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ULTRASONOGRAPHY FOR EVALUATION OF PELVIC HAEMATOMAS FOLLOWING VAGINAL HYSTERECTOMY
JIGNESH J KANSARIA*, SV PARULEKAR**, AS GUPTA***, AMIT PILANKAR+
*Lecturer; **Professor and Head; ***Associate Professor; +Third Year Resident, Department of Obstetrics and Gynaecology, Seth GS Medical College, KEM Hospital, Parel, Mumbai.
Study : A prospective study of 200 patients to assess role of ultrasonography in evaluation of pelvic haematomas following vaginal hysterectomy.
Aims : To Evaluate the pelvis, to detect pelvic haematomas, assess the importance of these haematomas in the postoperative period and their ideal management.
Results : 8% of patients were detected to have pelvic haematomas (all vaginal vault haematomas). 19% of the patients with pelvic haematomas developed post-operative morbidity. All patients with moderate and large size haematomas were drained vaginally. All small size (12) pelvic haematomas were managed by watchful expectancy successfully. All the pelvic haematomas were seen in patients who had undergone vaginal hysterectomy with vaginal repair.
Conclusion : Routine post vaginal hysterectomy ultrasound to evaluate for pelvic haematomas should be done in all patients undergoing vaginal hysterectomy with vaginal repair irrespective of being low risk for surgery.
INTRODUCTION
There are many applications of ultrasonography in gynaecology, although they are less crucial than in obstetrics. Primary use of ultrasonography in gynaecology is in evaluation of patients with adnexal masses. Role of ultrasonography in routine evaluation of post-hysterectomy patients is new and the role not well defined. The usual site for post hysterectomy pelvic haematoma formation is between the suture line of the vagina and the pelvic peritoneum i.e. vaginal vault haematoma.
SUBJECT AND METHODS
A prospective study was undertaken at Seth GS Medical College and KEM Hospital, during the period of 1999 to 2001 where 200 consecutive women who underwent vaginal hysterectomy for varying aetiological factors were subjected to transabdominal pelvic ultrasonography.
The ultrasonography was performed on day 4 post hysterectomy on full bladder, as the patient was well settled and ambulatory for ultrasonography examination. However, if the patient developed morbidity in any form then ultrasound examination was done earlier.
The aims of the study was to evaluate the pelvis and to detect pelvic haematoma, to assess the importance of these haematomas in the post-operative period, the need for drainage of these haematomas.
Those patients detected of having pelvic haematomas were subjected to follow up ultrasound scan at interval of 7 days. In our study, patients detected to have pelvic haematomas had only vaginal vault haematoma.
Patients with moderate and large size (1) haematomas were subjected to evacuation of haematoma. Patient with small sized haematomas (i.e. size of 2-3.9 cm) were observed for spontaneous resolution of the haematoma and development of any complications.
All patients who underwent hysterectomy were assessed preoperatively for presence of any high risk factors which includes hypertension, chronic intake of aspirin or other NSAIDs, ischaemic heart disease, anticoagulant therapy, diabetes mellitus, cerebrovascular disease, coagulation disturbance, chronic obstructive or restrictive lung disease, past history of vaginal surgery with local scarring including conservative surgery for prolapse.
Salient features of surgical technique of vaginal hysterectomy
Vaginal hysterectomy and in addition, anterior and posterior colporhhaphy where indicated was performed as per the routine steps. But additional important points to be emphasized are:
1. Liberal use of adrenaline saline infiltration; 1 in 3 lac dilution whenever not contraindicated.
2. Use of Na Ethamsylate injection (250 mg) intramuscularly where saline adrenaline infiltration was contraindicated.
3. Sharp dissection of the vaginal mucosa to open the anterior and posterior pouch in patients with past history of vaginal surgery and local vaginal scarring.
4. Use of electrocautery to cauterize the bleeders.
5. Taking free ties at all pedicles, achieving perfect, complete haemostasis at systolic BP of 90 mm Hg or more.
6. All residents doctors assisted by qualified doctors for all surgeries.
7. No use of oxidized cellulose.
8. No vaginal packing done postoperatively.
9. Patients with extensive pelvic dissection were given head low position for the first 24 hours postoperatively to decrease pelvic venous pressure.
