GYNOB1 Massive pubic symphysis separation following vaginal delivery causing retroperitoneal and vulvar hematomas. (Gynecology & Obstetrics).

GYNOB1 MASSIVE PUBIC SYMPHYSIS SEPARATION FOLLOWING VAGINAL DELIVERY CAUSING RETROPERITONEAL AND VULVAR HEMATOMAS. T. M. Hough, MD, D. Y. Parker, MD, D. G. Gallup, MD, and J. J. Burke II, MD. Mercer School of Medicine (Savannah), Memorial Health University Medical Center, Savannah, Ga.

Pubic symphysis separation is a rare clinically apparent complication of vaginal delivery, treated conservatively when diagnosed. A 32-year-old woman, gravida 4, para 2, abortion 1 at 40 3/7 weeks' gestation presented for induction of labor because of suspected fetal macrosomia. Her labor and delivery were rapid, resulting in the delivery of a viable male weighing 4695 grams over a second degree midline episiotomy. Several hours after delivery, the patient began complaining of severe rectal pain which radiated to the legs bilaterally. Examination revealed an expanding left labial hematoma, prompting evaluation in the operating room. Examination under anesthesia revealed the left vulvar hematoma and a large right para vaginal mass. An exploratory laparotomy was perfomed demonstrating a large right broad ligament and retroperitoneal hematoma communicating with the left vulvar hematoma across the Space of Retzius. A 4.5 cm symphysis separation had lacerated multiple periurethral veins resulting in hemorrhage. Th e patient received 6 units of packed red blood cells for the estimated 3 liter blood loss. Postoperatively, the symphysis separation was managed conservatively with bracing and physical therapy. However, continued pain with ambulation prompted open reduction and internal fixation. While pubic symphysis separation is a rare complication of vaginal delivery, development of a large vulvar/pelvic hematoma as a result had not been previously reported. Careful examination is warranted in any patient suspected to have symphysis separation following a vaginal delivery with special attention to concealed vulvar/pelvic bleeding.