hospital
discharge
CASE REPORT: Brief History and Findings
> Postpartum
> Admitted Day 7
Routine postpartum follow-up > Wound
for trial of > Evacuation dehiscence
No subjective complaints
labor of hematoma > Rectovaginal
>Stable
Delivered and ligation of
vital signs fistula (?)
bleeders
via NSD > Blood
PELVIC EXAMINATION FINDINGS: transfusion
(2u pRBC)
Cervix soft, admits 1 finger
Uterus enlarged to 12 to 14 week-size, well contracted
Minimal-foul smelling lochial discharge 85
No uterine or adnexal tenderness

> Postpartum
Day 1
> Post-
> Vulvovaginal
hematoma evacuation
Day 1
> Hospital
discharge
CASE REPORT: Brief History and Findings
> Postpartum
> Admitted Day 7
Routine postpartum follow-up > Wound
for trial of > Evacuation dehiscence
No subjective complaints
labor of hematoma > Rectovaginal
>Stable
Delivered and ligation of
vital signs fistula (?)
bleeders
via NSD > Blood
RECTAL EXAMINATION FINDINGS: transfusion
(2u pRBC)
Good sphincter tone
(+) 2 cm mucosal break at the rectal vault that communicates with the
85
right side of the wound dehiscence at the middle third of the vagina,
with fecaloid material

> Postpartum
Day 1
> Post-
> Vulvovaginal
hematoma evacuation
Day 1
> Hospital
discharge
CASE REPORT: Admitting Impression

Gravida 3 Para 3 (3-0-0-3)


Status post normal spontaneous delivery with perineal support
and repair of second degree perineal laceration, Day 7
Status post evacuation of vulvovaginal hematoma, ligation of
bleeders and repair, Day 6
Wound dehiscence
To consider Rectovaginal Fistula
CASE REPORT: Management

Soft diet Laboratory procedures:


IVF: D5LR 1L x 8 hours • CBC
Medications: • Urinalysis
• Clindamycin 900 mg/IV every 6 • BUN and Creatinine
hours • TPAG
• Amikacin 750 mg in 100 ml PNSS to • SGOT and SGPT
run for 30 mins once a day • Serum Na and K
• Diclofenac 100 mg/tablet twice a • Wound gram stain and culture
day • Endocervical culture
Wound flushing and scrubbing with
Referrals:
PNSS 2x a day
• Infectious disease specialist
• Lactation service
CASE REPORT: Course in the Ward
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

Signs and No subjective complaints (+) Bowel movement


Symptoms Voiding freely, (+) flatus, (-) bowel movement
Vital Signs Generally stable
Afebrile
Wound Findings As described SIZE: 6 x 5 cm SIZE: 6 x 4 cm
LOCATION: Dehiscence between 6 and 7 o’clock position of perineum extending to the LOCATION: Dehiscence at the 7 o’clock
posterior vaginal wall position of perineum extending to the
posterior vaginal wall

DESCRIPTION: Beefy red in some areas DESCRIPTION: Beefy red appearance in most tissues admixed with minimal fibrin deposits
admixed with necrotic tissues and isolated areas of necrotic tissues
Fistula As described 2 cm defect within the right side of the 2 cm defect within the right side of the 1.5 to 2 cm defect within the right side of the
dehiscence connected to the anal canal dehiscence connected to the anal canal with dehiscence connected to the anal canal with
greenish fecaloid material greenish fecaloid material
Laboratory Findings Hgb 103 Hgb 116 Barium fistulogram:
Hct 0.34 Hct 0.37 Fistulous tract in the
WBC 11.5 WBC 11.2 episiotomy incision
Plt 499 Plt 435 showing influx of
contrast material into
the rectum
Additional Blood transfusion Dietary fiber 5g
Intervention (1u pRBC)

Referrals IDS Surgery Urogynecology Social service


Lactation
CASE REPORT: Course in the Ward
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

Wound As SIZE: 6 x 5 cm SIZE: 6 x 4 cm


Findings described LOCATION: Dehiscence between 6 and 7 o’clock LOCATION: Dehiscence at
position of perineum extending to the posterior vaginal the 7 o’clock position of
wall perineum extending to the
posterior vaginal wall
DESCRIPTION: Beefy red DESCRIPTION: Beefy red appearance in most tissues
in some areas admixed admixed with minimal fibrin deposits and isolated areas
with necrotic tissues of necrotic tissues
Fistula As 2 cm defect within the right 2 cm defect within the right 1.5 to 2 cm defect within
described side of the dehiscence side of the dehiscence the right side of the
connected to the anal connected to the anal dehiscence connected to
canal canal with greenish the anal canal with
fecaloid material greenish fecaloid material
CASE REPORT: Disposition

