Re: hematoma
From: Joanne Bulley, MD (islesannie@gmail.com)
Thu Nov 27 07:00:45 2008
Thanks to Charles and to "vnellsch" (I would appreciate it of you would
you sign with your name)
I have 23 years with this patient and litigiousness is not in the wings
at all.
WBC: 68% neutrophils, no left shift
PT 10.2 INR 0.97
aPTT 29.8
But antibiotics are not a bad idea even without leukocytosis, since the
blood sure is a great culture medium as we all know.
I should get a call from the hospital shortly about the CT scan -
hopefully she is in the scanner now.
I will probably also call the other gyn in town for his thoughts. I get
along very well with him and he happens to be on call for their group
today.
Would others open just to let it drain?
Would you put in any packing?
At Thu, 27 Nov 2008, vnellsch wrote:
>
>i'll tell you, joanne, when i have had cases like these, i have found it
>best to
>assure drainage by taking out a few sutures, then giving something like
>levaquin p.o.,
>monitoring the cbc, and restraining myself from exploring unless the hct.
>gets too low.
>sometimes there is pressure from the patient and family to do something, but
>i think it
>is best to not explore unless you have a good reason. if they act litigious,
>i get a surgeon
>involved, who has always agreed with the course of action. of course, if
>they go down
>the road to dr. wonderful, who promptly takes them to surgery, then tells
>them that he/she saved
>their life, you are in a mess. good luck. vnellsch
>
>>>----- Original Message -----
>From: "Joanne Bulley, MD" <islesannie@gmail.com>
>To: "Multiple recipients of list OB-GYN-L" <ob-gyn-l@mail.obgyn.net>
>Sent: Thursday, November 27, 2008 6:24 AM
>Subject: GYN: hematoma
>
>> Happy Thanksgiving folks.
>>
>> 49yo G2P2 (babies were 9 & 11 pounds, if my recollection is correct,
>> delivered easily & a long time ago)
>> menses currently scant every 2-3 months, with intermittent hot flashes
>>
>> Rectocele repair 11/19/08
>>
>> ER this AM, came in after she started gushing blood at home.
>>
>> At 5-6 days post op she says she was feeling hot & cold, not sure if it
>> was just the hot flashes. Temp in 99's never over 99.8. Sore in rectal
>> area. She did not complain of that, but answered when asked. BMs
>> uncomfortable.
>>
>> Exam: repair intact, palpable hard mass upper portion of repair
>> extending along ischio-rectal area more to right. Bright red watery
>> blood actively draining.
>>
>> Preop Hgb/Hct: 13.5/38.9 WBC 5.23
>> Today: 11.1/32.0 WBC 6.42
>>
>> CT scan pending with contrast.
>>
>> Presumed diagnosis: hematoma filling ischio-rectal area & now draining
>> through suture line.
>>
>> Last one of these I saw was with the post partum vaginal hematomas.
>>
>> I know if I open the chance of actually finding the bleeder is nearly
>> nil and could increase bleeding.
>>
>> Any thoughts on management welcome.
>> Possibly go to OR and pack it under anesthesia (with or without
>> opening).
>> Not eager to open it and have tons of blood but no ability to find the
>> actual bleeder and end up losing more blood.
>>
>> Should have CT report in about 2 hours. Gotta let the contrast get down
>> there to discern bowel from hematoma.
>>
>> Thanks for any thoughts!
>>
>> --
>> Joanne Bulley, MD
>> solo gyn
>> Keene, NH
--
Joanne Bulley, MD
solo gyn
Keene, NH
