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Vulvar hematoma secondary to spontaneous rupture of the internal iliac artery: clinical review

      Vulvar hematomas occur rarely outside the obstetric population but may present after other trauma to the pelvis or perineum. Spontaneous rupture of the internal iliac artery is described mostly in the presence of an aneurysm, with atherosclerosis, connective tissue disease, infection, and trauma as causative factors. It most often presents with abdominal pain and neurologic or urologic symptoms. We present an unusual case of a spontaneous rupture of the internal iliac artery that presented as a vulvar hematoma in a nulliparous woman that was successfully treated with selective arterial embolization and surgical evacuation. The literature is reviewed and management options discussed.

      Key words

      Vulvar hematomas are rare, with an incidence in the obstetric population from 1:300 to 1:1500 deliveries.
      • Zahn C.M.
      • Yeomans E.R.
      Postpartum hemorrhage: placenta accreta, uterine inversion, and puerperal hematomas.
      They may also be the result of saddle injury, assault, or sexual trauma where the soft tissue of the vulva, with its rich vascular supply, is crushed against the osseous plane of the pelvis.
      • Virgili A.
      • Bianchi A.
      • Mollica G.
      • Corazza M.
      Serious hematoma of the vulva from a bicycle accident: a case report.
      Puerperal hematomas will occur mostly in the presence of episiotomy or laceration, but can also occur from spontaneous injury to a blood vessel.
      The presentation can be rapid after injury, or delayed secondary to pressure necrosis and subsequent vessel rupture. When arterial, the origin is usually from injury to one of the branches of the pudendal artery rather than the artery itself, including the posterior labial, transverse perineal, or posterior rectal branches.
      • Zahn C.M.
      • Yeomans E.R.
      Postpartum hemorrhage: placenta accreta, uterine inversion, and puerperal hematomas.
      • Ridgway L.
      Puerperal emergency: vaginal and vulvar hematomas.
      The bleeding can be venous in origin and is often from multiple sites.
      • Propst A.M.
      • Thorp Jr, J.M.
      Traumatic vulvar hematomas: conservative versus surgical management.
      We present a case of spontaneous rupture of the internal iliac artery with an unusual presentation as a vulvar hematoma. To our knowledge this is the first such case to be described in the literature.

      Case Report

      A 28-year-old woman presented with sudden-onset swelling and pain in her left labial region. Significant history was an incomplete spinal cord injury (L3) secondary to a motor vehicle accident 9 months earlier. Bladder emptying was by intermittent self-catheterization on sensation (around 350 mL). There was no history of sexual intercourse or trauma, particularly in relation to catheterization. However, although initially performed, catheterization became impossible as the labial swelling progressed. She was taking no antiplatelet or anticoagulant medications.
      On examination, the patient was hemodynamically stable and had developed urinary retention. There was an obvious vulvar hematoma significantly distorting her anatomy (Figure). Emergency staff members were unable to catheterize her so the urology service was consulted and flexible cystoscopy confirmed no bladder or urethral injury and assisted with indwelling catheter placement; 750 mL of clear urine was drained.
      Figure thumbnail gr1
      FIGUREVulvar hematoma with accompanying angiography
      Obvious left vulvar hematoma was significantly distorting anatomy (left). Computed tomographic angiography (right) demonstrating blush from rupture at region of pudendal artery (arrow), which was later coiled.
      Egan. Vulvar hematoma secondary to spontaneous rupture of the internal iliac artery: clinical review. Am J Obstet Gynecol 2009.
      Computed tomography of abdomen-pelvis with angiography revealed a large collection in the left labia with a suggested rupture of an internal iliac branch in the region of the left pudendal artery. Formal angiography confirmed this (Figure) and embolization was successful with coils. There was no evidence of aneurysm or atherosclerosis. Because of its size, the hematoma (> 500 mL) was surgically evacuated 24 hours after embolization. Further investigation demonstrated no coagulopathy, connective tissue disease, or infection as a cause of the hemorrhage. The hematoma resolved and the patient was discharged 2 weeks later.