Discharged stable
IV Antibiotics completed for 10 days shifted to oral
Ciprofloxacin 500 mg/tab 1 tablet every 12 hours for 7 days
Daily wound flushing and scrubbing
Await for spontaneous closure of the fistula
Follow up after 1 week at the Urogynecology Service
CASE REPORT: Final Diagnosis

Gravida 3 Para 3 (3-0-0-3)


Status post normal spontaneous delivery with perineal support
and repair of second degree perineal laceration under local
anesthesia, Postpartum day 17
Status post evacuation of vulvovaginal hematoma, ligation of
bleeders and repair under spinal anesthesia, Post operative
day 16
Wound dehiscence, Rectovaginal Fistula
Anemia, mild, corrected; Status post blood transfusion
Is there an
associated
obstetrical anal
sphincter
injury?
CLINICAL CORRELATION
AND DISCUSSION
Perineal
lacerations

Postpartum
Perineal Care
Rectovaginal Vulvovaginal
fistula
and hematoma
Management of
Complications

Key Points of
Discussion Perineal
wound
dehiscence
Perineal
lacerations

Postpartum
Perineal Care
Rectovaginal Vulvovaginal
fistula
and hematoma
Management of
Complications

Perineal
wound
dehiscence
PERINEAL LACERATIONS ASSOCIATED
WITH CHILDBIRTH: Background

• 2nd most common cause of postpartum


bleeding
• Major cause of morbidity and
mortality in several disorders involving
the female reproductive tract
Reyes, LD. (2014). Genital tract trauma in Philippine Obstetrical and Gynecological Society Foundation, Inc. Clinical practice guidelines on obstetric hemorrhage (pp. 115
– 157). Makati City, Metro Manila, Philippines: OVT-Graphic Line, Inc.
PERINEAL LACERATIONS ASSOCIATED
WITH CHILDBIRTH: Risk Factors

• Race—Asian women 1, 2 • Episiotomy 2


• First vaginal birth 1 • Previous perineal repair—scar tissue 1
• Nulliparity 2 • Fetal malposition 1
• Infant weight > 4000 g 1, 2 • Persistent OP position 2
• Female genital mutilation 1 • Operative vaginal delivery 1, 2
• Short perineal length 2 • Prolonged second stage of labor 1

1Webb S, Sherburn M, and Ismail KM. (2014). Managing perineal trauma after childbirth. BMJ. 349:g6829.
2Cunningham FG et al. (2018). Williams Obstetrics 25th Ed. [E-reader version]. Retrieved from https://t.me/ebookers
PERINEAL LACERATIONS ASSOCIATED
WITH CHILDBIRTH: Risk Factors

• Race—Asian women 1, 2 • Episiotomy 2


• First vaginal birth 1 • Previous perineal repair—scar tissue 1
• Nulliparity 2 CASE CORRELATION: • Fetal malposition 1
• Infant weight > 4000 g 1,• 2 Filipina • Persistent OP position 2
• Multiparous – Previous
• Female genital mutilation 1perineal repair (?)• Operative vaginal delivery 1, 2
• Short perineal length 2 • Prolonged second stage of labor 1

1Webb S, Sherburn M, and Ismail KM. (2014). Managing perineal trauma after childbirth. BMJ. 349:g6829.
2Cunningham FG et al. (2018). Williams Obstetrics 25th Ed. [E-reader version]. Retrieved from https://t.me/ebookers
PERINEAL LACERATIONS ASSOCIATED
WITH CHILDBIRTH: Anatomy

Female pelvic muscles at the level of the pelvic floor Muscles of the female perineum
PERINEAL LACERATIONS ASSOCIATED
WITH CHILDBIRTH: Anatomy

Anatomy of the anus and rectum


PERINEAL LACERATIONS ASSOCIATED
WITH CHILDBIRTH: Classification

LOCATION DESCRIPTION
Anterior perineal trauma Injury involving the labia, anterior
vagina, urethra or clitoris
Posterior perineal trauma Injury to the posterior vaginal
wall, perineal muscles or anal
sphincters and may extend
through the rectum

