The Post-Cesarean Section Symptomatic Bladder Flap Hematoma: A Modern Reappraisal

Written By: Sam Savage

Published Date: October 21, 2007 Last Edited: October 21, 2007

By Malvasi, A Tinelli, A; Tinelli, R; Rahimi, S; Resta, L; Tinelli, F G

Abstract The bladder-flap hematoma (BFH) is an unusual complication of the cesarean section (CS) performed by Misgaw Ladach method or Stark CS (performed without peritoneal closure) and it is an usual event after the visceral peritoneal closure performed during the traditional method. A BFH is generally thought of as a blood collection located in a space placed between the bladder and lower uterine segment (LUS), called vescico-uterine space. If, during a Stark CS, pathological fluid collections arise in this space by uterine suture bleeding, these decant into the large peritoneal cavity causing a hemoperitoneum. This last complication can be easily and accurately detectable by ultrasonography, which can be utilised by non-invasive monitoring as a guide for the clinical follow-up. In the authors’ experience, the CS by Stark method is associated with a lower febrile and infective morbidity and it is possible also to perform a successful conservative laparoscopy for the BFH management. Laparoscopical treatment of BFH offers to patients the potential clinical benefits of the minimally invasive endoscopical treatments, but it should be reserved for surgeons trained in extensive laparoscopic procedures.

Keywords: Bladder flap hematoma, cesarean section, Retzius space, ultrasonography, laparoscopy

Introduction

The bladder-flap hematoma (BFH) is an unusual complication of the cesarean section (CS) performed with Misgaw Ladach method or Stark CS, performed without peritoneal closure and it is a usual event after the visceral peritoneal closure performed during the traditional CS technique; when bleeding occurs at the laparotomical incision site, a hematoma arises between the bladder and lower uterine segment (LUS).

A BFH is generally thought of as a blood collection in a potential ‘pocket’ located between the bladder and LUS, called vescico-uterine space [1-4].

In a Stark CS, performed by not suturing the visceral peritoneum, the vescical-uterine space communicates with the large peritoneal cavity [3]; if, during a Stark CS, pathological fluid collections arise in this space, by uterine suture bleeding, because the visceral peritoneum is not sutured, these blood collections decant from the vescicouterine space into the large peritoneal cavity, causing a hemoperitoneum.

When the postoperative hemostasis is inadequate after the hysterorrafia, a sub-fascial hematoma (SFH) may arise between the bladder and the LUS; the SFH in the closed parietal peritoneum is limited in the Retzius space and it can be detected by ultrasonographic (US) examination as a solid area or a complex mass with clean walls and reinforcement of the distal echoes [5].

The flap hematoma is either closed to the incision site of the LUS, or covered, during surgery, by a fold on the incised, reflected and re-approximated peritoneum.

The SFH can be easily and accurately detectable by US, which can be utilised either by non-invasive monitoring or as a guide for the clinical follow-up; the post-CS BFH is an unusual complication, its frequency is unsteady and so is the treatment.

The aim was to study the post-CS BFH, by diagnostic imaging, in some patients; so the post-CS necrosis and dehiscence of the uterine incision sites were evaluated on seven women by computed tomography (CT), US and Magnetic Resonance Imaging (MRI). In these patients we detected two possible cases of BFH by CT, but conclude that MRI may be superior to CT in evaluating complications at the uterine incision site, because of its multiplanar capability and greater degree of soft tissue contrast [6].

In another scientific report, over a 67-month observation period, some authors founded, by MRI examination, in 50 patients with persistent low-grade fever following CS, 64% of BFH and concluded that BFH occurred in slightly more than half of the cases [7].

The bladder-flap haematoma: An appraisal

The post-CS BFH surgical treatment, reported in scientific literature, include: percutaneous drainage of febrile BFH, surgical transvaginal evacuation, laparotomical BFH evacuation, and laparoscopical drainage.

A study of Winsett et al. [8] included 10 patients with a bladder- flap hematoma that were evaluated for fever, mass, or dropping hematocrit after surgery. These collections can also extend over the bladder and uterus beneath the peritoneal reflection. No one US appearance was specific for BFH; however, the diagnosis can be made by finding a mass in the extraperitoneal pelvic space in the postoperative period.

