uhrad.com - Women's Diagnostic Imaging

Case Fifteen - Factor II Deficiency With Vulvar Hematoma

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Clinical History: This is a 33-year-old woman with Factor 11 deficiency. The patient underwent uneventful vaginal delivery. The patient presented several days later with a large vulvar hematoma and vaginal bleeding. The patient was taken to the operating room where a right vaginal wall laceration was repaired and the vulvar hematoma was evacuated. However, the patient rapidly developed recurrent vaginal bleeding and a large hematoma occurred on the right and then spread to the left vulvar region. Emergent pelvic arteriography was therefore requested.

Findings: Nonselective AP pelvic arteriogram (Image 1) demonstrates marked enlargement of the vulvar and labial tissues bilaterally with downward stretching of the internal pudendal arteries. A rapid focus of contrast extravasation consistent with hemorrhage is seen in the distal left internal pudendal. Selective left internal pudendal arteriogram (Image 2) confirms this finding. This vessel and several of its distal branches were successfully embolized with platinum microcoils and stainless steel coils. Post embolization arteriogram (Image 3) demonstrates complete occlusion of the left internal pudendal artery without evidence of recurrent bleeding.

Diagnosis: Factor 11 deficiency with vulvar hematoma.

Discussion: Embolization of pelvic bleeding is commonly performed in two scenarios: Pelvic trauma and gynecologic malignancies. The only surgical approach to bleeding such as this would be ligation of the hypogastric arteries bilaterally. An angiographic approach permits specific identification of the bleeding artery and sub-selective catheterization and embolization of that vessel or vessels.

References:
Castaneda Zuniga WR. Interventional Radiology. Williams and Wilkins, 1992.

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Submitted by:
Peter B. Sachs, M.D.