Bladder Flap Hematoma Research Articles

Conservative Management of a Large Bladder Flap Hematoma Post Cesarean Section: A Case Report and Mini Review of Literature

Conservative Management of a Large Bladder Flap Hematoma Post Cesarean Section: A Case Report and Mini Review of Literature

Multidetector computed tomography evaluation of postcesarean section acute complications

Background: Cesarean delivery is the most commonly performed major abdominal operation in women. Its rate ranges from 3% to 5% in Africa to 33% in the United States and 43.9% in Brazil with a reported worldwide global estimation of 15%. Although it is a safe procedure, cesarean delivery has a variety of acute and chronic complications. The various acute complications of cesarean section are hematomas, infection, uterine dehiscence or rupture, and pelvic thrombophlebitis. The overall complication rate is around 14.5%. Aim and Objectives: The aim and objective of this study is to evaluate the imaging findings of acute complications of cesarean section. Materials and Methods: This prospective study was done in the Department of Radiodiagnosis Govt Medical College, Srinagar from June 2019 to February 2020 in collaboration with department of general surgery and gynecology and obstetrics. All patients with suspected complication in immediate postcesarean period were evaluated with contrast-enhanced multidetector computed tomography (MDCT). Results: Out of 25 patients evaluated for suspected immediate postcesarean complications, five patients had bladder flap hematoma only, 8 had uterine dehiscence, six patients had uterine rupture, 3 had ureteric injury, one had gossypiboma while as 2 had pelvic sepsis. Conclusion: MDCT plays an important role in the detection and confirmation of multiple postcesarean acute complication and can also help in guiding the management of complication as well.

Post-Supravaginal Hysterectomy for Bladder Flap Hematoma in P3A0 Preterm Delivery by Cesarean Section due to Fetal Distress

Introduction: Bladder flap hematoma (BFH) is a rare complication of cesarean section (CS). BFH appears between the bladder and the lower uterine segment (LUS) when the visceral peritoneal is closed during traditional CS techniques and decreased uterine contractions. Surgery is the treatment of choice for the management of peritoneal closure in CS and the decrease in uterine contractions that cause BFH.Case Presentation: A 35-year-old G3P2A0 underwent a cesarean delivery due to fetal distress. CS was performed with the visceral peritoneal sutured as in the traditional technique. Six hours after CS, there was an increase in abdominal circumference, muscle defenses, hypotension, tachycardia, anemia, and leukocytosis. She had to undergo repeated laparotomy with acute abdomen after CS and hysterectomy because uterine atony was found.Conclusions: BFH can be caused by peritoneal closure during CS and decreased uterine contractions or uterine atony. Although there is no standard protocol for management, surgical approaches for cases with infection or bleeding and hysterectomy are performed to save the patient’s life from uterine atony.

Pelvic ultrasonography of the postpartum uterus in patients presenting to the emergency room with vaginal bleeding and pelvic pain.

Pelvic pain and vaginal bleeding are common symptoms in postpartum women presenting to the emergency room (ER). Pelvic ultrasonography plays a crucial role in evaluating symptomatic postpartum patients by allowing a rapid diagnosis and treatment initiation. The main goal of imaging is to distinguish between causes of pelvic pain and vaginal bleeding that may be managed conservatively and those requiring emergent intervention. This pictural essay focuses on the ultrasonographic features of common postpartum conditions for which patients may present to the ER with vaginal bleeding and pelvic pain, including retained products of conception, endometritis, uterine arteriovenous malformation, uterine artery pseudoaneurysm, ovarian vein thrombosis, bladder flap hematoma, and uterine dehiscence/rupture.

Multidetector Computed Tomography Evaluation of Uncommon Acute Post-Caesarean Section Complications