Female Perineum

Reyes, LD. (2014). Genital tract trauma in Philippine Obstetrical and Gynecological Society Foundation, Inc. Clinical practice guidelines on obstetric hemorrhage (pp. 115
– 157). Makati City, Metro Manila, Philippines: OVT-Graphic Line, Inc.
PERINEAL LACERATIONS ASSOCIATED
WITH CHILDBIRTH: Classification

DEPTH DESCRIPTION
First-degree lacerations Injury to the skin and subcutaneous tissue of the perineum and vaginal epithelium only
Perineal muscles remain intact
Second-degree lacerations Extend into the fascia and musculature of the perineal body, which includes the deep and
superficial transverse perineal muscles and fibers of the pubococcygeus and
bulbocavernosus muscles
Anal sphincter muscles remain intact
Third-degree lacerations Extend through the fascia and musculature of the perineal body and involve some or all of
the fibers of the external anal sphincter (EAS) and/or the internal anal sphincter (IAS)
Subclassification:
•3a – <50 percent of EAS thickness is torn
•3b – >50 percent of EAS thickness is torn
•3c – Both EAS and IAS are torn
Fourth-degree lacerations Involve the perineal structures, EAS, IAS, and the rectal mucosa
American College of Obstetricians and Gynecologists. (2016). Summary: Prevention and Management of Obstetric Lacerations at Vaginal Delivery: Correction. Practice
Bulletin No. 165. Obstetrics & Gynecology. 128:411.
PERINEAL LACERATIONS ASSOCIATED
WITH CHILDBIRTH: Management
DEPTH TECHNIQUE
First-degree lacerations Do not always require repair, and sutures are placed to control bleeding or restore anatomy
Fine-gauge absorbable or delayed-absorbable suture or adhesive glue
Second-degree lacerations Most studies support a continuous suturing method
Blunt needles
2–0 polyglactin 910 (traditional vs rapidly absorbed) or chromic catgut
Third-degree lacerations EAS: End-to-end technique vs Overlapping technique
IAS: Interrupted sutures

3-0 PDS and 2-0 polyglycolic acid or polyglactin 910


Fourth-degree lacerations Rectal mucosa - at a point 1 cm proximal to the wound apex, sutures are placed
approximately 0.5 cm apart in the rectal muscularis and do not enter the anorectal lumen.
4–0 polyglactin 910 or chromic catgut

Cunningham FG et al. (2018). Williams Obstetrics 25th Ed. [E-reader version]. Retrieved from https://t.me/ebookers
Reyes, LD. (2014). Genital tract trauma in Philippine Obstetrical and Gynecological Society Foundation, Inc. Clinical practice guidelines on obstetric hemorrhage (pp. 115
– 157). Makati City, Metro Manila, Philippines: OVT-Graphic Line, Inc.
PERINEAL LACERATIONS ASSOCIATED
WITH CHILDBIRTH: Management

• 2-layer vs 3-layer repair (for 1st and 2nd degree lacerations)


• Obliteration of dead spaces and prevention of overtightened sutures should be
ensured
• Pressure or packing for at least 24 hours for any significant dead space or if the
vagina is too friable to accept suturing
• Routine vaginal and rectal examination post-operatively

Reyes, LD. (2014). Genital tract trauma in Philippine Obstetrical and Gynecological Society Foundation, Inc. Clinical practice guidelines on obstetric hemorrhage (pp. 115
– 157). Makati City, Metro Manila, Philippines: OVT-Graphic Line, Inc.
Perineal
lacerations

Postpartum
Perineal Care
Rectovaginal Vulvovaginal
fistula
and hematoma
Management of
Complications

Perineal
wound
dehiscence
PURPUERAL GENITAL HEMATOMA:
Background

• The genital tract has rich vascular


supplies!
• Relatively uncommon but can be a
cause of serious morbidity and even
maternal death
Reyes, LD. (2014). Genital tract trauma in Philippine Obstetrical and Gynecological Society Foundation, Inc. Clinical practice guidelines on obstetric hemorrhage (pp. 115
– 157). Makati City, Metro Manila, Philippines: OVT-Graphic Line, Inc.
PURPUERAL GENITAL HEMATOMA:
Background

• Most common locations:


1. Vulva
2. Vaginal/paravaginal area
3. Retroperitoneum/subperitoneal

Reyes, LD. (2014). Genital tract trauma in Philippine Obstetrical and Gynecological Society Foundation, Inc. Clinical practice guidelines on obstetric hemorrhage (pp. 115
– 157). Makati City, Metro Manila, Philippines: OVT-Graphic Line, Inc.
PURPUERAL GENITAL HEMATOMA:
Risk Factors

