Pelvic Hematoma - Short Notes

• Blunt trauma with pelvic fracture (most common) - high-energy mechanisms (RTA, fall from height, crush injury)
• Penetrating pelvic/buttock trauma with vascular injury
• Bleeding disorders / anticoagulation
• Post-arteriography or catheterization puncture site bleeding
• Post-surgical (prostatectomy, pelvic surgery) - "perivesical pelvic hematoma"
• Obstetric hemorrhage (postpartum pelvic hematoma)

• The pelvis has a large retroperitoneal potential space (up to several liters) that can tamponade venous bleeding but also conceal massive blood loss without external signs.
• Most bleeding in pelvic fracture is venous (presacral venous plexus) rather than arterial, though arterial injury (superior gluteal, internal pudendal, obturator branches) causes more rapid, severe hemorrhage.
• Classified anatomically as a Zone 3 retroperitoneal hematoma (pelvic zone) in trauma zone classification - usually left unexplored/undisturbed in blunt trauma (tamponade effect) but explored in penetrating trauma - Sabiston Textbook of Surgery.
• "Open-book" pelvic fractures (widened symphysis/SI joints) increase pelvic volume and are especially associated with large hematomas - Roberts and Hedges' Clinical Procedures.

• Hemodynamic instability / hemorrhagic shock out of proportion to visible injury
• Perineal, scrotal, or vulvar/vaginal ecchymosis
• Scrotal hematoma (Destot's sign) - suggests pelvic fracture
• Pain, tenderness, instability on pelvic compression (avoid repeated exam - can dislodge clot)
• Rectal exam: boggy mass, indistinct landmarks, or a high-riding/displaced prostate ("pear-shaped bladder" sign on cystography from bladder displacement)
• Leg length discrepancy/rotational deformity may indicate associated fracture
• Large hematomas can compress the lumbosacral plexus causing lower-extremity neurologic deficits (plexopathy) - Bradley and Daroff's Neurology in Clinical Practice

• FAST exam (limited for retroperitoneal blood - open peritoneal lavage technique used above umbilicus in pelvic fracture to avoid false-positive from hematoma decompression)
• CT with IV contrast/CT angiography - imaging of choice; look for arterial blush or contrast extravasation indicating active arterial bleeding
• Retrograde cystography - "pear-shaped" bladder displacement suggests hematoma
• Angiography if CT shows large hematoma or blush - for localization and embolization

1. Resuscitation: ATLS principles, massive transfusion protocol as needed
2. Mechanical stabilization: pelvic binder/external fixation to reduce pelvic volume and tamponade venous bleeding - first-line in unstable patients
3. Angioembolization: for arterial bleeding source identified on CT/angiography
4. Preperitoneal pelvic packing: for ongoing hemodynamic instability, especially when angiography unavailable or as an adjunct
5. REBOA (resuscitative endovascular balloon occlusion of the aorta) - increasingly used bridge to definitive hemorrhage control in extremis
6. Avoid unnecessary surgical exploration of the hematoma itself in blunt trauma - disturbing it can release tamponade and worsen venous bleeding (Smith and Tanagho's General Urology; Campbell-Walsh Urology)
7. Surgical exploration reserved for penetrating injury or ongoing instability despite the above

• Hemorrhagic shock, coagulopathy
• Infection of hematoma (pelvic abscess), especially if communicating with ruptured bladder/urine
• Lumbosacral plexopathy
• Chronic bladder neck contracture if hematoma drains through urethrovesical anastomosis post-surgery
• Compartment-like pressure effects on adjacent viscera

Pelvic Hematoma - MS OBG Short Notes

Definition

Classification (by site) - key exam point

1. Vulval hematoma - below the pelvic fascia, involves vessels of vulva/perineum (branches of pudendal artery); presents early, visible, very painful
2. Vaginal/paravaginal hematoma - between vaginal mucosa and levator ani fascia; can track upward
3. Supralevator (subperitoneal/broad ligament) hematoma - above the pelvic diaphragm, extends into the broad ligament or retroperitoneum; can be concealed and cause massive occult blood loss - most dangerous type
4. Alternative classification: Infralevator (vulvar/vaginal - below levator ani) vs Supralevator (broad ligament/retroperitoneal - above levator ani)