In a report by Wiener et al. [9], subfascial hematomas were found in 12 (38%) of 32 patients referred for US evaluation of a fever or a fall in hemoglobin that occurred after a cesarean delivery. In all cases, sonography revealed cystic or complex masses of various sizes, beside the bladder.

Seven of the 12 patients had concomitant BFH between the LUS and posterior bladder margin. They concluded that distinction of subfascial hematomas (SFHs) from BFHs and superficial-wound hematomas must be made only if surgical evacuation is contemplated [9].

In another report, by Baker et al. [10], the uterine incision site was prospectively studied with US in 36 asymptomatic patients, 2 days after CS. The findings were compared with those seen in 21 symptomatic, post-CS patients. In the asymptomatic patients, the incision site was visualized as an oval symmetric region of distinct echogenicity interposed between the LUS and the posterior wall of the bladder. In eight of the 36 asymptomatic patients, a small round hypoechoic mass (less than 1.5 cm) was present in or adjacent to the uterine incision and it was distinct from the normal incision. These probably represented insignificant hematomas. Of the 21 symptomatic patients, 17 had either a SFH, a BFH, or endometritis. Significant BFHs were characteristically round, greater than 2 cm masses asymmetrically placed in or adjacent to the uterine incision. They concluded that, by using US, the normal appearance of the LUS can be distinguished from significant hematomas [10].

Woo et al. [11], on 14 patients who had CS with a subsequent fever, reported 13 BFHs by MRI examination; Lev-Toaff et al. [12], on 31 patients with a post-CS fever, found four hematomas either with MR or by US, and one of these required laparotomical treatment.

Achonolu et al. [13] used percutaneous drainage of collections in seven febrile post-CS patients with bladder flap hematoma; patients whose fevers are refractory to antibiotics frequently have pelvic blood collections.

The development of sophisticated imaging techniques has led to the frequent use of percutaneous drainage in the management of abdominal collections, hematomas were the most common collections associated with post-CS infections, and percutaneous drainage was a useful technique for obtaining material for culture and for distinguishing hematomas from abscesses.

In their study, most patients defervesced shortly after percutaneous drainage [13].

Six post-CS hematomas were identified: one in a patient with uterine hemorrage and DIG (diffuse intravascular coagulation) treated post-cesarean hysterectomy and one with a large BFH, treated with transvaginal evacuation of the pelvic hematoma; moreover they describes two patients with broad ligament hematomas.

The non-invasive instrumental differentiation between a simple hematoma and an infected hematoma or abscess can be difficult, but the presence of air inside it gives an evidence for the latter; the hemorrhage usually is confined by the overlying peritoneum but it may spread laterally along the broad ligaments into the retro peritoneum.

In our experience the non closuring of visceral peritoneum during a CS, is associated with a lower febrile and infective morbidity, in accordance to report of Cochrane review and other authors.

If a BFH succeeds, it is possible also to perform a successful conservative laparoscopy to treat and resolve this complication [14- 17]; so, by our experience, we report three cases of BFH, both treated by laparoscopy.

The bladder-flap hematoma: A modern minimally invasive surgical treatment

The first case concerns a 36 year-old females third pregnancy, with a BMD (body mass index) of 28 and a mean bloody pressure of 120 mmHg, submitted to a CS.

The CS was performed with the traditional technique and the visceral peritoneum was closed; the newborn weight was 3150 g with an Apgar score of 9, at 1 minute and 10 at 5 minutes; in the 4th post-operative day, the patient showed lower abdominal pain and anemia (hemoglobin of 7.2 mg/dl).

The ultrasound trans-abdominal examination (UTAE), carried out by a 5 MHz transvaginal transducer (Aloka SSd 2000 MultiView, Tokio, Japan) and performed by two experienced physicians, showed the presence of a BFH of 73 x 67 mm (Figure 1).

The post-operative follow-up was performed by UTAEs for 65 non- consecutive days, for evaluating of the BFH dimension and evolution and, during this period, the patient showed: disurya, persistent lower abdominal pain, and fever (38.7[degrees]C).