Nulliparity 1, 4 Pudendal nerve block 3


Prolonged second stage of labor 1,3,4 Incomplete suturing of vaginal lacerations 3
Instrumental delivery 1 – 4 Episiotomy 3, 4
A baby ≥ 4 kg 1, 4 Preeclampsia 4
Genital tract varicosities 1,3,4 Multifetal pregnancy 4
Precipitous uncontrolled delivery 2 Clotting disorders 4
Spontaneous 3

1Mawhinney S, and Holman R. (2007). Puerperal genital haematoma: a commonly missed diagnosis. The Obstetrician & Gynaecologist. 9:195 – 200.
2American College of Obstetricians and Gynecologists. (2017). Postpartum hemorrhage. Practice Bulletin No. 183. Obstetrics & Gynecology. 130:e168 – 86.
3Sultan AH, and Thakar R. (2014). Lower genital tract trauma in Baskett TF, Calder AA, and Arulkumaran S (12th ed.), Munro Kerr’s operative obstetrics (pp. 217 – 224).

China: Saunders Elsevier.


4Roman AS. (2017, December 14). Management of hematomas incurred as a result of obstetrical delivery. Retrieved from https://www.uptodate.com
PURPUERAL GENITAL HEMATOMA:
Risk Factors

Nulliparity 1, 4 Pudendal nerve block 3


Prolonged second stage of labor 1,3,4 Incomplete suturing of vaginal lacerations 3
Instrumental delivery 1 – 4 CORRELATION:
CASE Episiotomy 3, 4
• Multiparous
A baby ≥ 4 kg 1, 4 • s/p NSD with perineal Preeclampsia 4
Genital tract varicosities 1,3,4 and repair of 2ndMultifetal pregnancy 4
support
Precipitous uncontrolled degree laceration
delivery 2 underClotting disorders 4
local anesthesia
Spontaneous 3

1Mawhinney S, and Holman R. (2007). Puerperal genital haematoma: a commonly missed diagnosis. The Obstetrician & Gynaecologist. 9:195 – 200.
2American College of Obstetricians and Gynecologists. (2017). Postpartum hemorrhage. Practice Bulletin No. 183. Obstetrics & Gynecology. 130:e168 – 86.
3Sultan AH, and Thakar R. (2014). Lower genital tract trauma in Baskett TF, Calder AA, and Arulkumaran S (12th ed.), Munro Kerr’s operative obstetrics (pp. 217 – 224).

China: Saunders Elsevier.


4Roman AS. (2017, December 14). Management of hematomas incurred as a result of obstetrical delivery. Retrieved from https://www.uptodate.com
PURPUERAL GENITAL HEMATOMA:
Blood Supply

Pudenda Internal pudendal artery


Vagina Vaginal artery of the uterine artery
Cervix Cervicovaginal branch of the uterine artery
Uterus Uterine artery
Fallopian tubes Ovarian artery
Cervix

Blood Supply to the Female Reproductive Organs


PURPUERAL GENITAL HEMATOMA:
Blood Supply: Vagina

BLOOD SUPPLY OF THE VAGINA

Upper 1/3
Cervico-vaginal branch of the uterine
artery
Middle 1/3
Inferior vesical artery
Lower 1/3
Middle rectal and internal pudendal
arteries
PURPUERAL GENITAL HEMATOMA:
Blood Supply: Vagina

BLOOD SUPPLY OF THE VAGINA

Upper 1/3
Cervico-vaginal branch of the uterine
artery
Middle 1/3
Inferior vesical artery
Lower 1/3
CASE CORRELATION: Middle rectal and internal pudendal
(+) 8 x 6 cm fluctuant, tender arteries
mass between the 6 & 7
o’clock position of the
perineum extending to the
right posterior vaginal wall
PURPUERAL GENITAL HEMATOMA:
Blood Supply: Perineum

Arteries of the female perineum


PURPUERAL GENITAL HEMATOMA:
Blood Supply: Perineum

CASE CORRELATION:
(+) 8 x 6 cm fluctuant, tender
mass between the 6 & 7
o’clock position of the
perineum extending to the
right posterior vaginal wall
Arteries of the female perineum
PURPUERAL GENITAL HEMATOMA:
Anatomical and Blood Supply Correlation