Etiology / Risk Factors

• Operative vaginal delivery (forceps, vacuum)
• Prolonged or precipitate labor
• Episiotomy/perineal or vaginal lacerations, especially inadequate hemostasis at repair
• Macrosomic fetus, multiple gestation
• Pre-eclampsia, coagulopathy, vascular fragility
• Varicose veins of vulva
• Cesarean delivery - uterine artery/branch injury causing broad ligament hematoma
• Nulliparity

Clinical Features

• Vulval hematoma: sudden severe perineal/vulval pain out of proportion to delivery, tense tender bluish-purple swelling, may be visible immediately postpartum
• Vaginal hematoma: pelvic pressure/pain, rectal pressure, difficulty voiding; may be missed on external exam - requires vaginal exam
• Supralevator/broad ligament hematoma: often presents with signs of hypovolemic shock (tachycardia, hypotension) without visible external bleeding - a classic exam trap. Abdominal pain, distension, mass may be palpable on abdominal or bimanual exam. Rectal exam may reveal a bulging mass with displaced cervix/uterus.
• General: disproportionate drop in hemoglobin/hematocrit relative to observed blood loss

Diagnosis

• High index of suspicion in any postpartum patient with pain, shock, or falling hematocrit without obvious external bleeding
• Careful vaginal and rectal examination under adequate lighting/anesthesia if needed
• Ultrasound or CT to assess extent, especially for suspected retroperitoneal/broad ligament extension
• Serial hemoglobin/hematocrit, coagulation profile

Management

• Small, non-expanding hematoma (<5 cm, stable): conservative - ice packs, analgesia, close observation, serial exam, bladder catheterization if needed
• Large, expanding, or symptomatic hematoma / hemodynamically unstable patient: surgical evacuation
  • Incision and drainage of the hematoma cavity
  • Evacuate clots, identify and ligate bleeding vessel(s) - though diffuse venous oozing (rather than a discrete bleeder) is more commonly found
  • Achieve hemostasis with figure-of-8 sutures, electrocautery, or packing
  • Pack the vagina (not the hematoma cavity itself) or apply vulval pressure dressing to prevent recollection; leave a drain in the cavity if evacuated
  • Foley catheter for bladder drainage
• Broad ligament/retroperitoneal hematoma not accessible vaginally, or continued instability: laparotomy, uterine/internal iliac artery ligation, or interventional radiology with angioembolization
• Correct coagulopathy, blood/component transfusion as indicated
• Broad-spectrum antibiotics often given to prevent secondary infection of the hematoma

Complications

• Hemorrhagic/hypovolemic shock (can be rapid and severe with concealed supralevator hematomas)
• Infection/abscess formation within the hematoma
• Recurrent bleeding after evacuation
• Injury to adjacent structures (bladder, ureter, bowel) during drainage - caution due to anatomical proximity
• Anemia, prolonged hospital stay
• Rarely, DIC if massive concealed hemorrhage goes unrecognized

Exam pearls

• Always think of a concealed pelvic/broad ligament hematoma in a postpartum patient with unexplained tachycardia/hypotension and no external bleeding.
• Vulval hematomas are the most common and most easily diagnosed (visible); supralevator ones are the most dangerous because they are occult.
• Management principle: small/stable = conservative; large/expanding/unstable = surgical evacuation ± vaginal packing ± angioembolization for refractory cases.

