Index IntroductionCase reportDiscussionConclusionReferences:IntroductionThe vulva is not a common site of injury due to its location and the protective effects of spontaneous adduction of the thighs which prevents direct trauma to the vulva. However, some cases of both obstetric and non-obstetric vulvar hematomas have been reported, but the true incidence is unknown. Obstetric vulvar hematomas are usually observed postpartum following soft tissue injury or iatrogenic injury resulting from episiotomies1,2. Non-obstetric hematomas of the vulva, however, are usually due to direct trauma to the perineum1,3, or sexual intercourse (forced or consensual)4. Clinical features usually include severe pain in the vulva, swelling of the vulva that may increase rapidly with or without bleeding or tearing. Treatment options can be conservative (for small non-progressing hematomas)5 or surgical (for large or rapidly progressing hematomas) requiring prompt evacuation)6. The outcomes of both management options are good6,7, although some authors have reported that conservative management is associated with an increased need for antibiotics, blood and longer hospital stays8. This case report concerns a rapidly evolving vulvar hematoma following blunt trauma in a pregnant woman in the early third trimester who successfully completed the pregnancy after surgery and had a normal vaginal delivery. Say no to plagiarism. Get a tailor-made essay on "Why Violent Video Games Shouldn't Be Banned"? Get Original EssayCase ReportA 27-year-old unreserved G5P4+0 female (4 living infants) at 32 weeks' gestational age who presented to the emergency department complaining of vulvar pain and minor bleeding following a motor vehicle accident in which she was sitting astride a motorbike. She is said to have bounced repeatedly on the motorcycle during the accident. There was no bleeding from any other body site or orifice. No abdominal pain, no CSF ​​drainage and she still felt adequate fetal movement. On examination she was clearly in pain, afebrile (T 36.80C), not pale, anicteric, not dehydrated and without foot edema. His respiratory rate was 20 cycles per minute, his chest was clinically clear, his heart rate was 72 beats per minute, and his blood pressure was 120/80 mmhg. There was no abdominal or uterine tenderness and there was no uterine contraction. The symphysiofundus height was 30 cm, compatible with her gestational age of 32 weeks. There was no area of ​​tenderness. A single intrauterine fetus was palpated in a longitudinal position and in cephalic presentation. The fetal heart rate was 144 beats per minute and was regular. The vulva was smeared with blood but there was no active bleeding. A hematoma of the left vulva approximately 4 cm in diameter was noted. There was no obvious laceration in the vulva or vagina. The cervical bone was closed and there was no CSF ​​drainage. Her packed cell volume was 33%, urgent abdominal ultrasound revealed normal cesis at 32 weeks + 4 days of gestation and ruled out a broad ligament hematoma. She was hospitalized under close observation, given analgesics and haematinics and advised to report to the nurses if the pain worsened or the swelling increased. About 30 minutes after admission he suffered from severe pain and the hematoma had increased significantly, but the feto-maternal vital signs were normal. She subsequently underwent examination under anesthesia, evacuation of the hematoma and application of hemostatic stitches. During the surgery a huge hematoma of the left vulva occurredapproximately 10x10 cm which contained approximately 300 ml of coagulated blood which was evacuated through an incision on its most protruding part into the vagina. After evacuation, diffuse bleeding stitches from the hematoma wall were tied with 2-0 chromic sutures. The hematoma cavity was closed with chromic 2-0. Total blood loss was approximately 400 ml. An indwelling urinary catheter and vaginal pack were left in situ for 12 hours. She was administered analgesics, antibiotics, tocolytics and haematinics. The swelling of the vulva resolved and the woman was discharged after 48 hours upon admission with a red blood cell volume of 32%. She subsequently presented at term with spontaneous labor and had a successful vaginal delivery of a live male infant weighing 2.9 kg without any episiotomy, vulvar or perineal laceration. Discussion This was a 32-week pregnant woman who developed an acute vulvar hematoma following repeated trauma to the vulva while riding a commercial motorcycle. The loose connective tissue and smooth muscles of the vulva are richly supplied by branches of the pudendal artery; a significant branch of the internal iliac artery9. It drains into the labial veins, which are tributaries of the internal pudendal veins. Injury to the labial branches of the internal pudendal artery, which lies in the superficial fascia of the anterior and posterior pelvic triangle, can cause significant vulvar hematomas10. Factors that contributed to the development of the hematoma in this case include the loose connective tissue of the areola in the vulva allowing room for expansion, increased blood flow to the vulva and perineum during pregnancy, and repeated blunt trauma which led to ruptured blood vessels in the vulva. With uncontrolled extravasation of blood and room to expand, a worsening of the hematoma was inevitable. The incidence of vulvar hematomas, including those during pregnancy and childbirth, is unknown as there are very few reports of them 10,11. A similar case of traumatic vulvar hematoma was reported by Ekweani et al in a 36-week pregnant multipara who was managed conservatively and subsequently had a spontaneous vaginal delivery3 In addition to trauma3, vulvar hematomas have been linked to sexual intercourse4 consensual or forced, birth12 and in some cases they can be spontaneous10. Risk factors for the development of obstetric vulvar hematoma include nulliparity, age > 29 years, infant birth weight > 4 kg, instrumental vaginal delivery, prolonged labor, preeclampsia and haemorrhagic diathesis1,11. Approximately 87% of hematomas occur following repair of episiotomies or vaginal lacerations2. Obstetric hematomas can be vulvar/vulvovaginal, paravaginal, pelvic/subperitoneal13. In vulvar/vulvovaginal hematomas, bleeding is evident on the external surface with or without vaginal extension, limited superiorly by the anterior urogenital diaphragm. Both types result from lesions to the branches of the pudendal artery (the posterior rectal, transverse perineal, and posterior labial arteries). Paravaginal hematomas are not seen externally and can only be detected on vaginal examination. They result from damage to the descending branch of the uterine artery. The hematoma is confined to the paravaginal tissues in the space delimited inferiorly by the pelvic diaphragm and superiorly by the cardinal ligament. Subperitoneal hematomas are the result of damage to the branches of the uterine artery in the broad ligament. The hematoma develops within the broad ligament and can be dissected retroperitoneally. It may be clinically occult despite significant blood loss. A high index of suspicion is needed to promptly diagnose and manage these hematomas before signs of collapse develop. 2009; 48:200–202.