Anatomical Location Blood Supply Injured


Vulvar Branches of the pudendal artery
Inferior rectal, transverse perineal, posterior labial, urethral
Vulvovaginal
arteries, artery of the vestibule, deep and dorsal arteries of
the clitoris
Paravaginal Descending branch of the uterine artery
Supravaginal Uterine artery branches in the broad ligament
Subperitoneal

Reyes, LD. (2014). Genital tract trauma in Philippine Obstetrical and Gynecological Society Foundation, Inc. Clinical practice guidelines on obstetric hemorrhage (pp. 115
– 157). Makati City, Metro Manila, Philippines: OVT-Graphic Line, Inc.
Roman AS. (2017, December 14). Management of hematomas incurred as a result of obstetrical delivery. Retrieved from https://www.uptodate.com
PURPUERAL GENITAL HEMATOMA:
Diagnosis

• Clinical awareness
• Excessive perineal pain
• A change in vital signs disproportionate to the amount of
blood loss should prompt a gentle pelvic examination.
• Imaging may be helpful to confirm the diagnosis when there is
a high clinical suspicion for hematoma but the patient remains
hemodynamically stable.

Reyes, LD. (2014). Genital tract trauma in Philippine Obstetrical and Gynecological Society Foundation, Inc. Clinical practice guidelines on obstetric hemorrhage (pp. 115
– 157). Makati City, Metro Manila, Philippines: OVT-Graphic Line, Inc.
PURPUERAL GENITAL HEMATOMA:
Management

• Early recognition
• Prompt resuscitation and search for the cause
• Complete blood count and coagulation screen
• Adequate anesthesia
• Conservative management for small, non-expanding
hematoma (< 3 cm)
• Surgical evacuation, primary closure, and compression for
large hematoma (≥ 3 cm)

Reyes, LD. (2014). Genital tract trauma in Philippine Obstetrical and Gynecological Society Foundation, Inc. Clinical practice guidelines on obstetric hemorrhage (pp. 115
– 157). Makati City, Metro Manila, Philippines: OVT-Graphic Line, Inc.
Roman AS. (2017, December 14). Management of hematomas incurred as a result of obstetrical delivery. Retrieved from https://www.uptodate.com
PURPUERAL GENITAL HEMATOMA:
Management

• Vaginal packing/pressure or insertion of drains for 24 – 36


hours may be useful following drainage and repair of
paravaginal hematoma.
• Additional surgical intervention for failed first line
management
• Internal iliac artery ligation, hysterectomy, selective arterial
embolization

Reyes, LD. (2014). Genital tract trauma in Philippine Obstetrical and Gynecological Society Foundation, Inc. Clinical practice guidelines on obstetric hemorrhage (pp. 115
– 157). Makati City, Metro Manila, Philippines: OVT-Graphic Line, Inc.
Roman AS. (2017, December 14). Management of hematomas incurred as a result of obstetrical delivery. Retrieved from https://www.uptodate.com
Perineal
lacerations

Postpartum
Perineal Care
Rectovaginal Vulvovaginal
fistula
and hematoma
Management of
Complications

Perineal
wound
dehiscence
PERINEAL WOUND DEHISCENCE:
Background

• Wound breakdown
• Separation of sutured perineal skin,
vaginal mucosa or the underlying
perineal muscles

Esteban, LK. (2015). Episiotomy wound dehiscence in Philippine Infectious Diseases Society for Obstetrics and Gynecology, Inc. and Philippine Obstetrical and
Gynecological Society Foundation, Inc. Clinical practice guidelines on obstetric and gynecologic infectious diseases (pp. 18 – 26). Makati City, Metro Manila,
Philippines: OVT-Graphic Line, Inc.
PERINEAL WOUND DEHISCENCE:
Background

• Partial or Complete
• Peak time of separation is ~ 10 to 14
days following vaginal delivery

Berkowitz LR, and Foust-Wright, CE. (2018, May 24). Postpartum perineal care and management of complications. Retrieved from https://www.uptodate.com
PERINEAL WOUND DEHISCENCE:
Risk Factors

Infection Medical conditions


Hematoma formation Therapies
Sub-optimal care (poor suturing techniques) Operative vaginal delivery
Poor nutrition Episiotomy
Obesity Prolonged second stage of labor
Smoking Birth weight
Stress Third and fourth degree tears
Tissue hypoxia Meconium stained amniotic fluid
Poor hygiene

Dudley, L. (2014). Perineal re-suturing versus expectant management following vaginal delivery complicated by a dehisced wound ‘The PREVIEW Study’. Staffordshire
University, England, United Kingdom.
PERINEAL WOUND DEHISCENCE:
Risk Factors

Infection ??? Medical conditions


Hematoma formation √ Therapies
Sub-optimal care (poor suturing techniques) Operative vaginal delivery
Poor nutrition Episiotomy
Obesity Prolonged second stage of labor
Smoking Birth weight
Stress Third and fourth degree tears ???
Tissue hypoxia ??? Meconium stained amniotic fluid
Poor hygiene ???

