Postpartal Pelvic Hemorrhage in a Patient with Hellp Syndrome Treated with Hemostatic Sponge

Case Report

A 21-year-old primigravida with a regular course of pregnancy and uneventful medical history came to the emergency obstetrics department at 39+4 weeks of pregnancy due to nausea, severe headache, epigastric pain, hypertension, and laboratory signs of HELLP syndrome (E 2.58, Hgb 90, Htc 0.253, Trc 106, AST 152, ALT 193, LDH 698, uric acid 379). On admission, blood pressure was 145/95 and 165/105 mmHg and proteinuria was moderate. Cervical dilatation was 4 cm and cardiotocography (CTG) was reactive. Amniotomy was performed and amniotic fluid was milky white. Soon after administration of oxytocin infusion and epidural analgesia, a lateral episiotomy was performed and a healthy male newborn, 3250/50, AS 10/10 was delivered. Early postpartum course was ordinary under the supervision of vital functions and antihypertensive therapy (Urapidil) and low-molecular-weight heparin. Due to severe headaches and nausea, magnetic resonance imaging (MRI) of the brain and an ophthalmological examination were performed indicating normal findings. The second day of puerperium, strong pain appeared at the episiotomy site and in the pelvis with the inability of flatus continence. Left pararectal and paravaginal hematoma was found and it was decided to perform surgical revision under general anesthesia. An organized hematoma, 9 cm in diameter, with diffuse bleeding from the levator muscles was found ([Fig. 1]). Revision of the episiotomy wound and evacuation of the hematoma were performed. Adequate hemostasis was achieved and drainage of the paravaginal space was placed. Tranexamic acid 1 g, crystalloid and colloid solutions and blood transfusion (3 units of erythrocyte concentrate) were administered. Two hours after the procedure, fresh bleeding occurred via the drainage system and did not stop with vaginal gauze tamponade compression. Laboratory findings showed anemia and thrombocytopenia with initial disseminated intravascular coagulopathy as a part of HELLP syndrome (E 2.60, Hgb 75, Htc 0.209, Trc 49, fibrinogen 3.0, D-dimer>4200, AST 312, ALT 135, LDH 510). Surgical wound revision was performed again; 1 g of tranexamic acid was repeatedly administered. Two units of red cell concentrate were administered preoperatively. Diffuse pararectal and paravaginal supralevator bleeding all the way to the promontorium was found. We placed several hemostatic sutures but with little success, so a hemostatic sponge was applied (Gelfoam®, Pfizer) and the bleeding stopped. The episiotomy wound was sutured and drainage connected to a negative pressure collection device was set in the pararectal space to control bleeding. Repeated laboratory findings improved (E 3.79, Hb 111, Htc 0,320, Trc 365, fibrinogen, 6.0, D-dimer levels>4200, AST 312, ALT 135, LDH 510) and there was no additional bleeding. Postpartum bladder atony resolved with administration of tamsulosin 0.4 mg for 5 days. Control MRI of pelvis indicated the state after hematoma evacuation and surgical wound revision with residual foreign body (sponge) ([Fig. 2]).

Fig. 1 Paravaginal pelvic hemathoma.

Fig. 2 MRI pictures of surgical sponge in tretament of pelvic hemorrhage.

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