Complications of Radiotherapy - MS OBG Short Notes

Classification - Acute vs Late (key exam framework)

A. Acute/Early Complications (during or within weeks of treatment)

• Skin: erythema, desquamation, dermatitis over treatment field
• GI: nausea, vomiting, diarrhea, acute radiation enteritis/proctitis (self-limited; severity does not predict chronic disease - Schwartz's Principles of Surgery)
• GU: acute cystitis - dysuria, frequency, hematuria
• Hematologic: bone marrow suppression - leukopenia, thrombocytopenia (more with pelvic RT due to marrow-containing bones)
• General: fatigue, anorexia
• Vulvovaginal: mucositis, vaginal discharge

B. Late/Chronic Complications (months-years later) - most exam-relevant for OBG

Gynecologic/Reproductive

• Vaginal stenosis, fibrosis, dryness, shortening - leads to dyspareunia and sexual dysfunction; managed with vaginal dilators, topical estrogen, pelvic floor physiotherapy (Berek & Novak's Gynecology)
• Premature menopause/ovarian failure - dose-dependent; ~600 cGy can induce menopause in women ≥40 years; adolescents need ~2000 cGy fractionated for similar effect (Creasy & Resnik's Maternal-Fetal Medicine)
• Infertility - if ovaries not transposed/shielded prior to RT
• Uterine effects: reduced uterine volume, impaired endometrial receptivity, increased risk of miscarriage, preterm birth, and placental abnormalities in survivors who conceive later

GI Tract

• Chronic radiation enteritis/proctitis: bowel wall fibrosis, strictures, malabsorption, chronic diarrhea, rectal bleeding from telangiectasias; can require transfusion; refractory cases have high morbidity (Goldman-Cecil Medicine)
• Rectovaginal fistula - late complication, may need Martius flap or bowel repair (Berek & Novak's Gynecology)
• Bowel obstruction from adhesions/strictures

Genitourinary Tract

• Radiation cystitis: chronic hematuria, bladder fibrosis, reduced bladder capacity
• Vesicovaginal fistula (VVF): cervical, vaginal, and endometrial carcinoma together account for a significant proportion of VVF cases from RT (Campbell-Walsh Urology)
• Ureteral stricture / ureteroarterial fistula - risk factor is prior pelvic RT, especially with indwelling stents
• Rectourethral fistula (more relevant in male pelvic RT)

Vascular/Soft Tissue

• Pelvic vessel fibrosis and stenosis
• Lymphedema (from lymphatic fibrosis, worse if combined with lymphadenectomy)
• Soft tissue/bone: osteoradionecrosis (more classically pubic bone/sacrum in pelvic RT)

Other Systemic

• Secondary malignancy in the irradiated field (long-term risk, e.g., secondary sarcoma, bladder/rectal cancer)
• Skin: chronic fibrosis, telangiectasia, pigment changes

Management Principles (short exam points)

• Vaginal stenosis: regular dilator use (start once acute mucositis resolves), lubricants, topical/vaginal estrogen, pelvic floor physiotherapy
• Radiation proctitis/enteritis: sucralfate, argon plasma coagulation for bleeding telangiectasias, ACE inhibitors/statins shown to reduce acute GI symptoms during pelvic RT, surgery reserved for strictures/fistulas refractory to medical management
• Cystitis: hydration, hyperbaric oxygen for hemorrhagic cystitis, cystoscopic fulguration if bleeding
• Fistulas (VVF/RVF): often need delayed surgical repair (e.g., Martius flap) once inflammation subsides
• Ovarian failure/infertility prevention: ovarian transposition (oophoropexy) before pelvic RT in women wishing to preserve fertility/ovarian function
• Bone marrow suppression: monitor CBC, dose modification/breaks if severe

Exam pearls

• Acute toxicity severity does not predict chronic complication risk (important distractor).
• Vaginal stenosis and premature menopause are the two complications most specific to OBG practice.
• Fistulas (vesicovaginal, rectovaginal) are late complications, typically presenting months to years after treatment, and require multidisciplinary surgical management.
• Ovarian transposition is the key preventive strategy to discuss for fertility preservation before pelvic RT.