      Comment

      The pudendal artery is the terminal branch of the anterior division of the internal iliac artery. It travels inferolaterally, passing through the greater sciatic foramen and enters the ischioanal fossa through the lesser sciatic foramen. It then passes through the pudendal canal and divides into its terminal branches that supply the external genitalia and perineum. Extension of a hematoma in this area is limited by Colles fascia and the urogenital diaphragm and is, therefore, directed toward the skin.
      • Moore K.
      • Dalley A.
      Clinically oriented anatomy.
      Spontaneous rupture of the internal iliac artery occurs almost exclusively at the site of an aneurysm, usually related to atherosclerosis. Rarely, infection or connective tissue disease are responsible.
      • Dix F.P.
      • Titi M.
      • Al-Khaffaf H.
      The isolated internal iliac artery aneurysm–a review.
      Injury to the internal iliac artery results in immediate bleeding or pseudoaneurysm formation in a variety of settings: pelvic fracture or penetrating injury, intrapartum and postpartum, or intaoperatively.
      • Dix F.P.
      • Titi M.
      • Al-Khaffaf H.
      The isolated internal iliac artery aneurysm–a review.
      • Vedantham S.
      • Goodwin S.C.
      • McLucas B.
      • Mohr G.
      Uterine artery embolization: an underused method of controlling pelvic hemorrhage.
      One report documented perineal hemorrhage after spontaneous pudendal artery pseudoaneurysm rupture in the setting of bowel cancer resection, local radiotherapy, and abscess formation.
      • Mann D.
      • Satin R.
      • Gordon P.H.
      Neurologic sequelae following transcatheter embolization to control massive perineal hemorrhage.
      In our case spinal cord injury with intermittent self-catheterization made trauma the most likely cause of rupture. However, with no supporting history or positive findings after extensive investigation we must conclude that the cause was spontaneous.
      Presenting symptoms of internal iliac rupture are varied and depend on the site and extent of hemorrhage. They include abdominal, groin, and buttock pain, along with neurologic and urologic symptoms. The patient may also be hemodynamically unstable. Rupture into the bladder, ureter, rectum, and rectus sheath were reported,
      • Dix F.P.
      • Titi M.
      • Al-Khaffaf H.
      The isolated internal iliac artery aneurysm–a review.
      but not vulvar hematoma.
      The management of a vulvar hematoma is somewhat controversial. The patient must first be adequately resuscitated.
      • Ridgway L.
      Puerperal emergency: vaginal and vulvar hematomas.
      The hematoma itself may be managed conservatively, surgically, or with selective arterial embolization. Small hematomas can be managed expectantly but exact criteria for when a hematoma will benefit from surgery have not been established. It is generally agreed that if it is significantly large or expanding, intervention is required.
      • Zahn C.M.
      • Yeomans E.R.
      Postpartum hemorrhage: placenta accreta, uterine inversion, and puerperal hematomas.
      • Ridgway L.
      Puerperal emergency: vaginal and vulvar hematomas.
      • Propst A.M.
      • Thorp Jr, J.M.
      Traumatic vulvar hematomas: conservative versus surgical management.
      Surgery involves incision and evacuation of hematoma with ligation of any bleeding points. As the source of bleeding is often venous, ligation is not always possible. However, evacuation of the clot is important in the prevention of pressure necrosis and infection.
      • Zahn C.M.
      • Yeomans E.R.
      Postpartum hemorrhage: placenta accreta, uterine inversion, and puerperal hematomas.
      • Ridgway L.
      Puerperal emergency: vaginal and vulvar hematomas.
      Ultrasound, computed tomography, or magnetic resonance imaging may be appropriate to further investigate the size, site, and expansion of the hematoma.
      • Guerriero S.
      • Ajossa S.
      • Bargellini R.
      • Amucano G.
      • Marongiu D.
      • Melis G.B.
      Puerperal vulvovaginal hematoma: sonographic findings with MRI correlation.
      Surgical intervention has long been used for treatment of pelvic hemorrhage in numerous settings.
      • Vedantham S.
      • Goodwin S.C.
      • McLucas B.
      • Mohr G.
      Uterine artery embolization: an underused method of controlling pelvic hemorrhage.
      As identification of the injured vessel is difficult, ligation of the internal iliac can be performed with resulting hemostasis achieved by reduction in pulse pressure distal to the site of ligation.
      • Burchell R.C.
      Internal iliac artery ligation.
      The success rate varies between studies and cause of hemorrhage
      • Vedantham S.
      • Goodwin S.C.
      • McLucas B.
      • Mohr G.
      Uterine artery embolization: an underused method of controlling pelvic hemorrhage.
      and we would recommend it only in the presence of other indications for laparotomy or failure of previous interventions.
      Selective angiographic embolization is emerging as a safe and effective alternative to surgery for pelvic hemorrhage. It is well established in trauma management with increasing support in obstetric literature. However, a direct comparison in large or randomized trials has not yet been performed.
      • Vedantham S.
      • Goodwin S.C.
      • McLucas B.
      • Mohr G.
      Uterine artery embolization: an underused method of controlling pelvic hemorrhage.

      Conclusion

      Vulvar hematoma is an uncommon presentation that has not previously been reported as secondary to spontaneous rupture of the internal iliac artery. Although trauma is usually the most likely cause, in the absence of positive findings at cystoscopy and surgery, it must be presumed to be spontaneous. Although the artery responsible is usually a branch of the pudendal artery, a more proximal site should be considered particularly if the cause is unknown. Selective arterial embolization with or without surgery is an effective treatment option for larger or expanding hematomas.

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        American Journal of Obstetrics & GynecologyVol. 201Issue 3
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          We read with interest the letter by Palacios-Jaraquemada and we thank them for their contribution. Firstly, as with any report not all views obtained at arteriography are published and the 3-dimensional appreciation of anatomy is lost in any still image. We stand by our original description based on the real-time images and the image displayed in the report. As they point out, the ruptured vessel may have been a vaginal branch of the internal iliac artery. We would also like to highlight that we did state that we “suspected rupture of an internal iliac branch in the region of the left pudendal artery.”1 We believe this description to be broader but indeed it describes the exact same vessel.
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