What is the management of a hematoma (collection of blood outside of blood vessels) following a cesarean section (CS)?

Management of Hematoma Following Cesarean Section

For hematomas after cesarean section, immediate surgical drainage via re-laparotomy is indicated when conservative management with observation, analgesics, and antibiotics fails, or when the patient develops hemodynamic instability, persistent fever, worsening pain, or declining hemoglobin despite conservative measures. 1

Initial Assessment and Conservative Management

Diagnostic Approach:

• Measure hemoglobin levels serially to detect ongoing blood loss 1
• Obtain ultrasound imaging to identify hematoma location (wound, subfascial, Retzius space, or intraperitoneal) and size 1, 2
• Monitor for signs of infection including fever, elevated inflammatory markers, and increasing abdominal pain 1
• Assess coagulation parameters, particularly if there was significant intraoperative bleeding or underlying coagulopathy 3, 2

Conservative Management Strategy:

• Initiate close observation with serial hemoglobin measurements and clinical monitoring 1
• Provide analgesics for pain control 1
• Administer prophylactic antibiotics to prevent secondary infection 1
• Consider ultrasound-guided percutaneous drainage for accessible hematomas as a first-line intervention before surgical re-exploration 1

Indications for Surgical Intervention

Proceed to re-laparotomy when:

• Ultrasound-guided percutaneous drainage fails to resolve the hematoma 1
• Clinical deterioration occurs with persistent fever, worsening pain, or hemodynamic instability 1, 2
• Hemoglobin continues to decline despite conservative measures 1
• Suspected vascular injury or ongoing bleeding (hemoperitoneum on ultrasound) requires urgent surgical exploration under general anesthesia 2

Surgical Management

Operative Technique:

• Perform re-laparotomy to evacuate the hematoma completely 1
• Achieve meticulous hemostasis of all bleeding points 1
• Place negative pressure drainage in the hematoma cavity (such as the Retzius space if involved) 1
• If uterine artery pseudoaneurysm is identified and embolization unavailable, perform surgical ligation of the internal iliac artery 4

Specific Hematoma Locations

Retzius Space Hematomas:

• These represent rare complications in the extraperitoneal space between the pubic symphysis and bladder 1
• May extend below the rectus abdominis muscles and require surgical drainage when large or symptomatic 1

Subcutaneous/Wound Hematomas:

• Consider vascular injury including uterine artery pseudoaneurysm if accompanied by vaginal bleeding 4
• CT angiography can identify pseudoaneurysms requiring embolization or surgical ligation 4

Postoperative Hemorrhage Management

For persistent bleeding after initial cesarean:

• Initiate uterotonic therapy (oxytocin or sulprostone depending on severity) 2
• Consider intrauterine balloon tamponade or arterial embolization in hemodynamically stable patients 2
• Proceed to urgent laparotomy if hemodynamic instability develops 2

Thromboprophylaxis Considerations

Critical timing for anticoagulation:

• Severe bleeding during or after cesarean is a thrombotic risk factor requiring antithrombotic prophylaxis with heparin 2
• Do not initiate pharmacologic thromboprophylaxis until coagulation normalizes and hemostasis is secured 2
• In cases with significant intraoperative bleeding complications, individualize timing of prophylaxis initiation, potentially using unfractionated heparin given its shorter half-life and reversibility 3
• Once bleeding is controlled, initiate prophylactic anticoagulation as postpartum hemorrhage and blood transfusion are VTE risk factors 3

Common Pitfalls to Avoid

• Do not delay surgical intervention when percutaneous drainage fails or clinical deterioration occurs—persistent symptoms after conservative measures mandate re-operation 1
• Do not underestimate blood loss after cesarean section, as it is frequently underestimated and occurs in 5-10% of cases 5
• Do not start anticoagulation prematurely in patients with hematomas—wait until hemostasis is achieved and coagulation normalizes 2
• Do not miss vascular injuries such as uterine artery pseudoaneurysm, which can present with delayed bleeding and require specific vascular intervention 4

Follow-up

• Discharge typically occurs 5 days after re-operation for hematoma drainage 1
• Obtain follow-up blood tests and ultrasound imaging 10 days post-operatively to confirm resolution 1
• Monitor for post-thrombotic complications given the increased VTE risk from bleeding and surgery 2