Management of Postpartum Retroperitoneal Hematoma After Episiotomy
The management of postpartum retroperitoneal hematoma depends critically on hemodynamic status: hemodynamically stable patients should undergo CT angiography followed by super-selective angioembolization as first-line treatment, while hemodynamically unstable patients require immediate surgical evacuation without delay for imaging. 1
Immediate Assessment and Stabilization
Upon recognizing a retroperitoneal hematoma (bluish, painful discoloration suggesting deep tissue bleeding), immediately assess:
- Vital signs and hemodynamic stability - check for hypotension, tachycardia, signs of hypovolemia 1
- Establish large-bore IV access (two lines) and begin aggressive fluid resuscitation if any instability present 1
- Obtain baseline labs: complete blood count, coagulation profile, type and crossmatch for blood products 1
- Maintain normothermia (>36°C) as hypothermia impairs clotting factor function 1
Critical pitfall: Retroperitoneal hematomas can sequester >2 liters of blood without obvious external bleeding, so never underestimate blood loss based on visible bleeding alone 1
Diagnostic Imaging Strategy
For hemodynamically STABLE patients:
- CT angiography (CTA) of abdomen/pelvis with IV contrast is the diagnostic modality of choice 1, 2
- CTA identifies active bleeding, locates the source, determines hematoma size, and detects arterial extravasation, pseudoaneurysms, or arteriovenous fistulas 1
- This imaging guides whether embolization is feasible 2
For hemodynamically UNSTABLE patients:
- Proceed directly to surgical exploration WITHOUT imaging - do not delay for CT 1
- Imaging in unstable patients wastes critical time and worsens outcomes 1
Definitive Management Algorithm
Hemodynamically Stable Patients:
Super-selective angioembolization is first-line treatment, achieving cessation of bleeding in nearly 100% of cases when active bleeding is identified on angiography 1
Hemodynamically Unstable Patients:
Immediate surgical evacuation is mandatory 1
Why the Other Options Are WRONG:
A. Packing alone - Insufficient for retroperitoneal hematomas as it does not control arterial bleeding sources and delays definitive treatment in unstable patients 1
B. Aspiration - Explicitly contraindicated: does not address the underlying vascular injury causing ongoing bleeding and introduces infection risk into a sterile hematoma 1
D. Blood transfusion if Hb <10 g/dL - This arbitrary threshold approach is incorrect. Transfuse based on clinical presentation and hemodynamic instability, NOT arbitrary hemoglobin thresholds 1. In massive hemorrhage, transfuse packed red blood cells, fresh frozen plasma, and platelets in 1:1:1 ratio 1
Blood Product Management
- Do not wait for hemoglobin levels to guide transfusion - treat based on clinical presentation 1
- In massive hemorrhage: use 1:1:1 ratio of packed RBCs:FFP:platelets 1
- Administer tranexamic acid 1g IV within 1-3 hours of bleeding onset to reduce maternal morbidity and mortality 1
Adjunctive Medical Management
- Administer uterotonic agents (oxytocin, methylergonovine, carboprost, or misoprostol) to ensure adequate uterine tone and prevent additional bleeding 1
- Consider prophylactic tranexamic acid to reduce ongoing bleeding risk 1
Post-Intervention Monitoring
- Close hemodynamic monitoring for at least 24-48 hours 3
- Serial hemoglobin/hematocrit checks 3
- Monitor for signs of ongoing bleeding, infection, or delayed complications 3
Answer to the multiple choice question: C. Surgical evacuation (if hemodynamically unstable) OR angioembolization (if hemodynamically stable after CTA confirms active bleeding). The question's option D is fundamentally flawed as transfusion decisions should never be based solely on arbitrary Hb thresholds 1.