Introduction. The most common major abdominal surgery in women is caesarean section. Despite being a safe procedure, a variety of complications, both acute and chronic, can occur. About 14.5% of caesarean sections result in complications. Infection followed by postpartum haemorrhage is the most frequent complication. Imaging modalities such as ultrasonography and multidetector computed tomography are often used in the evaluation of suspected uncommon post-caesarean complications. Computed tomography has been found to be a good initial modality for assessing acute postoperative complications after caesarean delivery.
 The objective of the research was to evaluate the imaging findings and the characteristic visual manifestations of atypical acute complications of caesarean section, other than common complications such as postpartum haemorrhage, wound infection, etc.
 Materials and Methods. This prospective study was carried out at the Department of Radiodiagnosis and Imaging, Government Medical College, Srinagar from June 2019 to February 2020 in collaboration with the Department of General Surgery and Gynaecology and Obstetrics of the Sher-i-Kashmir Institute of Medical Sciences. All patients with suspected complication in the immediate post-caesarean period were evaluated with contrast-enhanced multidetector computed tomography.
 Results. Out of 427 patients who underwent caesarean section, 25 patients were suspected of having uncommon acute complications. Out of 25 patients evaluated for suspected immediate post-caesarean complication, only 5 patients had bladder flap hematoma, 8 patients were diagnosed with uterine dehiscence, 6 patients had uterine rupture, 3 patients suffered from ureteral injury, 1 patient had gossypiboma, 2 patients developed pelvic sepsis.
 Conclusions. Multidetector computed tomography plays an important role in detection and confirmation of multiple acute complications after caesarean delivery and can also help in guiding the management of complications as well.

Multidetector CT appearance of the pelvis after cesarean delivery: normal and abnormal acute findings.

Cesarean section (CS) may have several acute complications that can occur in the early postoperative period. The most common acute complications are hematomas and hemorrhage, infection, ovarian vein thrombosis, uterine dehiscence and rupture. Pelvic hematomas usually occur at specific sites and include bladder flap hematoma (between the lower uterine segment and the bladder) and subfascial or rectus sheath hematoma (rectus sheath or prevescical space). Puerperal hemorrhage can be associated with uterine dehiscence or rupture. Pelvic infections include endometritis, abscess, wound infection, and retained product of conception. Radiologists play an important role in the diagnosis and management of postoperative complications as a result of increasing use of multidetector CT in emergency room. The knowledge of normal and abnormal postsurgical anatomy and findings should facilitate the correct diagnosis so that the best management can be chosen for the patient, avoiding unnecessary surgical interventions and additional treatments. In this article we review the surgical cesarean technique and imaging CT technique followed by description of normal and abnormal post-CS CT findings.

A Case of Bladder Flap Hematoma Presenting With Hematuria

A Case of Bladder Flap Hematoma Presenting With Hematuria

Imaging after Cesarean Delivery: Acute and Chronic Complications

Cesarean delivery is a commonly performed operation and accounts for nearly one-third of all births in the United States. Although it is a safe procedure, cesarean delivery has a variety of acute and chronic complications that prompt imaging with ultrasonography (US), computed tomography, and magnetic resonance imaging. Acute complications include hematomas in specific locations that are unique to the procedure, as well as a variety of infections. A bladder flap hematoma occurs in the space between the bladder and the lower uterine segment, whereas a subfascial hematoma is an extraperitoneal collection located in the prevesical space posterior to the rectus muscles and anterior to the peritoneum. Puerperal infections after cesarean delivery include abscesses, wound infections and dehiscence, uterine dehiscence and rupture, and pelvic thrombophlebitis. The prevalence of chronic complications related to the healed cesarean delivery scar is unknown, but the scar may result in technical limitations for pelvic US due to the adhesions between the anterior lower uterine segment and the anterior abdominal wall. The cesarean delivery scar also leaves the patient susceptible to several unique diagnoses. A cesarean scar "niche" is a tethering of the endometrium that can serve as a reservoir for intermenstrual blood and fluid. Intrauterine devices can be malpositioned in the cesarean delivery scar, and endometrial implants can develop in the abdominal wall years after surgery. These patients are also at increased risk for implantation abnormalities including cesarean scar ectopic pregnancy, retained products of conception, and placenta accreta. Familiarity with the normal postoperative findings following cesarean delivery is necessary to recognize acute and chronic complications, which are being encountered with increasing frequency.