Dudley, L. (2014). Perineal re-suturing versus expectant management following vaginal delivery complicated by a dehisced wound ‘The PREVIEW Study’. Staffordshire
University, England, United Kingdom.
PERINEAL WOUND DEHISCENCE:
Signs and Symptoms

SIGNS SYMPTOMS

Edema Pain
Erythema Fever
Exudate formation Difficulty or inability to void
Tenderness Stool and flatal incontinence
Dehiscence of the repair

Esteban, LK. (2015). Episiotomy wound dehiscence in Philippine Infectious Diseases Society for Obstetrics and Gynecology, Inc. and Philippine Obstetrical and
Gynecological Society Foundation, Inc. Clinical practice guidelines on obstetric and gynecologic infectious diseases (pp. 18 – 26). Makati City, Metro Manila,
Philippines: OVT-Graphic Line, Inc.
PERINEAL WOUND DEHISCENCE:
Management

✓ Baseline CBC
✓ Wound debridement
✓ Daily wound preparation and irrigation*
*Half strength Daikin’s solution, betadine impregnated brush, or a combination
of povidone iodine, hydrogen peroxide, and normal saline
✓ Early repair (within 3 – 14 days) once the wound is exudate-free and covered with
pink granulation tissue
✓ Repair by layered closure with either chromic catgut or polyglactin under regional
anesthesia

Esteban, LK. (2015). Episiotomy wound dehiscence in Philippine Infectious Diseases Society for Obstetrics and Gynecology, Inc. and Philippine Obstetrical and
Gynecological Society Foundation, Inc. Clinical practice guidelines on obstetric and gynecologic infectious diseases (pp. 18 – 26). Makati City, Metro Manila,
Philippines: OVT-Graphic Line, Inc.
PERINEAL WOUND DEHISCENCE:
Management

✓ Preoperative preparation for patients with fourth degree laceration includes


mechanical bowel preparation with oral electrolyte solutions.
✓ Episiotomy wound dehiscence without significant cellulitis or abscess formation
does not require antibiotics.
✓ IV antibiotics for cases of episiotomy dehiscence with infection
First (cefazolin) and second (cefoxitin, cefotetan) generation cephalosporins,
penicillins with a beta-lactamase inhibitors and clindamycin for 48 to 72 hours
or until resolution of infections
✓ A pre-operative prophylactic antibiotic must be given prior to repair.

Esteban, LK. (2015). Episiotomy wound dehiscence in Philippine Infectious Diseases Society for Obstetrics and Gynecology, Inc. and Philippine Obstetrical and
Gynecological Society Foundation, Inc. Clinical practice guidelines on obstetric and gynecologic infectious diseases (pp. 18 – 26). Makati City, Metro Manila,
Philippines: OVT-Graphic Line, Inc.
PERINEAL WOUND DEHISCENCE:
Post operative Care

✓ Sitz bath 3 to 4 times a day and heat lamps for 24 – 48 hours


✓ Low residue diet for 1 to 3 days for those with repair of dehisced fourth degree
laceration
✓ Follow up 1 – 3 days and 10 – 14 days after repair

Esteban, LK. (2015). Episiotomy wound dehiscence in Philippine Infectious Diseases Society for Obstetrics and Gynecology, Inc. and Philippine Obstetrical and
Gynecological Society Foundation, Inc. Clinical practice guidelines on obstetric and gynecologic infectious diseases (pp. 18 – 26). Makati City, Metro Manila,
Philippines: OVT-Graphic Line, Inc.
Perineal
lacerations

Postpartum
Perineal Care
Rectovaginal Vulvovaginal
fistula
and hematoma
Management of
Complications

Perineal
wound
dehiscence
RECTOVAGINAL FISTULA:
Background

• Congenital or acquired epithelial lined


tracts between the vagina and rectum
• Underlying cause of a fistula - most
important predictor of a successful
outcome

Hoffman BL et al. (2012). Williams Gynecology, China: McGraw – Hill.