TECHNIQUE OF VAGINAL VAULT HAEMATOMA DRAINAGE
Patients with moderate and large size haematomas were taken in the operation theatre for haematoma evacuation.
Under lithotomy position, with aseptic precautions, without anaesthesia, the central two sutures of chronic catgut were removed, which is followed by digital exploration and evacuation of haematoma. This was followed by hydrogen peroxide saline irrigation. In the ward, the patient was given head high position and hydrogen peroxide saline followed by povidone iodine solution (5%) douch twice a day for the next seven days. As pelvic peritoneum re-epithelializes by 24 hours, there is no risk of the hydrogen peroxide-saline-povidone iodine douch spilling into the peritoneal cavity.
OBSERVATIONS
The 200 patients who underwent vaginal hysterectomy (with vaginal repair) were assessed for various parameters.
Of the 200 patients who underwent vaginal hysterectomy 112 also underwent colporhhaphy for vaginal relaxation Table 1.
TABLE 1
Type of vaginal hysterectomy
52% of the patients underwent vaginal hysterectomy for genial prolapse. 6 out of 20 patients with fibroid uterus had a uterine size of 12 weeks, other 10 patients had a uterine size of 8-10 weeks, Table 2.
TABLE 2
Indications for vaginal hysterectomy (with vaginal repair)
24% of patients who underwent vaginal hysterectomy were hypertensive.
16% of these hypertensive patients developed pelvic haematomas of varying size. Hypertensive patients were at increased risk of developing pelvic haematomas, Table 3.16 patients (8%) were detected to have pelvic haematomas, all of which were vaginal vault haematoma, on routine post hysterectomy transabdominal pelvic ultrasonography.
TABLE 3
Correlation between the high risk factors and number of patients who developed pelvic haematomas
All the 16 patients with pelvic haematomas, had vaginal vault haematomas. All the vaginal vault haematomas were seen in patients who had undergone vaginal hysterectomy with vaginal repair. No pelvic haematomas were seen in patients who had undergone only vaginal hysterectomy, Table 4.
TABLE 4
Type of vaginal hysterectomy and vaginal vault haematomas
Nineteen per cent of patients with vaginal vault haematoma developed post operative morbidity. Post operative morbidity was assessed by the following parameters which includes post operative fever, drop in haemoglobin, need for blood transfusion, bleeding per vaginum, Table 5.
TABLE 5
Relationship of vaginal vault haematoma to postoperative morbidity
12 patients with small vaginal vault haematomas were managed by no active intervention (Table 6). Follow up scans were done weekly. Spontaneous resolution of the haematomas occurred at an average duration of 31 days.
TABLE 6
Relationship of the size of the haematoma, clinically symptomatic and clinical management
3 of 4 patients with moderate and large size haematomas had evidence of post operative morbidity and required vaginal drainage of the haematoma.[1] One patient with moderate size haematoma had no signs of post operative morbidity but for prompt recovery, haematoma drainage was done Table 6. Fig. 1 shows large vaginal vault haematoma on transabdominal pelvic ultrasonography.
Majority of these vaginal vault haematomas were encountered in surgeries done by junior resident doctors, Table 7. Though the resident doctors were all assisted, all time by consultants, it is likely that during assisting vaginal surgery, some part of surgical dissection at depth may escape close scrutiny.
TABLE 7
Relationship of vaginal vault haematoma to surgeon
DISCUSSION
A post-operative pelvic haematoma can cause serious morbidity, especially if it is large and becomes infected. Haematomas can develop along the vaginal vault, along the pelvic side wall, in the paravesical space, in the abdominal wall, in the ischiorectal fossa and vulva.[2]
The post-operative pelvic haematomas may give a varying clinical picture. Many patients may be asymptomatic whereas some may present with postoperative bleeding per vaginum (spotting to profuse bleeding per vaginum) postoperative discomfort, abdominal distension, paralytic ileus, continuous fever, foul smelling discharge per vaginum, abscess formation, tenesmus, nausea, vomiting, diarrhoea. This clinical presentation may be complicated by development of septicaemia, subsequently septic shock, acute renal failure, ARDS. Rarely rectovaginal fistula formation may also occur. Retching and straining after surgery increases the risk of pelvic haematomas. None of our patients with pelvic haematomas had any episodes of retching or straining in the early postoperative period.