Utility of Multidetector CT in Severe Postpartum Hemorrhage

Postpartum hemorrhage is one of the leading causes of maternal mortality worldwide. According to the time when postpartum hemorrhage develops, it is classified as (a) primary, or early, postpartum hemorrhage (within the first 24 hours after delivery) or (b) secondary, or late, postpartum hemorrhage (>24 hours to 6 weeks after delivery). Primary postpartum hemorrhage may be caused by uterine atony (75%-90% of cases), trauma of the lower portion of the genital tract, uterine rupture, uterine inversion, bladder flap hematoma, retention of blood clots or placental fragments, and coagulation disorders. Secondary postpartum hemorrhage may be caused by uterine subinvolution, coagulopathies, and abnormalities of the uterine vasculature. Extrauterine sources of bleeding include rectus sheath hematoma, direct arterial injuries, and the HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome. Severe postpartum hemorrhage is a life-threatening condition that is diagnosed on the basis of the findings from clinical examination, with or without ultrasonography. Computed tomography (CT) and magnetic resonance imaging are useful in the characterization of postpartum hemorrhage when medical treatment fails. Multidetector CT has an important role when intraabdominal bleeding is suspected and can be considered in cases of recurrent bleeding after embolization, as well as for the evaluation of postsurgical complications. A proposed clinical and CT imaging algorithm for postpartum hemorrhage is presented. A multidisciplinary approach to postpartum hemorrhage is essential to optimize the role of diagnostic and interventional radiology in obstetric hemorrhage, to avoid hysterectomy and thus preserve fertility.

Laparoscopic treatment of post-cesarean section bladder flap hematoma: A feasible and safe approach

Bladder-flap haematoma (BFH) is a puerperal complication after caesarean section; it consists of a blood collection between the bladder and the lower uterine segment, in the vesico-uterine space, and it results from bleeding at the uterine suture. Ten symptomatic women were hospitalized and underwent a laparoscopy performed by tumescence incision, bladder wall detachment from the vesico-uterine space, drainage of the fluid material inside the collection, washing of the haematoma site and peritoneal suturing. After seven days, the time it takes to develop a BFH after caesarean section, laparoscopically collected dates were, on average: Total laparoscopy time 31 min, intrasurgical blood loss 36.5 ml, two patients with a draining catheter in the pelvis, two women who developed post-operative urinary symptoms; the duration of hospital stay was 1.3 days. None of the women had complications during the post-dismissal follow-up, and no further therapeutic intervention was required. No clear, defined and standardized protocols exist for the clinical and surgical management of post-caesarean section BFH; the conservative laparoscopic approach proposed would offer women a potentially safe and feasible minimally invasive treatment, reserving hysterectomy for severe uterine necrosis, myometritis or abscess formations. These findings should be confirmed by large extensive trials.

Laparoscopic treatment of post-cesarean section bladder flap hematoma: A feasible and safe approach

Laparoscopic treatment of post-cesarean section bladder flap hematoma: A feasible and safe approach

F90Sonography of bladder flap hematoma in cesarean section with open and closed peritoneum: a prospective randomized study

In our randomized study, we've examined sonographically 238 first c.s. carried out through Stark technique and 46 traditional repeat c.s. with open peritoneum (284 with open peritoneum), compared to 253 women who underwent a first c.s. with the classic technique and 51 previous traditional c.s. (304 c.s. with closed peritoneum) the aim of our investigation is the sonographic evaluation of patients with open peritoneum and those with closed peritoneum to discriminate the frequency of bladder flap hematomas in the two techniques. The statistical analysis has been conducted with the test of Student considering significant a value of P < 0.05. C.s. with PROM, abruptio placentae, and placenta previa have been excluded from our study. For this reason all the patients of the two groups were examined by transvaginal and transabdominal sonography, on the 3rd and 12th postoperative day, to demonstrate the possible presence of retrovescical collections/hematomas, assuming as sonographic criterion the presence of a fluid or mixed mass on the lower‐uterine‐segment (L.U.S.), of three or more centimetres, clean wall, with reinforcement of distal echoes. It has been observed that in the group with open peritoneum c.s., there were masses of mixed ecostructure referring to hematomas on the 12th day in 9 cases (3.16%), while in the group with closed visceral peritoneum in 48 cases (15.78%) (P < 0.05). Sonography, which is a simple reliable riproducible and low cost technique let us confirm previous experiences made by TAC and MR whic indicate that bladder flap hematomas are usual in post‐c.s. In 39 cases (81.25%), they were collections on the L.U.S. from 3 to 4.2 cm, in 6 (12.50%) from 4.2 to 5 cm (4.16%) and only in one case it was a lateral collection of 6 cm (2.08%) which did not require surgical treatment anyway (the last 3 cases have been observed by MR which which confirmed sonographic findings). In addition in 104 patients (36.61%), there was the presence of a fluid collection in Douglas region due to the amniotic liquid usually not removed according to the Stark technique. Besides in 22 patients (45.83%) the bladder‐flap hematoma was associated with fever (values > 38.5 °C), in this group other causes of febrile morbidity were obviously excluded. The characteristic of these c.s. was a significant intraoperative blood loss, evaluated with a drop in Hb of 3 or more g/dL. On the contrary it was observed a significant differences of the intestinal functionality restarting 8.6 h at c.s. with open peritoneum and 42.7 h (P < 0.05) at c.s. with closed peritoneum but a careful examination confirms that therapid resumption is favoured by regional anaesthesia as regards general anaesthesia, rather than by surgical technique. Subsequently 82 women undergoing the first Stark c.s., have been reoperated with the same technique, with open peritoneum, but not significant differences have been observed in comparison to c.s. with closed peritoneum from a postsurgical adhesion profile. According to the data of literature, peritoneum closure in c.s. lengthens operative time and in some cases favours hematomas on the L.U.S. which increase postoperative morbidity, antibiotics use 2.6 and 4.8 (P < 0.01), length of Hospital staying and costs.

