Pelvic hematocele secondary to gynecological pathology

Specialty: Gynecology and breast.

• Blood collection in Douglas's cul-de-sac
• accumulated pelvic hemoperitoneum
• encapsulated pelvic blood

Why it occurs

• Tubal ectopic pregnancy rupture
• Rupture of a large-volume hemorrhagic luteal cyst
• Massive retrograde menstrual reflux (associated with cervical or vaginal obstructive malformations)
• Accidental uterine perforation during curettage or hysteroscopy
• Penetrating pelvic trauma or rupture of pelvic varicose veins

Initial workup

Rapid quantitative beta-hCG blood test (essential to absolutely rule out ruptured ectopic pregnancy). Urgent transvaginal ultrasound (dense free fluid with lumps is observed in the pouch of Douglas and abdominal cavity). Immediate complete blood count with serial hematocrit and hemoglobin levels. Diagnostic puncture of the Douglas cul-de-sac (culdocentesis, no longer used but useful if ultrasound is not available, removing blood that does not clot).

Standard management

• There are no outpatient drugs available for the treatment of acute hematocele with instability. Cannulation of two large-caliber venous lines, rehydration with crystalloid fluid therapy and transfusion of blood products according to the massive hemorrhage protocol are required. If the patient is hemodynamically stable and the hematocele is secondary to a self-limited ruptured hemorrhagic luteal cyst, conservative management may be chosen under strict hospital surveillance, combining intravenous analgesics and complete rest (note: hemodynamic instability requires emergency laparoscopy or surgical laparotomy).