Large Concealed Postpartum Supra Levator Pelvic Hematoma following an Uncomplicated Spontaneous Vaginal Birth - Successful Conservative Management of Supra Levator Component following Evacuation of Infralevator Paravaginal Hematoma

A primigravida of Asian origin, presented with a history of pre-labour rupture of membranes and abdominal pain at 37 weeks 6 days of gestation. Her BMI was 31, with an A-negative blood group and was diagnosed with Gestational Diabetes Mellitus (GDM) which was being managed with metformin. She developed gestational hypertension late in pregnancy, which was well controlled with Labetalol. She was also diagnosed to have Group B Streptococcus (GBS) colonisation of the vagina. Her labour progressed well and she had a normal spontaneous vaginal birth. Her immediate postnatal period was uneventful. After 3 hours of birth, the patient experienced pelvic pain and was diagnosed with a paravaginal hematoma. Examination under general anaesthesia with intra operative ultrasound was done. A lateral vaginal wall hematoma near right fornixes of 3- 4 cm was found and this was evacuated and haemostasis was achieved after the repair of the lateral vaginal wall. There were no cervical or vaginal lacerations. A vaginal pack was kept in situ for 12 hours and an indwelling bladder catheter was inserted for 12 hours. Intra-operative abdominal ultrasound scan revealed a pelvic haematoma with poorly defined margins. Hence, MRI of the pelvis with and without contrast was performed in the post-operative period and an occult large supra levator paravaginal hematoma (right vaginal forniceal hematoma with pelvic extension) was identified. The post-operative period was uneventful with a stable haemoglobin level and the patient was hemodynamically stable. Inputs from an interventional radiologist was obtained, and a joint decision was made for conservative management. Why this Case is Unique A spontaneous vaginal birth, with no traumatic tears, minimal blood loss, a normal Hb, but with 11.6 cm hematoma. A complete resolution occurred without the need for embolization.