RECTOVAGINAL FISTULA:
Classification

Glowacki CA and Zitsman S. (2017). Rectovaginal fistula in Lippincott Continuing Medical Education Institute, Inc. Topics in obstetrics & gynecology. 37 (2):1 –6.
RECTOVAGINAL FISTULA:
Classification

SIZE Measurement
Small < 0.5 cm
Medium 0.5 to 2.5 cm
Large > 2.5 cm

Das B and Synder M. (2016). Rectovaginal fistulae. Clin Colon Rectal Surg. 29:50–56.
RECTOVAGINAL FISTULA:
Risk Factors

• Obstetric complications • Traumatic obstetric


• Inflammatory bowel disease • Foreign body
• Infection • Iatrogenic
• Previous surgery in the anorectal • Inflammatory
area
• Neoplastic
• Pelvic radiation therapy
• Neoplasm
• Trauma
Hoffman BL et al. (2012). Williams gynecology. China: McGraw – Hill. Lobo RA, Gershenson DM, Lentz GM, and Valea FA. (2017). Comprehensive
gynecology 7th ed. China: McGraw – Hill.
RECTOVAGINAL FISTULA:
Risk Factors

• Obstetric complications • Third or fourth degree laceration repair dehiscence


• Unrecognized vaginal laceration during operative
• Inflammatory bowel disease vaginal or precipitous delivery
• Infection
• Previous surgery in the anorectal area
• Pelvic radiation therapy
• Neoplasm
• Trauma

Hoffman BL et al. (2012). Williams gynecology. China: McGraw – Hill.


RECTOVAGINAL FISTULA:
Risk Factors

• Obstetric complications • Crohn disease > Ulcerative colitis

• Inflammatory bowel disease


• Infection
• Previous surgery in the anorectal area
• Pelvic radiation therapy
• Neoplasm
• Trauma

Hoffman BL et al. (2012). Williams gynecology. China: McGraw – Hill.


RECTOVAGINAL FISTULA:
Risk Factors

• Obstetric complications • Cryptoglandular abscess located in the anterior


aspect of the anal canal
• Inflammatory bowel disease • Lymphogranuloma venereum
• Tuberculosis
• Infection • Bartholin gland duct abscess
• Previous surgery in the anorectal area • Human immunodeficiency virus infection
• Diverticular disease
• Pelvic radiation therapy
• Neoplasm
• Trauma

Hoffman BL et al. (2012). Williams gynecology. China: McGraw – Hill.


RECTOVAGINAL FISTULA:
Risk Factors

• Obstetric complications • Hemorrhoidectomy


• Low anterior resection
• Inflammatory bowel disease • Excision of rectal tumors
• Hysterectomy
• Infection • Posterior vaginal wall repairs
• Previous surgery in the anorectal area
• Pelvic radiation therapy
• Neoplasm
• Trauma

Hoffman BL et al. (2012). Williams gynecology. China: McGraw – Hill.


RECTOVAGINAL FISTULA:
Risk Factors

• Obstetric complications
• Inflammatory bowel disease
• Infection
• Previous surgery in the anorectal area
• Pelvic radiation therapy
• Neoplasm
• Trauma

Hoffman BL et al. (2012). Williams gynecology. China: McGraw – Hill.


RECTOVAGINAL FISTULA:
Risk Factors

• Obstetric complications • Invasive cervical or vaginal cancer


• Anal or rectal cancer
• Inflammatory bowel disease
• Infection
• Previous surgery in the anorectal area
• Pelvic radiation therapy
• Neoplasm
• Trauma

Hoffman BL et al. (2012). Williams gynecology. China: McGraw – Hill.


RECTOVAGINAL FISTULA:
Risk Factors

• Obstetric complications • Intraoperative


• Coital
• Inflammatory bowel disease
• Infection
• Previous surgery in the anorectal area
• Pelvic radiation therapy
• Neoplasm
• Trauma

Hoffman BL et al. (2012). Williams gynecology. China: McGraw – Hill.


Lobo RA, Gershenson DM, Lentz GM, and
Valea FA. (2017). Comprehensive gynecology
7th ed. China: McGraw – Hill.
RECTOVAGINAL FISTULA:
Diagnosis

• Presenting symptoms are often suggestive of the underlying etiology


✓ Flatus or stool leakage per vagina
✓ Recurrent bladder or vaginal infection
✓ Rectal or vaginal bleeding or pain
✓ Fecal incontinence
✓ Diarrhea
✓ Abdominal cramping
✓ Fever

Hoffman BL et al. (2012). Williams gynecology. China: McGraw – Hill.