In our study, 8% of the patients were identified by ultrasonography to have vaginal vault haematomas. Whereas, in a study by Thomas AJ et al 1998[1], 25% of the patients had a vault haematoma. In another study by Haines CJ et al 1995[3], 42.4% patients had vaginal vault haematoma on sonographic assessment.
In our study, 3 of the 16 patients (i.e. 19%) with vaginal vault haematoma developed post operative morbidity, all on day 3 post operative.
In a study by Thomson AJ et al 1998[1], incidence of febrile morbidity was 31% in patients with vaginal vault haematomas. In another study by Haines CJ et al 1995[3] there was no correlation between the presence of a collection and indices of postoperative morbidity. Ultrasonography is helpful in detecting and delineating its exact size and location of pelvic haematomas. An extended morbid and complicated post-operative course can be alleviated if the haematoma can be drained.[2] A simple drainage through the vaginal vault can be accomplished by probing with a sinus forceps, as was done in all the four cases in our study. In our study, all the four moderate and large size pelvic haematomas were drained vaginally followed by hydrogen peroxide - saline - povidone iodine douches twice a day for the next seven to ten days.
A small penrose drain may be inserted through the drainage tract and left in place for a day or so. If drainage cannot be achieved in this simple way, drainage with guidance of ultrasonography or if it fails then using computed tomography or through an abdominal incision may be necessary. If the haematoma can be drained, the patient’s recovery will be more prompt.[2]
In exceptional cases where drainage may be difficult or contraindicated and infection is not a serious problem, the haematoma may be allowed to gradually resolve over a few months. Unfortunately sometimes, a haematoma will not resolve completely but persists and continues to cause pain.[2] In our study, all the postoperative haematomas were situated in close proximity to the vaginal vault, hence vaginal drainage was possible. 12 patients with small vaginal vault haematomas were unlikely to cause postoperative morbidity and proved so. They were left alone with watchful expectancy and follow-up ultrasonography for resolution of the haematoma done weekly. Spontaneous resolution was noted in all the 12 patients with haematomas. A mean duration of 31 days was required for resolution of the haematoma. None of these 12 patients developed post-operative morbidity.
COMMENT
This study suggests that asymptomatic pelvic haematomas can be recognized by early postoperative ultrasound scan which are unlikely to be detected clinically. Most of these haematomas resolve spontaneously (small haematomas), though 19% (one fifth) of all haematomas (moderate and large size haematomas) may develop post-operative morbidity. Patients with high risk factors especially hypertensive and on prolonged aspirin intake were at more risk of developing vaginal vault haematoma. All the pelvic haematomas were seen in patients who had undergone vaginal hysterectomy with vaginal repair. Thus, this study enables one to follow up these patients with vaginal vault haematomas, plan out further line of management as per the size of the haematoma and prevent development of further complications.
CONCLUSION
All patients undergoing vaginal hysterectomy alone do not require to undergo routine postoperative pelvic ultrasound scan. But routine postoperative sonography of the vaginal vault on Day 3 to 5 should be done in all patients undergoing vaginal hysterectomy with vaginal repair, both low and high risk patients.
REFERENCES
1.Thomson AJ, Sproston AR, Farquharson RG. Ultrasound detection of vault hematoma following vaginal hysterectomy. Br Obstet Gynaecol 1998; 105 (2) : 211-5.
2.Te Linde’s Operative Gynaecology. JB Lippincott 8th edition, Pennsylvania. Control of Pelvic. Hemorrhage 1997; 197-232.
3.Haines CJ, Shan YO, Hung TW, Chung TK, Leung DH. Sonographic assessment of the vaginal vault following hysterectomy. Acta Obstet Gynecol Scand 1995; 74 (3) : 220-3.
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