Broad ligament hematoma following a normal vaginal delivery
© Springer-Verlag Berlin / Heidelberg 2006
Received: 16 November 2005
Accepted: 29 December 2005
Published: 8 March 2006
Broad ligament hematoma is an unusual complication that can occur during delivery, just after delivery or later in the puerperium. Rapid labor, cesarean section, instrumental deliveries, and trauma have been suggested as predisposing factors. A case of a broad ligament hematoma developing after normal vaginal delivery is presented. A high level of suspicion and the use of imaging modalities such as trans-vaginal ultrasound and computerized tomography confirmed the diagnosis. Conservative management was employed due to the patient’s hemodynamic stability.
Postpartum hemorrhage (PPH) is a frequent complication of labor. The extent of the bleeding may be clinically underestimated until shock develops. This complication is one of the major causes of maternal death . The most common cause is uterine atony; however, clinical examination and a high level of suspicion should arise to exclude other causes . Hematomas may develop anywhere along the genital tract and sequester a significant amount of blood, which often exceeds clinical estimates. Broad ligament hematoma is an unusual complication that can occur during delivery, just after delivery or later in the puerperium. Trauma is believed to be the major causal factor of immediate hematoma, while pressure necrosis may cause late onset hematoma. A case of a broad ligament hematoma developed after a spontaneously vaginal delivery and managed conservatively is presented.
Broad ligament hematoma following normal vaginal delivery is fortunately an uncommon complication of labor. Usually these hematomas are the result of upper vaginal, cervical or uterine laceration extending into the uterine or vaginal arteries. Several cases of broad ligament hematomas were described in the early 1960s and 1970s [3–5]. Rapid labor, cesarean section, instrumental deliveries, and trauma were suggested as predisposing factors in the formation of broad ligament hematoma [6, 7]. Diagnosis at that time was based on the clinical impression of internal hemorrhage. Classic findings included persistent postpartum pain together with shock, elevated uterine fundus, and a unilateral fluctuating mass. Treatment differed (conservative management, packing or abdominal hysterectomy) based on the patient’s hemodynamic situation. All cases of trauma complicated by pelvic fractures in pregnant patients should raise the suspicion of broad ligament hematoma. A fetal death resulting from bilateral large broad ligament hematomas associated with pelvic fractures after a motor vehicle accident was reported recently . The underlying mechanism suggested by the authors was a reduction in utero-placental blood flow due to blood loss and tamponade on uterine vessels resulting in fetal hypoxia and death.
Rapid diagnosis is of utmost importance and will determine the treatment options. Even large hematomas can frequently evade adequate assessment by physical examination alone. Nowadays, imaging studies may help the clinician to confirm the diagnosis. Ultrasound, CT, or MRI have been used to diagnose and treat pelvic hematomas. It has been suggested that MRI depicts postpartum hemorrhage even in deep extraperitoneal regions where the hematoma is clinically non-apparent, and in addition it can delineate the extent of the hematoma . However, this tool is not as accessible as ultrasound in every medical center. Ultrasound remains the method of choice for diagnosis of broad ligament hematomas, demonstrating its relationship to the pelvic organs.
In our case, a high level of suspicion led us to perform transvaginal ultrasound and to detect the hematoma that developed during or after delivery. We cannot exclude the possibility that the broad ligament hematoma was iatrogenic, resulting from insertion of the intra-uterine catheter, a complication that has not been described. Fortunately, our patient was hemodynamically stable, there were no signs of coagulopathy, and the hematoma did not expand. In patients in whom continued bleeding is suspected, laparotomy may be indicated, although conservative procedures to treat broad ligament hematoma such as uterine arterial embolization (UAE) have also been reported .
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