Re: Vulvar haematoma
From: Joanne Bulley, MD (islesannie@yahoo.com)
Sat Jan 21 10:35:33 2006
Good lesson here - we all appeared to make the assumption that the
hematoma was went up the right paracolic space and made the mass ... but
then a retroperitoneal hematoma should not be palpable the way you
described ... because it is retroperitoneal.
And we all know what it means to *assume*
Thanks for the interesting case and lesson, El.
Joanne
At Sat, 21 Jan 2006, Dr Eberhard Lisse wrote:
>
>Well,
>
>we remembered that the first thing to do during a code is to take your
>own pulse and decided not to panic :-)-O
>
>So we rescuscitated her nicely, and went for Ultrasound with the first
>unit of blood hanging. Uterus was well contracted and no sign of
>bleeding into the abdomen or peritoneum but this large vulvar haematoma.
>
>She stabilized and so we decided to hang on and watch.
>
>This morning she was very well, the vulvar haemaoma not increasing in
>size, Hb 11mg% after 3 units, which means we could probably have gotten
>away without transfusion the hypovolemia having been caused by
>insufficient fluids during the day (orally and iv).
>
>The mass? Constipated ascending colon. (Fairly endemic here, by the way,
>due to diet).
>
>They can hurt you more...
>
>el
>
>on 1/21/06 6:24 AM D. Ashley Hill said the following:
>> At Fri, 20 Jan 2006, DoctorJoe@aol.com wrote:
>>
>>>In a message dated 1/20/06 2:13:24 PM, el@lisse.NA writes:
>>>
>>>>Next Diagnostic Step?
>>>>
>>>>Next Therapeutic Step?
>>>>
>>>Laparotomy for drainage of retroperitoneal hematoma?
>>>
>>>Joe P.
>>
>> My vote, also. Here is my thinking, given the story thus far: I don't
>> think this is a a straightforward vulvar hematoma, which is an
>> intrafascial hematoma that will tamponade itself (unless the vulvar skin
>> ruptures) since Colles' fascia limits the spread. A paravaginal
>> hematoma is suprafascial but can be quite large. However, a paravaginal
>> hematoma should not produce a large mass like El described going up
>> towards the liver. This sounds like a retroperitoneal hematoma,
>> particularly since the belly is fairly soft but there is shock and a
>> hard mass up the right paracolic gutter. I don't think further
>> diagnostic evaluation outside of a Bard-Parker is necessary, given the
>> clinical situation.
>>
>> Since the patient is in shock, I would consider a set of coag studies,
>> transfusion as indicated, then evacuation of the hematoma and possible
>> unilateral hypogastric artery ligation if still bleeding. Opening up
>> the broad ligament into the retroperitoneum (similar to how one would
>> look for the ureter during an abdominal hysterectomy) allows access to
>> the hypogastric vessels and the hematoma. I would leave the peritoneum
>> over the hematoma open after evacuation, and place a drain.
>>
>> Well, what's the rest of the story?! Probably something weird like
>> Ascaris of the broad ligament :) Thx,
>>
>> --
>> D. Ashley Hill, MD
>> Associate Director
>> Department of Obstetrics and Gynecology
>> Florida Hospital Family Practice Residency
>> and Loch Haven Ob/Gyn Group
>> Orlando, Florida
--
Joanne Bulley, MD
Keene, NH, USA
"Love is indescribable and unconditional.
I could tell you a thousand things that it is not, but not one that it is."
— Duke Ellington, American jazz artist (1899-1974).