Anterior vaginotomy: Abdominal delivery without a uterine incision

To determine whether planned anterior vaginotomy is a logical and safe means of avoiding a uterine scar with term abdominal delivery. I recorded the complications of the technique and whether vaginal birth after anterior vaginotomy occurred. Thirteen anterior vaginotomies were done when the vagina had advanced during prolonged second stage. The procedure appears safe, although one patient had a postpartum bladder flap hematoma and one had gross hematuria postpartum. Three had postpartum endometritis and one was given a blood transfusion. In the six with records of follow-up pregnancies, two had elective cesareans, four attempted vaginal birth after vaginotomy with two failures (delivered by cesarean). The two successful procedures were uncomplicated. I conclude that unintended anterior vaginotomy should be coded. Such coding and analysis are required before it can be recommended that anterior vaginotomy replace cesarean after considerable vaginal advancement occurs. Vaginal advancement (and cervical retraction) during the second stage of labor requires further study.

Complications of cesarean section: role of transperineal US.

The pelvic area was prospectively examined with transabdominal and transperineal ultrasonography (US) in 22 patients referred for US evaluation for possible complications of cesarean section. The region of the uterine wound was seen with transabdominal US in all patients and with transperineal US in 20. The two in whom transperineal US did not reveal the lower uterus had undergone scanning with their bladders empty. Bladder flap hematomas were revealed with transabdominal US in 10 patients and with transperineal US in nine. Transabdominal and transperineal diagnoses regarding bladder flap hematoma were in agreement in all 19 patients who underwent transperineal US with a distended urinary bladder. With the transabdominal approach, subfascial hematomas were seen in nine patients, but none were revealed with the transperineal technique. In one patient, a hematoma in the space of Retzius was seen only with transperineal US. These findings indicate that transperineal US can complement transabdominal US in evaluation for complications of cesarean section.

Sonographic demonstration of bladder-flap hematoma.

A bladder-flap hematoma is generally thought of as a blood collection in a potential space located between the urinary bladder and lower uterine segment (vesicouterine space). These collections can also extend over the bladder and uterus beneath the peritoneal reflection. In this study, ten patients with a bladder-flap hematoma were evaluated for fever, mass, or dropping hematocrit after surgery. No one sonographic appearance is specific for bladder-flap hematoma; however, the diagnosis can be made by finding a mass in the extraperitoneal pelvic space in the postoperative patient.

Sonography of post-cesarean-section bladder-flap hematoma.

A bladder-flap hematoma is an unusual complication of a lower-uterine transverse cesarean section. As a result of bleeding at the incision site, a hematoma forms between the bladder and lower uterine segment. The clinical, sonographic, and surgical findings in seven patients with this complication are described. In all, sonography showed a solid or complex mass of varying sizes interposed between the posterior bladder wall and the anterior uterine wall. Differentiation of a hematoma from an infected hematoma/abscess can be difficult, but the presence of air in the mass strongly suggests the latter. Sonography can detect this complication easily and accurately, and therefore significantly focus and guide therapy.