Recurrent spontaneous bilateral perineal obstetric hematoma: a case report and review of six cases

Spontaneous bilateral perineal hematoma during pregnancy is a rare obstetric complication. We report a case of recurrent bilateral perineal hematoma in a primigravid woman, representing only the seventh such case documented in the English-language literature. The patient demonstrated an unusual triphasic course, with transient intrapartum swelling followed by three postpartum hematoma episodes. A 33-year-old primigravid woman (G1P0) developed recurrent spontaneous perineal hematomas in the postpartum period. Serial complete blood count and coagulation testing were performed at admission and after each hematoma episode. Platelet count, PT, APTT, and fibrinogen remained within normal limits, whereas hemoglobin decreased because of ongoing blood loss, with a nadir of 77 g/L. In the absence of a personal or family history of bleeding disorders, these findings argued against an underlying coagulopathy. Ultrasound examination revealed perineal venous congestion and dilated vessels within the hematoma cavity, suggesting that vascular fragility contributed to recurrence. Standard surgical evacuation and primary closure failed to prevent rebleeding after the first two episodes. Ultimately, a U-shaped compression suture technique was employed, achieving durable hemostasis. No episiotomy was performed during delivery. This case indicates that recurrent spontaneous perineal hematoma may result from pregnancy-related venous congestion and vascular fragility rather than a single bleeding vessel. When conventional evacuation and cavity closure are ineffective, the novel U-shaped compression suture technique—developed and applied here for the first time in refractory recurrent perineal hematomas—provides a simple, effective, and reproducible hemostatic alternative. Unlike existing suturing methods, this technique avoids further trauma to fragile venous structures, achieves broad tamponade of diffuse venous oozing, and requires no specialized instruments, making it highly applicable in routine obstetric practice. Given the substantial morbidity and potential mortality of large perineal hematomas, prompt diagnosis and individualized management, including the use of this innovative suture technique, are critical.