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Case Report Review International Journal of Women’s and Reproduction Sciences International Journal of Women’s HealthHealth and Reproduction Sciences Vol.Vol. 3, No. 3, July 2015, 126–131 4, No. 4, October 2016, 205–207 ISSN 2330- 4456 ISSN 2330- 4456
Women onBladder the OtherFlap SideHematoma of War and Poverty: Its With Effect A Case of Presenting on the Health of Reproduction Hematuria Ayse Cevirme*, Yasemin Hamlaci , Kevser Ozdemir Gülşah İlhan , Fatma Ferda Verit Atmaca, Ali Galip Zebitay, Hüseyin Gültekin, Ahmet Hasan Ergin, Karolin Ohanoğlu 1
2*
2
Abstract
War and poverty are ‘extraordinary conditions created by human intervention’ and ‘preventable public health problems.’ War and
Abstract poverty have many negative effects on human health, especially women’s health. Health problems arising due to war and poverty are
Objectives: Patients with bladder flapallhematoma usually withgynecologic a mass lesion, signs ofproblems hypovolemia and/or infection. We being observed as sexual abuse and rape, kinds of violence andpresent subsequent and obstetrics with physiological herein introduce acourses, patientand thatpregnancies presentedaswith an extraordinary of bladder flap marriages hematoma. and psychological the result of undesired sign but forced or obliged and even rapes. Certainly, Case with term our hospital labor. She underwent cesarean delivery due to unjustPresentation: treatment suchAaswoman being unable to gainpregnancy footing onpresented the land itto is lived (asylum in seeker, refugee, etc.) and being deprived of persistent late decelerations. Cesarean delivery was performed with the traditional cesarean section method. On the first postoperative social security, citizenship rights and human rights brings about the deprivation of access to health services and of provision of hour, patientfordeveloped hemorrhage due atony. She had severe anemia and tachycardia. servicethe intended gynecologypostpartum and obstetrics. The purpose of to thisuterine article is to address effects of war and poverty on the healthTransvaginal of ultrasonography revealed of 86contribution × 77 mm solid interposed between lower uterine segment and bladder. Slow-onset reproduction of women andthe to presence offer scientific andmass solutions. hematuria noticed in the previously clear urinary discharge. The patient was treated conservatively. Keywords: was Poverty, Reproductive health, War Conclusion: Hematuria may be a sign of bladder flap hematoma. Though no exact and standardized protocols exist for the management, conservative approach is one of the treatment modalities and may be offered for eligible patients. Keywords: Bladder flap, Cesarean section, Complication, Hematuria thought that severe military conflicts in Africa shorten Introduction the expected lifetime for more than 2 years. In general, Throughout the history of the world, the ones who had WHOtemic had calculated that 269 thousand diedwas unreconfronted the bitterest face of poverty and war had alIntroduction diseases. Prenatal screeningpeople of thehad fetus in 1999 due to the effect of wars and that loss of 8.44 mil- due to ways been the women. As known poverty and war affects Bladder flap hematoma is an unusual complication of cemarkable. The patient underwent cesarean delivery lion healthy years of life had occurred (2,3). human health either directly or indirectly, the effects of sarean delivery. The exact incidence is unknown (1). A persistent late decelerations during active labor. Cesarean Wars negatively affect the provision of health services. this condition on health and status of women in the sofew paper has been written on this surgical complication delivery was performed with the technique of traditional Health institutions such as hospitals, laboratories and ciety should not be ignored. This study intends to cast (2-5). method. The visceral peritoneum was sutured health centers are direct targets of war. Moreover, the wars as in the light on the effects of war and poverty on the reproductive Bladder flap formation has been an important step in traditional technique. The newborn’s weight was 3220 g cause the migration of qualified health employees, and health of women. For this purpose, the face of war affectstandard cesarean delivery.ofAimmigration, cesarean delivery can be thus with an Apgar score of 7 atAssessments 1 minute and 9 atindi5 minutes. the health services hitches. made ing the women, the problem inequalities performed either by suturing suturing visceral cate that On the theeffect first ofpostoperative the patient ofdeveloped destruction inhour, the infrastructure in distribution of income based or on not gender and thethe effects health continues for 5-10 years even after the finalization of all these onWhen the reproductive health of women will be peritoneum. visceral peritoneum is reapproximatpostpartum hemorrhage due to uterine atony. She had se(3). Due to tachycardia. resource requirements in theultrasonograreaddressed. ed, bleeding at the incision site may result in bladder flap of conflicts vere anemia and Transvaginal investments after war,ofthe sharemm allocated to hematoma. The traditional method closes visceral and structuring phy revealed the presence 86×77 solid mass interhealth has decreased (1). War and Women’s Health parietal peritoneum, and therefore may lead to this composed between lower uterine segment and bladder (FigFamine, synonymous with war and poverty, is clearer for plication (6). ure 1). Preoperative hemoglobin level was 11 mg/dL and women; war means deep disadvantages such as full deMortalities and Morbidities Patients with bladder flap hematoma usually present with postoperative drop in hemoglobin was 5 mg/dL. Although struction, loss of future and uncertainty for women. Wars The ones who are most affected from wars are women and aare mass lesion, signs of hypovolemia (tachycardia, drop in bleeding time (2 minutes), platelet count (165.000/mcL), conflicts that destroy families, societies and cultures children. While deaths depending on direct violence afhemoglobin level, decreased urinary output) and/or inandmale fibrinogen levelthe (310 mg/dL) were slow-onset fect the population, indirect deaths killnormal, children, that negatively affect the health of community and cause fection (fever, leukocytosis) (2-5). In the present case, we hematuria was noticed in the previously clear urinary diswomen and elders more. In Iraq between 1990-1994, inviolation of human rights. According to the data of World introduce a patient who presented with Bank, an extraordinary charge.had Sheshown was transfused erythrocyte susfant deaths this realitywith in its4 units more of bare form Health Organization (WHO) and World in 2002 sign bladder flap hematoma. andof4 600% units of plasma. with pension an increase (4).fresh Thefrozen war taking five The yearsfollow ups warsofhad been among the first ten reasons which killed of the wereunder performed transabdomincreases thepatient child deaths age of 5 using by 13%.serial Also 47% the most and caused disabilities. Civil losses are at the rate of allinal the refugees in the The worldbladder and 50%flap of asylum seekerswas stable of 90% within all losses (1). Case Presentation ultrasounds. hematoma and displaced people arethe women and girls and 44% refhas many nulliparous, negative effects human of AWar 25-year-old 40on weeks andhealth. 5 daysOne pregnant in dimension and patient was clinically asymptomatic. ugees and asylum seekers are children under the age of these is its effect of shortening the average human life. woman presented to Suleymaniye Maternity, Research Intravenous antibiotic therapy with ampicillin/sulbactam 18 (5). According to the data of WHO, the average human life is and Education Hospital in labor. Transabdominal ultra(4 g/day) was ordered. Urinary catheter was not removed As the result of wars and armed conflicts, women are 68.1 years for males and 72.7 years for females. It is being
sonography showed 3490 g fetus in cephalic presentation. until gross hematuria was resolved. She had no fever or She had regular contractions on non-stress test. Her cerleukocytosis during the follow-up period. Transvaginal Received 12 December 2014, Accepteda25dilatation April 2015, Available online vical examination revealed of 4 cm and1 July an 2015 efultrasonography on seventh post-operative day showed 1 2 facement 80%. She was hospitalized in order to perform an obvious reduction in hematoma size (32×33 mm) (FigDepartment of of Nursing, Sakarya University, Sakarya, Turkey. Department of Midwifery, Sakarya University, Sakarya, Turkey. *Corresponding author: Yasemin Hamlaci, Department of Midwifery, Sakarya University, Turkey. Tel: +905556080628, vaginal delivery. ureSakarya, 2). The patient was discharged with oral ampicillin/ Email:
[email protected] The woman had neither obstetric risk factors nor syssulbactam (1.5 g/day) on the seventh post-operative day Received 23 January 2016, Accepted 15 April 2016, Available online 19 May 2016 Department of Obstetrics and Gynecology, Suleymaniye Research and Training Hospital, Istanbul, Turkey. *Corresponding Author: Gülşah İlhan, Tel: +905327019824; Email:
[email protected]
İlhan et al
and outpatient clinic control was advised. Examination of patient on 14th post-operative day showed complete resolution of the hematoma. The patient has been following up and have had no complaints on postoperative ninth month. Discussion Cesarean delivery is the most common major surgical operation in women worldwide (7). It is definitely important to use the most effective and the safest operation technique. Despite the fact that cesarean delivery is a routine surgical procedure, an unanimity on the most appropriate operative technique to use have not yet been concluded. Standardized, evidence-based techniques are imperative to minimize complications of the operation. The traditional method is one of the most commonly used cesarean delivery techniques (8). In this method, visceral and parietal peritoneum is closed respectively and a potential space for blood collection is formed. Bladder flap hematoma is formed as a result of bleeding at the incision site and located between urinary bladder and lower uterine segment. The source of bleeding is the injury of uterine vessels (5). In a cesarean section performed with Misgav Ladach or Stark method by not suturing the visceral peritoneum, the vesico-uterine space communicates with the large peritoneal cavity and this may prevent the formation of a bladder flap hematoma (9). The exact incidence of this complication