How should a subcutaneous hematoma in pregnancy be managed?

Management of Subcutaneous Hematoma in Pregnancy

Subcutaneous hematomas in pregnancy should be managed conservatively with close observation, serial hemoglobin monitoring, and pain control, reserving surgical intervention only for cases with hemodynamic instability or rapidly expanding hematomas.

Initial Assessment and Risk Stratification

When a subcutaneous hematoma is identified in pregnancy, immediately assess:

• Hemodynamic stability: Check vital signs, orthostatic changes, and signs of ongoing bleeding 1
• Hematoma characteristics: Document size, location, and whether it is expanding 1, 2
• Laboratory evaluation: Obtain complete blood count to assess hemoglobin drop and coagulation studies if there is concern for underlying coagulopathy 3
• Blood type and screen: Essential for potential transfusion needs 4

Conservative Management Approach

For stable patients with non-expanding hematomas, conservative management is the preferred initial strategy:

• Observation with serial monitoring: Most subcutaneous hematomas resolve spontaneously without surgical intervention 2, 3
• Serial hemoglobin checks: Monitor for ongoing blood loss, particularly if there was an acute drop in hemoglobin 5, 3
• Pain management: Provide adequate analgesia while avoiding medications that could affect coagulation
• Activity modification: Recommend rest and avoidance of activities that increase intra-abdominal pressure

In a retrospective review of vulvar hematomas (a common location for subcutaneous hematomas in pregnancy), 13 of 13 obstetric hematomas managed conservatively resolved without subsequent surgical intervention 2. Similarly, a case report of a large subcutaneous lumbar hematoma after epidural block was managed conservatively with good outcome, though complicated by fever requiring antibiotics 3.

Indications for Surgical Intervention

Surgical debridement or interventional radiology should be considered when:

• Hemodynamic instability: Tachycardia, hypotension, or signs of shock despite resuscitation 1
• Rapidly expanding hematoma: Documented growth on serial examinations, particularly if exceeding 12 cm 1
• Significant hemoglobin drop: Acute decrease requiring transfusion (e.g., drop from 12.8 to 8 g/dL) 5
• Failed conservative management: Persistent bleeding or worsening clinical status after 24-48 hours of observation 1, 2

Interventional Options

When intervention is required, the approach depends on available resources and clinical urgency:

• Arterial embolization: Preferred when interventional radiology is available, as it can control bleeding without extensive surgery 1
• Surgical debridement: Required when embolization is unavailable or unsuccessful, or when there is concern for infection 1
• Combined approach: Some cases may require both embolization and subsequent debridement 1

A case series of postpartum vulvar hematomas demonstrated that optimal management depends on maternal hemodynamic condition, bleeding status, and availability of interventional radiology 1.

Special Considerations

Anticoagulation management: If the patient is receiving anticoagulation (such as LMWH for VTE prophylaxis or treatment), temporarily hold anticoagulation until the hematoma stabilizes 6. The decision to resume should balance thrombotic risk against bleeding risk.

Location-specific concerns:

• Subcapsular hepatic hematomas require imaging with ultrasound or MRI and multidisciplinary consultation with general surgery 5, 7
• Vulvar/perineal hematomas may require examination under anesthesia to assess extent 1, 2
• Lumbar subcutaneous hematomas after epidural placement warrant evaluation for deeper extension into epidural space 3

Common Pitfalls to Avoid

• Premature surgical intervention: Rushing to surgery in stable patients often leads to unnecessary morbidity, as most hematomas resolve spontaneously 2
• Inadequate monitoring: Failing to obtain serial hemoglobin levels can miss ongoing bleeding 5
• Ignoring infection risk: Large hematomas can become infected, requiring antibiotic coverage if fever develops 3
• Overlooking underlying pathology: In cases without clear trauma, investigate for preeclampsia, HELLP syndrome, or coagulopathy 7