A Case of Atraumatic and Non-obstetric Vulvar Hematoma from Contralateral Internal Iliac Artery Rupture

Case Presentation: An 18-year-old female, gravida 0, para 0, with no significant past medical history presented with spontaneous left vulvar hematoma that started two hours prior to arrival. History also revealed amenorrhea for the past nine months, menorrhagia three days ago, and oral contraceptive use. Her vitals demonstrated tachycardia to 130s beats per minute but otherwise were normal, consistent with an early stage of hemorrhagic shock. Physical exam was remarkable for significant left labia majora hematoma with active hemorrhage on computed tomography from the right internal iliac artery. She underwent emergent gelfoam embolization with interventional radiology and subsequent hematoma evacuation with an obstetrician gynecologist. Discussion: Etiologies of vulvar hematomas fall within two categories: obstetric or non-obstetric. In rare circumstances, hematomas that lack evidence of obstetric or traumatic events are presumed to be of spontaneous artery rupture origin. Vulvar hematomas are a clinical diagnosis but can be challenging. The hallmark symptom is moderate to severe pain that is usually in the perineum but can be in the groin, abdominal and/or buttock regions depending on the size and location of the hematoma. A proper history and physical exam are essential to rule out the differential diagnoses such as vulvar varicosities, folliculitis, Bartholin gland cysts/abscesses or vulvar cancer. Management of vulvar hematomas is not well defined. Ultimately, clinical decision should be based on degree of hemodynamic stability, size of the hematoma, rate of expansion, risk or presence of pressure necrosis, urologic symptoms and presence of unremitting pain. To date, there are three reported spontaneous vulvar hematomas due to pudendal artery rupture and one due to internal iliac artery rupture. To the best of our knowledge, our case represents the second reported account of non-obstetric, non-traumatic spontaneous vulvar hematoma due to internal iliac artery rupture and the first reported account where the resulting hematoma was contralateral to the affected artery.