What are the next steps for managing a hematoma after a Cesarean (C-section) section?

Management of Post-Cesarean Hematoma

For post-cesarean hematomas, initial evaluation with CT imaging is essential to determine the size, location, and presence of active bleeding, followed by appropriate intervention based on hemodynamic status and hematoma characteristics.

Initial Assessment and Diagnosis

• Obtain immediate CT with intravenous contrast to:

  • Determine hematoma size and location
  • Identify active extravasation
  • Evaluate relationship to adjacent organs
  • Distinguish between supralevator vs infralevator location 1

• Laboratory studies:

  • Complete blood count (hemoglobin/hematocrit)
  • Coagulation studies (PT, aPTT, fibrinogen)
  • Type and screen/crossmatch
  • Venous blood gas for rapid hemoglobin and lactate measurement 1
  • Lactate >2 mmol/L indicates shock 1

Management Algorithm Based on Hematoma Characteristics

Small Hematomas (<4-5 cm)

• Small subfascial and bladder flap hematomas (<4 cm) are often clinically insignificant 1
• Management:
  • Conservative observation
  • Pain control
  • Serial hemoglobin monitoring
  • Early mobilization to prevent thromboembolism 1

Large Hematomas (>5 cm) or Symptomatic Hematomas

• Large hematomas (>5 cm) warrant closer attention, especially bladder flap hematomas which may indicate uterine dehiscence 1
• Management options based on hemodynamic status:

Hemodynamically Stable Patients

1. Conservative management with close monitoring:

   • Serial hemoglobin checks
   • Vital sign monitoring
   • Pain control
   • Consider antibiotics if signs of infection present 2

2. Ultrasound-guided percutaneous drainage if:

   • Patient has persistent pain
   • Fever develops
   • Inflammatory markers increase 2

Hemodynamically Unstable Patients or Failed Conservative Management

1. Surgical intervention:

   • Laparoscopic approach for accessible hematomas:

     • Tumescence incision
     • Drainage of fluid collection
     • Washing of hematoma site
     • Average procedure time: 31 minutes 3

   • Laparotomy for:

     • Large hematomas with active bleeding
     • Failed minimally invasive approaches
     • Suspected uterine dehiscence/rupture 2

2. Angiography with embolization for:

   • Active arterial bleeding identified on CT
   • Persistent bleeding after surgical exploration
   • High-risk surgical candidates 1

Blood Product Management

If significant bleeding is present:

• Obtain large-bore IV access
• Consider warmed blood products 1, 4
• For ongoing hemorrhage after 4 units of RBC, add FFP in 1:1 ratio until coagulation results available 1
• Monitor fibrinogen levels - normal pregnancy level is 4-6 g/L
  • Fibrinogen <3 g/L with ongoing bleeding warrants replacement with cryoprecipitate or fibrinogen concentrate 1
• Use point-of-care testing when available for rapid assessment 1

Special Considerations

• Uterine dehiscence/rupture: Hematoma >5 cm at bladder flap should raise suspicion for uterine dehiscence (disruption of endometrial and myometrial layers with intact serosa) 1

• Coagulopathy: Assess for and correct any underlying coagulation disorders before invasive procedures 2

• Thromboprophylaxis:

  • Early mobilization is recommended for all patients 1
  • For high-risk patients with additional risk factors, consider pharmacologic prophylaxis (LMWH) or mechanical prophylaxis (elastic stockings or intermittent pneumatic compression) 1

Follow-up

• For surgically managed cases:

  • Monitor wound drains for ongoing bleeding
  • Repeat imaging to ensure resolution
  • Laboratory tests 7-10 days post-procedure 2

• For conservatively managed cases:

  • Follow-up ultrasound to document resolution
  • Monitor for delayed complications (infection, thrombosis)

Pitfalls to Avoid

• Do not delay imaging in symptomatic patients - early detection improves outcomes
• Avoid misinterpreting hypodense edema at cesarean incision as dehiscence in first postpartum week 1
• Do not underestimate blood loss - directly measure abnormal bleeding by weighing blood-soaked pads 1
• Remember that normal fibrinogen levels in pregnancy are higher (4-6 g/L) than non-pregnant state 1