RECTOVAGINAL FISTULA:
Diagnosis

• Thorough rectovaginal examination


• Rule out concomitant sphincter injury! (“Dovetail sign”)
• Air bubble test
• Methylene blue tampon test
• Probe
• Contrast study
• Vaginoscopy, proctoscopy or colonoscopy for non-obstetric fistula
• Endoanal ultrasound

Hoffman BL et al. (2012). Williams gynecology. China: McGraw – Hill.


Glowacki CA and Zitsman S. (2017). Rectovaginal fistula in Lippincott Continuing Medical Education Institute, Inc. Topics in obstetrics & gynecology. 37 (2):1 –6.
RECTOVAGINAL FISTULA:
Management

GOALS
• To restore the anatomy and function
• To improve the quality of life for
patients
RECTOVAGINAL FISTULA:
Management: Conservative

Small and minimally symptomatic RVFs following obstetric trauma


Waiting period: 6 to 9 months
Interval follow – up

Hoffman BL et al. (2012). Williams gynecology. China: McGraw – Hill.


Glowacki CA and Zitsman S. (2017). Rectovaginal fistula in Lippincott Continuing Medical Education Institute, Inc. Topics in obstetrics & gynecology. 37 (2):1 –6.
Glowacki CA and Zitsman S. (2017). Rectovaginal fistula in Lippincott Continuing Medical Education Institute, Inc. Topics in obstetrics & gynecology. 37 (2):1 –6.
RECTOVAGINAL FISTULA:
Management: Surgical

Basic Principles:
✓ Proper timing of the repair
✓ Wide mobilization of the adjacent tissue planes
✓ Complete excision of the fistula tract
✓ Multilayered closure (Tension-free approximation of all layers)

Lobo RA, Gershenson DM, Lentz GM, and Valea FA. (2017). Comprehensive gynecology 7th ed. China: McGraw – Hill.
RECTOVAGINAL FISTULA:
Management: Surgical

Timing and Preparation:


✓ RVF secondary to recent obstetric trauma can be successfully repaired 6 to 7 days
after initial debridement.
✓ Some sources recommend a preparation period of 3 to 6 months to allow for
healing of infected and inflamed tissue
✓ Bowel preparation
• A clear diet 24 to 48 hours before surgery
• Bowel prep agent
• ± Enema
✓ Antibiotic prophylaxis

Glowacki CA and Zitsman S. (2017). Rectovaginal fistula in Lippincott Continuing Medical Education Institute, Inc. Topics in obstetrics & gynecology. 37 (2):1 –6.
RECTOVAGINAL FISTULA:
Management: Surgical

Techniques:
✓Transanal
✓Transvaginal
✓Perineal
✓Abdominal

Glowacki CA and Zitsman S. (2017). Rectovaginal fistula in Lippincott Continuing Medical Education Institute, Inc. Topics in obstetrics & gynecology. 37 (2):1 –6.
RECTOVAGINAL FISTULA:
Management: Surgical

LOCATION PROCEDURE
Obstetric related Transvaginal or transanal approach through episioproctotomy,
defects or Low fistula Fistulotomy with a tension-free layered closure without episioproctotomy, or
Fistulotomy with transvaginal purse-string method of repair without
episioproctotomy
Midlevel Transvaginally or transanally by a tension-free layered closure or an
endorectal advancement flap

High Transabdominal approach using bowel resection of the involved segment


followed by primary bowel reanastomosis

Hoffman BL et al. (2012). Williams gynecology. China: McGraw – Hill.


RECTOVAGINAL FISTULA:
Postoperative Care

GOAL: To keep the bowel movements soft, but formed


• Clear liquid diet continued for the fist 3 days after surgery, followed by a low-
residue diet
• Broad-spectrum antibiotics should be continued for 2 weeks
• Sitz baths, two or three times daily, followed by the use of a blow dryer or heat
lamp, keep the area clean and dry

Lobo RA, Gershenson DM, Lentz GM, and Valea FA. (2017). Comprehensive gynecology 7th ed. China: McGraw – Hill.
In hindsight,

Complications can be prevented


but it may be unavoidable in the
presence of multiple risk factors.

Rule out obstetrical anal sphincter


injury when confronted with
perineal dehiscence and/or RVFs
associated with obstetric trauma.
Thank you!