Broad ligament hematoma after normal vaginal delivery: a rare case scenario

INTRODUCTION

Pelvic hematoma which is collection of blood above levator ani is termed as broad ligament or supralevator hematoma. Broad ligament hematoma following normal vaginal delivery is a very rare event. Huge amount of hematoma collection can occur between the folds of broad ligament extending to natural cleavage lines of connective tissue before developing shock. Hence high index of suspicion is needed in patients with manifestations of postpartum hemorrhage with no or minimal vaginal bleeding that can occur during delivery, just after delivery or later in the puerperium.

CASE REPORT

This was a 25 years old para 2, stillbirth 1 at 9 hour postpartum referred from government primary hospital after delivery with diagnosis of hypovolumic shock due to suspected uterine rupture. She was induced for term prelabor rupture of membrane and delivered vaginally a 3000 gram neonate with good Apgar score. Her first stage of labor lasted for 10 hours and second stage 1 hour. No episiotomy or instrumental delivery performed and placenta managed actively. Three hours after delivery she developed intermittent minimal vaginal bleeding, abdominal pain, easy fatigability, dizziness and her vitals start to deteriorate. She was resuscitated with two litters of normal saline, transfused one unit of whole blood and referred to our tertiary center for better evaluation and management. At admission, patient was acutely sick looking, conscious with pulse 120 beats per minute (bpm) and blood pressure (BP) of 110/60 mmHg. She had pale conjunctiva and 24 week sized well contracted uterus. There was 16 weeek sized, tender anterior uterine wall mass. Genital examination revealed no vulvar or vaginal swelling, active vaginal bleeding or lower genital tract laceration. Immediately after admission hematocrit (hct) was 25% (Hgb=7.4 mg/dl), platlate=225,000, blood group and Rh=A+, prothrombin time (PT) and activated partial thromboplastin time (aPTT) in normal limit. Transabdominal ultrasound showed 8×6 cm hypoechoic mass on lower uterine segment extending to right broad ligament. Broad ligament hematoma was considered and expectant management planned. The plan was to follow her pulse rate, respiratory rate, blood pressure, urine output and serial Hct. She was started on ampicillin 2 gm IV QID and metronidazole 500 mg IV TID. She was also transfused additional 2 units of whole blood. Her blood pressure and urine output was normal throughout follow up and pulse rate ranges from 104-116 bpm. The serial hct was 25%, 29%, 30%, 32%, 31%, 27% and 22% at 1, 6, 12, 18, 24, 30 and 36 hours of admission respectively. At 36 hours of admission she was also complaining easy fatigublity, light headedness and become pale with pulse rate of 122 bpm. At this time the repeated transabdominal ultrasound showed increasing hematoma (10×8 cm) and minimal hemoperitoneum. Considering expanding broad ligament hematoma emergency laparotomy decided.

Informed consent was taken and under general anesthesia with midline vertical incision abdomen entered. Intraoperatively there was about 300 ml hemoperitoneum, 12×9 cm hematoma on anterior lower uterine segment extending more to right broad ligament. Hemoperitoneum sucked out and hematoma evacuated.

There was about 5 cm superficial vertical tear with no communication to endometrium or cervical canal. The tear extends down to the cervix which was bleeding and ligated. There was also multiple oozing from surface not responding for compression for which unilateral uterine artery and ovarian artery ligation tried. There was technical difficulty for internal iliac artery ligation. Finally total hysterectomy was done and received additional two units of whole blood post operatively. She was fully recovered and discharged on 6^th post-operative day.

DISCUSSION

Broad ligament hematoma following normal vaginal delivery is a rare complication. Incidence of puerperal hematoma was cited as to be 1/309 to 1/1500 and large hematoma as 1/4000 vaginal deliveries but has not specified incidence of supralevator hematoma.¹ In one study done in 2009, broad ligament hematoma was found to be 1/20,000 vaginal deliveries.² Puerperal hematoma can be classified as vulvar, vulvovaginal, paravaginal and retroperitoneal hematoma or as vulvar, vaginal ,vulvovaginal and subperitoneal.^1,3 Broad ligament hematoma can be seen during cesarean delivery due to lacerations to branches of uterine or vaginal vessels.¹ It can also follows precipitated labor, instrumental delivery, delivery of multiples, prolonged second stage, vigorous uterine massage, birth weight above 4000 grams, coagulation abnormality.^4-6 Broad ligament hematoma following spontaneous vaginal delivery follows mainly uterine rupture. But can happen due to cervical tear extending to lower uterine segment or the exact cause for the hematoma may not be elucidated.^1,2 In our case the superficial vessel tear may be attributed. Fifty percent can recognized immediately while the rest are discovered sub acutely after 24 hours of delivery.² Clinical presentation includes postpartum lower abdominal or perineal pain together with shock, elevated uterine fundus, unilateral fluctuating mass, urge to defecate, and inability to pass urine.^7,8

Ultrasound is not helpful for small sized broad ligament hematoma rather magnetic resonance imaging (MRI) is recommended.⁹ But large sized broad ligament hematoma like in our case can be diagnosed with clinical feature and ultrasound.

Broad ligament hematoma can be managed conservatively or surgically depending on patient’s hemodynamic status, size and rate of hematoma expansion. Hemodynamically stable patient with small size non expanding hematoma can be managed expectantly. However, hemodynamically unstable or patients with expanding hematoma needs resuscitation followed by laparotomy. Our case initially was stable except tachycardia and expectant management was tried with strict follow up. But later she developed hemodynamic instability and expanding hematoma, for which, she undergo laparotomy. Preserving her fertility with compression of bleeding site or uterine and ovarian artery ligation was not successful. Finally total hysterectomy performed. Internal iliac artery ligation or angiographic embolization has been proposed as options of surgical management depending on clinical condition of a patient.^1,5

CONCLUSION

Broad ligament hematoma is a rare complication after spontaneous vaginal delivery. High degree of suspicion for supralevator hematoma is needed in maternal collapse with minimal or no obvious vaginal bleeding. Clinically stable patients with non-expanding broad ligament hematoma can be managed conservatively. Close follow up is needed since expansion of hematoma and clinical deterioration like in our case occurs as late as 45 hours of delivery or 36 hours of confirmed diagnosis of hematoma.

ACKNOWLEDGEMENTS

Authors would like to thank the client who gave us her consent to publish her condition.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

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