Manchanda: Pelvic hematomas in the postpartum state
I read with great interest the article published by Vardar et al., entitled "Pelvic ultrasonography of the postpartum uterus in patients presenting to the emergency room with vaginal bleeding and pelvic pain" [1]. The authors summarized the imaging manifestations of common causes of vaginal bleeding and pelvic pain in the postpartum state.
Hematomas in the postpartum state can occur as a complication of both vaginal and cesarean deliveries. With the rising incidence of cesarean-section deliveries, there has been an increase in the number of post-cesarean complications [2], including subcutaneous hematoma, rectus sheath hematoma, subfascial hematoma, and bladder flap and retroperitoneal hematomas, as described by the authors [1]. However, it is also necessary to keep in mind puerperal hematomas after vaginal delivery. These have been classified as revealed (infralevator) hematomas and concealed hematomas [3]. Infralevator hematomas can be vulval, paravaginal, or ischiorectal in location and are usually diagnosed clinically. Concealed hematomas include supralevator hematomas, broad ligament hematomas, and intraperitoneal or retroperitoneal hematomas and usually present with abdominal pain or varying degrees of shock.
A high index of suspicion is required, and the radiologist is often the first person to alert the clinician about this potentially life-threatening diagnosis. Ultrasonography is the baseline imaging modality and allows early detection of pelvic hematomas. Cross-sectional imaging in the form of contrast-enhanced computed tomography is essential to delineate the extent of involvement and may show contrast extravasation from branches of the internal pudendal artery, uterine artery, or the internal iliac artery. Small hematomas can be managed conservatively; however, incision and drainage may be required in larger hematomas. Supralevator perivaginal space hematomas are drained through the vaginal wall and infralevator hematomas through the perineum [4]. Hence, it is essential to distinguish between these two lesion types on computed tomography. Larger hematomas may require exploratory laparotomy. Radiologically guided drainage and transarterial embolization have also been described in the literature as the primary management approaches.
In conclusion, the authors have nicely illustrated the ultrasonographic evaluation of varying etiologies of pelvic pain and bleeding in the postpartum state. I would like to add that pelvic hematomas after vaginal delivery, despite their relative infrequency, should also be kept in mind while evaluating such patients in an emergency setting.

Conflict of Interest

No potential conflict of interest relevant to this article was reported.

References

1. Vardar Z, Dupuis CS, Goldstein AJ, Siddiqui E, Vardar BU, Kim YH. Pelvic ultrasonography of the postpartum uterus in patients presenting to the emergency room with vaginal bleeding and pelvic pain. Ultrasonography 2022;41:782–795.
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2. Nair AD, Manchanda S, Gamanagatti S, Kachhawa G, Bhatla N. Post caesarean section complications conundrum: role of imaging. Br J Radiol 2022;95:20211344.
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3. Rafi J, Khalil H. Maternal morbidity and mortality associated with retroperitoneal haematomas in pregnancy. JRSM Open 2018;9:2054270417746059.
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4. Yamashita Y, Torashima M, Harada M, Yamamoto H, Takahashi M. Postpartum extraperitoneal pelvic hematoma: imaging findings. AJR Am J Roentgenol 1993;161:805–808.
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