Puerperal hematomas: Report of 73 cases and review of the literature

Abstract

We have reviewed the literature of the last decade relating to puerperal hematomas. We have attempted to compile a total listing of possible causative factors, a total listing of the symptoms which have been reported, and a complete tabulation of the various therapeutic suggestions that have been offered so that these data might be easily available in one communication.We have studied our own experience and find it in general accord with that of the literature. There was no maternal mortality in our series. One-third of the patients were morbid. Over one-half of the patients were primigravidas. Prolonged labor did not seem to be an etiological factor. We found no prolongation of the second stage of labor in this study. Nonetheless, it seems eminently logical that such prolongation might well increase the incidence of puerperal blood tumors. The type of anesthesia appeared to be of no significance. It is undoubtedly true that saddle block anesthesia may prevent the early complaint of inordinate pain. Obviously, more vigilant postpartum supervision is necessary for these patients.The incidence of forceps delivery (73 per cent) in this series is much higher than in all but one of the previously reported studies. Hamilton noted an overall operative incidence of 42 per cent in all the cases in the literature. Our high incidence of forceps delivery as well as our high incidence of occurrence suggests to us that trauma may be an important etiological factor. We are compelled, for example, to disagree with the terminology employed by McNally and Ehrlich10 in their recent publication and with one of their conclusions. They report 52 instances of puerperal hematomas with an incidence of 80 per cent operative delivery (low forceps). This is the only series that has come to our attention with a higher operative incidence than our own. They contend that, with the exception of one breech delivery and 3 patients delivered by the Scanzoni maneuver, “all patients can be considered to have delivered normally” and that trauma is not, therefore, a significant etiological factor. These patients may have delivered in the usual fashion, i.e., saddle block anesthesia with low forceps delivery, but not in the normal fashion and such statistics (80 per cent operative delivery) most certainly do not exclude trauma as a causative item.In terms of therapy, it may be unequivocally stated that active management is surely indicated for the expanding varieties.Not to be obscured by the plea for conservative obstetrics (nontraumatic delivery, meticulous episiotomy closure, and precise hemostasis) and the plea for active therapy, when indicated, is the important suggestion that the obstetrical diagnostican must be alert to the very possibility that this complication may occur Delay in diagnosis means needless destruction of tissue. Early recognition is crucial.