The patient immediately recovered and was treated by antibiotic therapy (cefoxitin 2 g intravenously) plus tobramicine (160 mg/ daily) for 10 days, but no important improvement was observed and the patient was submitted to a laparoscopic treatment.

The second case concerns a 39 year-old womans second pregnancy without general risk factors, with a BMD of 27 and a mean blood pressure of 115 mmHg, submitted to a CS. The CS was performed by the traditional method, suturing the visceral peritoneum; the weight of the newborn was 3700 g, with an Apgar score of 7 at 1 minute and 10 at 5 minutes; in the 3rd post-operative day, the patient showed anemia (hemoglobin of 8.4 mg/dl).

Figure 1. Pre-operative trans-abdominal ultrasonography that shows a solid area or a complex mass with the clean walls and reinforcement of the distal echoes (BFH).

In agreement with the patient, the post-operative follow-up was performed, as in the first patient, by serial UTAEs in 85 days and, at during this period, the patient was treated by endoscopy, and operative laparoscopy, for persistent lower abdominal pain and fever (38.9[degrees]C).

Then the patient recovered and was treated by antibiotic therapy (cefoxitin 2 g intravenously) plus tobramicine (160 mg/daily) for 13 days, but no important improvement was observed and the patient was submitted to a laparoscopic treatment.

In the third case, a 29 year old females first pregnancy, without general risk factors, with a BMD of 25 and a mean bloody pressure of 105 mmHg, was submitted to CS by traditional method too, suturing the visceral peritoneum; the newborn weight was 2800 g, with an Apgar score of 9-10 at 5 minutes; in the 4th post-operative day, the patient showed an heavy anemia (hemoglobin of 6.5 mg/dl), without clinical signs of compromising.

In agreement with the patient, the post-operative follow-up was performed, as in the first patient, by serial UTAEs in 35 days and, at during this period, the patient was treated laparoscopically for persistent fever (38.4[degrees]C).

As in the above patients, the patient recovered and was treated by an antibiotic therapy (cefoxitin 2 g intravenously) plus tobramicine (160 mg/daily) for 9 days, but no important improvement was observed and, in agreement with the patient, she was submitted to a laparoscopy.

All the laparoscopical treatments were performed by standardized methods, described as follows: the entire procedures were performed through operative laparoscopy and all patients had antibiotic prophylaxis (cefoxitin 2 g intravenously) and perioperative low molecular weight enoxaparin (40 mg/24 h subcutaneously) administration.

The patient was usually placed in the dorsolithotomy position, with the legs in universal Alien stirrups; the vaginal cavity was cleaned with povidone-iodine solution and a Foley catheter was placed in the bladder, after an application of intraoperative lower extremity sequential compression devices for venous thrombosis prophylaxis.

All procedures were performed under general endotracheal anesthesia; an orogastric tube was inserted by the anesthesiologist to decompress the stomach and it was removed at the end of the operation. After a carbon dioxide pneumoperitoneum by Veress needle (Auto-Suture(TM), Norwalk, CT) induced at the level of umbilicus, a 10 mm diameter trocar (Wolf(R); Richard Wolf, Knittlingen, Germany) that incorporates the zero-degree laparoscope (Karl Storz, Tuttlingen, Germany) was inserted through a supraumbilical vertical incision and the entrance into the abdominal cavity was made under direct visualization (Visual Access method); then the laparoscope was connected to a video monitor and a digital DVD recording, for all the operation time.

Once the umbilical trocar had been safety introduced into the abdominal cavity, the intra-abdominal pressure was maintained at 15 mmHg, to avoid embolie complications.

Three supra-pubic ancillary trocars were placed in the following way: one 5 mm diameter trocar was inserted in the midline, 3 cm under the umbilicus, and one in each iliac fossa (5 mm diameter on the left side and 10 mm diameter on the right size), laterally to inferior epigastric vessels. Before the operative procedure, all the pelvic structures were inspected and the abdomen explored through the laparoscope in a clockwise fashion.

