Large supralevator haematoma: a dilemma in diagnosis and management

This is a case of postpartum haemorrhage following vaginal delivery of a primigravida in her late 20s resulting from a supralevator haematoma. She delivered in a low-resource hospital setting, with a late diagnosis of severe pre-eclampsia and haemolysis, elevated liver enzymes and low platelet count (HELLP), subsequently developed traumatic postpartum haemorrhage and vaginal haematoma, and was referred to our hospital for further management. She was constantly monitored, and serial ultrasonography revealed an expanding paravaginal haematoma. CT, 4 hours after admission, showed a large ill-defined collection with hyperdense areas of blood attenuation measuring ~8.0×6.2×12.2 cm in toto in the vaginal canal and right paravaginal region with supralevator extension, abutting the rectum posteriorly. The expanding haematoma caused gradual hypovolaemic shock, and hence, she was taken up for vaginal evacuation of supralevator haematoma with drainage tube insertion under ultrasound guidance. She received multiple blood product transfusion. Drain tube was removed on postoperative day 3. Follow-up scan was done and resolving haematoma noted. The patient was discharged on postoperative day 5 in a stable condition. She was followed up in outpatient department, and there was complete resolution of haematoma by 4 weeks.