(220) Clinical Predictors and Surgical Intervention in Postpartum Vaginal and Vulvar Hematomas: A Matched Case-Control Study

To identify risk factors for postpartum vaginal or vulvar hematoma and early clinical predictors of surgical intervention.

Study Design:

A retrospective matched case-control study was conducted at a tertiary, university-affiliated center (2012–2024). Women diagnosed with vaginal or vulvar hematoma (cases) during the postpartum hospitalization were matched 1:3 by maternal and gestational age to controls. Independent risk factors were identified using conditional logistic regression with a Cox regression model. A risk score was derived from the multivariable model, and ROC analysis assessed performance. A subgroup analysis evaluated predictors of surgery.

Results:

Among 147,045 deliveries, 57 women (0.039%) had postpartum hematoma; 170 matched controls were included. Diagnosis occurred 1.0 ± 1.6 days after delivery. Hematoma was associated with vacuum-assisted delivery (21.1% vs 4.7%, p< 0.001), episiotomy (24.6% vs 2.4%, p< 0.001), second-degree laceration (38.6% vs 15.3%, p< 0.001), nulliparity, and lower body mass index (BMI; p< 0.001). In multivariable analysis, episiotomy (OR 35.9, 95% CI 5.6–232.4), second-degree laceration (OR 10.3, 95% CI 3.2–32.9), and vacuum delivery (OR 5.0, 95% CI 1.0–24.5) independently increased risk, whereas higher BMI (OR 0.69/unit, 95% CI 0.55–0.85) and epidural analgesia (OR 0.33, 95% CI 0.12–0.93) were protective. The model’s AUC was 0.83; a score ≥3 yielded 68% sensitivity and 79% specificity. Among women with hematoma, 26.3% required surgery. Time to surgery averaged 6.5 ± 3.8 hours. Prolonged second stage (20% vs 2.4%, p< 0.05) was significantly associated with surgery, with trends toward more vacuum deliveries, no epidural, and greater hemoglobin decline. Postpartum hemorrhage and blood transfusion rates did not differ.

Conclusion:

Postpartum hematoma, though rare, follows a recognizable pattern. Vacuum-assisted delivery, episiotomy, second-degree laceration, and low BMI increase its risk, whereas epidural analgesia is protective. Early recognition may aid risk stratification, monitoring, and timely management.