is unknown. Burger et al (1) showed the sonographic evaluation of 48 patients operated with low transverse cesarean delivery. Fourteen of them had fluid collection between the bladder and uterus but none of the patients had any symptoms. The diagnosis of bladder flap hematoma is based on a mass between bladder and uterus in the postoperative patient presenting with drop in hematocrit level or fever. Ultrasonographic evaluation shows a well-circumferenced complex collection located between bladder and uterus causing posterior shadowing (2). In our case, cesarean delivery was performed by traditional method. Initial symptoms of the patient was vaginal bleeding, tachycardia and drop in hemoglobin level. Transvaginal ultrasonography revealed the presence of well-circumferenced, solid mass interposed between lower uterine segment and bladder. It
Figure 1. Transvaginal Ultrasonography of Bladder Flap Hematoma at Postoperative First Hour. BPH: bladder flap hematoma. 206
was thought that decreased uterine tonus has led to bleeding of the Kerr incision and resulted in bladder flap hematoma. During the following hours, fusion of the blood through the bladder was trigger reason of hematuria. The scientific literature have no clear and defined protocol for clinical management, or for its surgical treatment. Surgical management of symptomatic postcesarean section bladder flap hematoma, include laparoscopic-laparotomic drainage, percutaneous ultrasound or computed tomography-guided aspiration (10), surgical transvaginal evacuation, and additive obliteration therapy (injection of a sealant such as an antibiotic doxycycline into the hematoma) (9,11). Transabdominal or transvaginal ultrasound-guided drainage and additive obliteration therapy in these circumstances can be performed safely, avoids further surgery and might cause only little discomfort to the patient. Baker et al (5) reported seven patients with bladder flap hematoma in 1985. All sonographies demonstrated characteristic localisation. Postoperative hemoglobin drop ranged between 1.3-6 mg/dL in this case series. One patient underwent hysterectomy and another had exploratory laparotomy. Five of the patients were treated conservatively in this case series. Winsett et al (2) reported 10 cases of bladder flap hematoma in 1986. Bladder flap hematoma resulted from primary low transverse cesarean section in six patients. In four patients, a low transverse cesarean section with classic extension, a transabdominal hysterectomy with bilateral salpingo-oophorectomy, a transvaginal hysterectomy, a right salpingo-oophorectomy with left salpingectomy were performed, respectively. Ultrasonography demonstrated a mass lesion in the characteristic localisation. Hematoma was treated surgically in five patients and the other five patients were treated with antibiotic alone. Tinelli et al (4) reported two cases of bladder flap hematoma in 2007. These cases were submitted to laparoscopic treatment. Tinelli et al (3) in 2009 reported 10 symptomatic women undergoing laparoscopy. The essential steps of the operation were expressed as incision of the tumescence, bladder wall dissection from the vesico-uterine space, drainage of the collection, washing of the hemato-
Figure 2. Transvaginal Ultrasonography of Bladder Flap Hematoma on Seventh Postoperative Day. BPH: bladder flap hematoma.
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ma site and peritoneal suturing. As mentioned, no standardized treatment for bladder flap hematoma exists in the literature. It might be deduced that antibiotic therapy is the first treatment step and surgery may be considered in cases with infection or bleeding. In our study; the patient was treated conservatively. We started intravenous antibiotic therapy with ampicillin/sulbactam (4 g/day). She had no fever or leukocytosis during the follow-up period. Transvaginal ultrasonography on seventh post-operative day showed an obvious reduction in hematoma size (32×33 mm). This obvious reduction of hematoma size might be explained by fusion of the blood through the bladder and resulted in hematuria. The slow-onset hematuria of the patient might be explained in this way. In conclusion, bladder flap hematomas are unusual complications of a standard cesarean delivery. Their detection using sonography is an easy and accurate way. However, hematuria was not mentioned in any of the above mentioned cases, it may be a sign of bladder flap hematoma. Conservative approach is one of the treatment modalities and may be offered for patients in stable clinical status.
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Ethical Issues The authors have obtained permission before using patient data and images.
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Conflict of Interests Authors declare that they have no competing interests.
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Financial Support None.
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Acknowledgments None to be declared. References 1. Burger NF, Darazs B, Boes EG. An echographic evaluation during the early puerperium of the uterine wound after caesarean section. J Clin Ultrasound 1982;10(6):271-4. doi: 10.1002/jcu.1870100605. 2. Winsett MZ, Fagan CJ, Bedi DG. Sonographic
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