Postpartum paravaginal hematoma and lower-extremity infection Ashwin Chatwani, MD, Todd Shapiro, MD, Amitabh Mitra, MD, Anna LevToaff, MD, and E. Albert Reece, MD Philadelphia, Pennsylvania We report a case of infection of the lower extremity after a normal vaginal delivery. The infection originated in an occult obturator internus muscle hematoma, and diagnosis was based on a clinical suspicion and characteristic findings on computerized tomography scan. These findings permitted prompt surgical drainage, debridement, and antibiotic therapy and resulted in a successful outcome. (AM J OSSTET GVNECOL

1992;166:598-600.)

Key words: Paravaginal hematoma, necrotizing fascitis Infection of the lower extremity is an extremely rare condition in obstetric patients. Retropsoal and subgluteal infections and necrotizing fascitis of the lower extremity have all been reported 12 in the obstetric literature. The origin of the infection is presumed to be a paravaginal hematoma. However, the actual presence of a paravaginal hematoma with subsequent abscess formation and spread through the pelvis into the lower

From the Departments of Obstetrics, G),llecology and Reproductive Sciences and Diagnostic Imaging, Temple Universit.~ School ofMedIClne. Received for publication MaJ 24, 1991; accepted August 4, 1991. Reprint requests: Ashwill Chatwani, MD, De/It. of Obstetrirs, Gynecology & Reproductive Sciences, Temple Ulliversity School orMedicille, 3401 N. Broad St., Philadelphia, PA 19140. 6/1/33042

extremity has never been previously demonstrated. Additionally, obturator internus muscle hematoma with or without infection has also not been reported previously in the absence of pudendal or paracervical block anesthesia. Hibbard et aU have described the possible route of spread of a paravaginal hematoma abscess. These routes may include a spread through the lesser sciatic foramen towards the hip joint or upward through the broad ligament through the pelvic sidewall. Failure to recognize this rare complication can be associated with severe morbidity or even death.

Case report F.j., a 27-year-old black woman, gravida 2, para I, with no significant past medical history was seen in the

Fig. 1. A CT scan of pelvis I week postpartum shows hematoma muscle deviating bladder (B) left.

(H)

of right obturator internus

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Paravaginal hematoma 599

Fig. 2. A (;T scan shows gas formation (arrows) in obturator internus muscle disseminating into subgluteal region.

labor and delivery suite at 41 weeks' gestation in spontaneous labor after an uneventful prenatal course. She was fully dilated with the vertex at + 1 station on admission. She had an uncomplicated normal delivery of a 9-pound female infant after a second stage lasting 1 hour, 5 minutes. No episiotomy was required nor did she receive perineal or pudendal block anesthesia. She had no vaginal or perineal lacerations noted at delivery. The patient was discharged home in satisfactory condition on the third postpartum day. The patient returned 1 week later complaining of shooting pains in the right buttock radiating down to the back of her thigh. The pelvic examination revealed tenderness along the right ischial spine area with fullness. A computed tomographic (CT) scan of the pelvis was done, which revealed a hematoma of the right obturator internus muscle extending towards the ischial spine (Fig. 1). Admission was recommended for evacuation of the hematoma but was refused by the patient. She returned 1 week later with severe pain in the right leg and inability to walk. Physical examination revealed a very ill patient in excruciating pain. Her temperature was 40.2° C. The right leg was swollen and tender with bullae present around the knee joint and lateral aspect of the thigh. A second CT scan was done, which showed a gas collection extending from the right obturator internus muscle into the subgluteal region (Fig. 2). The scout image from the second CT scan examination demonstrated a large amount of soft tissue gas in the subgluteal region extending into the thigh down to the upper calf (Fig. 3). The patient was started on ampicillin, gentamicin, and c1indamycin and was taken to the operating room where a fasciotomy of the right buttock, thigh, and leg was performed. l'iecrotic fascia and purulent material were noted to the level of the midcalf. After adequate drainage and debridement, the wound was left open.

Fig. 3. Scout film for (;T scan done 2 weeks postpartum shows gas formation around greater trochanter and disseminated down the leg (arrows).

Cultures of the pus revealed Escherichia coli and enterococcus. After multiple surgical debridements, antibiotic therapy, whirlpool treatment, and extensive physical therapy, the patient was discharged home on the sixty-first hospital day. At the time of discharge, she was fully ambulatory except for some residual discomfort and a slight limp.

Comment Infection or necrotizing fascitis of the lower extremity after delivery is a rare occurrence. The origin of

600 Chatwani at al.

this infection is presumed to be a paravaginal hematoma. This complication involving hematoma formation, subsequent infection, and spread to the lower extremity has only been reported with paracervical or pudendal block anesthesia. The present communication describes the first documented case of paravaginal hematoma with subsequent infection and extensions into the lower extremity after an uncomplicated delivery. The development of a paravaginal hematoma after spontaneous delivery can conceivably occur from rupture or laceration of the pudendal vessel as it courses through the obturator internus fascia. These patients usually remain asymptomatic for a varying period. The initial symptoms are often confused with an orthopedic problem resulting from pregnancy or delivery. In any paravaginal hematoma, infection can develop by penetrance of vaginal bacteria through small lacerations. Once the hematoma is infected, an abscess may develop. This abscess can extend along the fascia through the lesser sciatic foramen and then along the

February 1992 Am J Obstet Gynecol

course of the sciatic nerve down the leg. Alternatively, the infection can spread along the base of the broad ligament to the pelvic sidewall and then through the greater sciatic foramen along the course of the sciatic nerve. An early infection may respond to antibiotics, but, once the destructive abscess has developed and spread has occurred, incision and drainage with debridement of the necrotic tissue along with antibiotic therapy becomes necessary. This case presents a very rare complication of normal vaginal delivery. A postpartum patient with sciatic nerve-type pain should raise the suspicion of a paravaginal hematoma. Prompt investigation with a CT scan and immediate treatment will prevent complication as described herein.

REFERENCES 1. Lowthian JT, Gillard LJ. Postpartum necrotizing fascitis. Obstet Gynecol 1980;56:661-3. 2. Hibbard LT, Snyder EN, McVann RM. Subgluteal and retropsoal infection in obstetric practice. Obstet Gynecol 1972;39: 137-50.