In the first case, the pelvic-abdominal inspection showed an 8 cm left tumescence between the posterior bladder wall and anterior lower uterine body, as described by UTAE, so we proceeded in the following way: by a transversal incision of 2 cm by bipolar forceps, we decollated the bladder wall from the BFH, then performed some biopsies of the borders and drained the purulent material with macroscopic abscess characteristic, inside the collection (Figure 2).

Figure 2. Laparoscopical incision of BFH.

Once time exposed the cavity surface of BFH, we washed it by povidone-iodine solution and, at the end of the procedure, we placed a catheter inside the pelvis for drainage; the total operative laparoscopical time was of 35 minutes, with small blood loss (

The final histological examination of BFP and its borders showed purulent material with an abscess pseudo capsule (Figure 3).

The woman was discharged after 72 hours and the post-operative UTAE in the 3rd post-operative day showed an important reduction in size of the precedent uterine scare collection (Figure 4).

In the second case, the pelvic-abdominal inspection showed a 9 cm right tumescence between the posterior bladder wall and anterior uterine wall; so we proceeded as in the first case: we decollated the posterior bladder wall from the BFH, by a transversal incision of 2 cm by bipolar forceps, then performed some biopsies and drained the fluid material (with abscess characteristic too), inside the collection, washing it by polivinilpirrolidone solution, diluted at 20% and sutured its border by some vicryl 2-0 singular stenches, for a marsupialization (Figure 5).

Figure 3. Histological examination of BFH: purulent material.

Figure 4. Pre-operative trans-vaginal ultrasonography that shows a transversal section of uterus, BFH and LUS.

As in the first case, the final histological examination of BFP and its borders showed purulent material with an abscess pseudo capsule (Figure 6).

At the end of laparoscopy we placed a catheter inside the pelvis for drainage; the total operative laparoscopical time was 25 minutes, with small blood loss (

The patient was discharged after 48 hours and the post-operative UTAE showed an important reduction of the collection.

In the third patient, the laparoscopical inspection showed a 7 cm right tumescence between the posterior bladder wall and anterior uterine wall, as described by UTAE.

Figure 5. Drainage of bladder flap hematoma by laparoscopy.

Figure 6. Histological examination of BFH: numerous inflammatory cells prevalently composed of neutrophil granulocytes.

We proceeded by decollating the posterior bladder wall from the BFH after a transversal incision of 2 cm by bipolar forceps, performed some biopsies, and drained the abscess and washed it.

Finally we sutured the borders of the surgically traumatized area (Figure 5); as in the other cases, the final histological examination of BFP showed purulent material with an abscess pseudo capsule (Figure 6).

Conclusion

The scientific literature on surgical treatment of a symptomatic post-CS BFH include various procedures: percutaneous drainage of febrile BFH, surgical trans-vaginal evacuation, laparotomical evacuation and laparoscopic drainage.

Hence, because of its safety, laparoscopy is an effective and suitable method for management of BFH and it expands the spectrum of minimally invasive surgical procedures for the treatment in this puerperal complication. Up until now, not much evidence has been described in scientific literature on BFH minimally invasive treatment, so it needs several other studies or surgical reports to show the possibilities and the advantages of various surgical opportunities in BFH treatment.

Laparoscopical treatment of BFH offers to patients the potential clinical benefits of the minimally invasive treatments, but it should be reserved for surgeons trained in extensive laparoscopical procedures.

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A. MALVASI1, A. TINELLI2, R. TINELLI2, S. RAHIMI3, L. RESTA4, & F. G. TINELLI2

1 Department of Obstetrics and Gynaecology, Santa Maria Hospital, Bari, Italy, 2 Department of Obstetrics and Gynaecology, Vito Fazzi Hospital, Lecce, Italy, 3 Department of Pathology, Ospedale San Carlo-IDIIRCCS, Rome, Italy, and 4 Department of Pathology, University Medical School of Bari, Italy

(Received 11 February 2007; revised 21 February 2007; accepted 3 April 2007)

Correspondence: Dr Antonio Malvasi, Department of Obstetrics and Gynecology, ‘Santa Maria’ Hospital, Via A. De Ferraris 18-D, 70124 Bari, Italy. Tel: +39/336/824085. E-mail: [email protected]

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