A 30-year-old woman, gravida 1 para 0, is admitted to the hospital in active labor and undergoes a forceps-assisted vaginal delivery due to recurrent late fetal heart rate decelerations. The patient delivers a 4.2 kg (9.3 lb) infant with Apgar scores of 7 and 9 at 1 and 5 minutes, respectively. An hour after delivery, the patient begins to feel dizzy and lightheaded. She has no chest pain or shortness of breath and has had no loss of consciousness. Temperature is 37.2 C (99 F), blood pressure is 90/50 mm Hg, and pulse is 120/min. The patient appears pale and is diaphoretic. Cardiac examination shows sinus tachycardia but no rubs or murmurs. The lungs are clear to auscultation. The uterus is firm, nontender, and palpable at the umbilicus. On pelvic examination, there is minimal blood on the perineal pad. A large, purple mass protrudes medially into the vagina. Which of the following is the most likely diagnosis in this patient?

Question

A 30-year-old woman, gravida 1 para 0, is admitted to the hospital in active labor and undergoes a forceps-assisted vaginal delivery due to recurrent late fetal heart rate decelerations.  The patient delivers a 4.2 kg (9.3 lb) infant with Apgar scores of 7 and 9 at 1 and 5 minutes, respectively.  An hour after delivery, the patient begins to feel dizzy and lightheaded.  She has no chest pain or shortness of breath and has had no loss of consciousness.  Temperature is 37.2 C (99 F), blood pressure is 90/50 mm Hg, and pulse is 120/min.  The patient appears pale and is diaphoretic.  Cardiac examination shows sinus tachycardia but no rubs or murmurs.  The lungs are clear to auscultation.  The uterus is firm, nontender, and palpable at the umbilicus.  On pelvic examination, there is minimal blood on the perineal pad.  A large, purple mass protrudes medially into the vagina.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_da65_9536_bc81_0909feb2cefd_MD0003_00 This patient's hypovolemic shock and protruding vaginal mass is most likely due to a vaginal hematoma, a potentially life-threatening postpartum complication. During delivery, stretching of the vaginal canal can injure the uterine artery, particularly in nulliparous patients undergoing operative vaginal delivery (eg, forceps-assisted) or delivering an infant ≥4000 g (8.8 lb). The resultant injury can cause massive postpartum bleeding, as the uterine artery during pregnancy enlarges and supplies the uterus with up to 30% of total cardiac output. Because the blood collects in the paravaginal space (a large potential space), patients often have massive occult bleeding, evidenced only by hypovolemic shock (eg, hypotension, tachycardia, diaphoresis) initially. However, as blood continues to collect within the paravaginal tissue, patients can develop a protruding vaginal mass, often associated with rectal or vaginal pressure and minimal vaginal bleeding. Hematomas are managed based on hemodynamic stability and whether they continue to expand. Nonexpanding vaginal hematomas are observed whereas expanding hematomas require treatment (eg, arterial embolization, surgery). (Choice A) Amniotic fluid embolism is a rare obstetrical emergency causing rapid hemodynamic instability and pulmonary edema. This patient has no chest pain or shortness of breath and her lungs are clear to auscultation, making this diagnosis unlikely. (Choice B) A cervical laceration presents with heavy vaginal bleeding, not a vaginal mass. (Choice C) A retained placenta is associated with uterine atony (ie, enlarged, boggy uterus) and heavy vaginal bleeding, which is not seen in this patient with a firm uterus and minimal vaginal bleeding. (Choice D) Uterine inversion is a rare obstetrical emergency that can present with a vaginal mass, massive hemorrhage, and hypovolemic shock. This patient's uterus is firm and palpable at the umbilicus, making this diagnosis unlikely. Uterine inversion (Choice E) Uterine rupture is an obstetrical emergency due to uterine wall rupture (eg, patients with prior myomectomy). It is typically associated with severe abdominal pain and heavy vaginal bleeding, not seen in this patient. Uterine rupture Educational objective: Vaginal hematoma is a potentially life-threatening postpartum complication that presents with a vaginal mass and possible hypovolemic shock due to massive occult bleeding. References: Evaluation of risk factors in women with puerperal genital hematomas. (http://www.ncbi.nlm.nih.gov/pubmed/26043648) Vaginal hematoma during parturition: a population-based study. (http://www.ncbi.nlm.nih.gov/pubmed/15144338) Puerperal hematoma: a cause of postpartum hemorrhage after a normal vaginal delivery. (http://www.ncbi.nlm.nih.gov/pubmed/26185557) Selective arterial embolization as a first-line treatment for postpartum hematomas. (http://www.ncbi.nlm.nih.gov/pubmed/23344403)

A 30-Year-Old Woman, Gravida 1 Para 0, Is Admitted to the Hospital