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Broad-ligament haematoma in the post-partum period – A case report.

Dr.Lekha.K. D.G.O, Dr.Ramesh kumar PP.MD.DGO.,Dr.Padmam Warrior MD.DGO.,Government District Hospital, Thrissur.

TOGS, Vol 2 No1,Februaryl 2006.

 

Mrs X, a 26 year old G3 P2 L2 had a normal delivery at term on 27.09.05 with an episiotomy. During her intra-partum period, she did not need any induction or acceleration with oxytocics as she had regular good labour pains, which came on spontaneously. She was a booked case antenatally and her antenatal period was unremarkable.

She was posted for post-partum sterilization on the following day. At 1.30 PM, she went to relieve herself, and when she came back, she was gasping and was feeling giddy. The student nurses who saw her thought there was something amiss and the first author was summoned. On examination, her pulse and blood pressure were unrecordable. She was gasping, and had severe pallor. There was marked abdominal distension. The anaesthetist, who was readily available at that time, ventilated her immediately. As she had significant abdominal distension, haemoperitoneum was suspected and she was taken up for laparotomy immediately.

Laparotomy revealed massive haemoperitoneum with a haematoma in the right broad ligament, the upper margin of which could not be traced. The haematoma was fairly fresh in appearance. It appeared difficult to trace the origin of the haematoma. It was decided to do a hysterectomy, after which the general condition of the patient improved remarkably. However, there appeared to be many oozers coming from the lateral pelvic wall on the right side. By now, the general surgeon was also summoned to help. After tracing the ureter, the bleeding points were cauterized with bipolar cautery. There was a large vein which was oozing, lateral to the point where the uterine vessels normally enter the uterus laterally. The exact origin of the vein could not be ascertained. Reasonable haemostasis was achieved and the abdomen closed after putting in a drain.

The patient’s condition was stable, but since she had been in severe shock for a long time and had undergone extensive surgery, she was transferred to a hospital with a ventilator, where she recuperated very well. In this case, prompt detection of hypotension with immediate ventilation and remedial haemostatic measures saved the patient’s life.

 

Literature review:

Puerperal hematomas may be classified as vulvar, vulvovaginal, paravaginal, or retroperitoneal. Infrequently, the torn vessel lies above the pelvic fascia. In that event, the hematoma develops above it. In its early stages, the hematoma forms a rounded swelling that projects into the upper portion of the vaginal canal and may almost occlude its lumen. If the bleeding continues, it dissects retroperitoneally, and thus may form a tumor palpable above the Poupart ligament, or it may dissect upward, eventually reaching the lower margin of the diaphragm. Branches of the uterine artery may be involved with these types of hematomas. Subperitoneal hematomas may be associated with branches of the uterine artery or other vasculature in the broad ligament. Vascular injury may either be immediate, resulting from failure to recognize or repair direct vessel injury, or delayed, resulting from pressure necrosis and rupture of a vessel with subsequent hematoma formation. Most hematomas will present within 24 hours of delivery.

Muthulakshmi et al have described a haematoma which developed spontaneously in a primigravida who had a home delivery in United Kingdom. She delivered a 3.5kg baby at home. 40 minutes after an unremarkable labour, she felt faint and experienced a pressure in the anal region. It progressed to a painful sensation and as it continued, she was transferred to a hospital 3.5 hours later.  On  abdominal examination the uterus was atonic. Because of continued bleeding and a haemoglobin of 7.0 g/dl, she was taken to theatre for examination under anaesthesia. A large posterior left lateral wall paravaginal haematoma was found and drained. This resulted from active arterial bleeding from the posterior left vaginal wall, which was sutured with ‘0’ vicryl using a figure-of-eight haemostatic sutures. She was transfused 7 pints of blood, inspite of which she continued to have a haemoglobin lower than 9mm Hg. A pelvic ultrasound scan demonstrated a broad ligament haematoma, and this was confirmed by a computed tomography scan of abdomen and pelvis showing a huge haematoma postero-lateral to vagina and anterior to rectum. The cervix

was displaced superiorly. In spite of aggressive supportive management, during which the patient received 14 units of blood, the haemoglobin level remained low (7.7 g/dl) and she continued to be haemodynamically unstable. Examination under anesthesia did not reveal any further source or reason for the haematoma. As the expertise and facilities to perform uterine artery embolisation were readily available, it was carried out on the second post delivery day under sedation with an anaesthetist present. There were no immediate or short-term post procedure complications. The patient was discharged home on the 16th day after delivery. She was readmitted on two occasions because of high temperature, and was managed with intravenous antibiotics.

Banas.T. et al reported on a patient who developed haemorrhage from ruptured ovarian vessels. A 41 year old patient who had a spontaneous delivery and an uneventful immediate post-partum period developed a fainting attack with features of oligovolemic shock on the second post-partum day. She had to be laparotomised because of severe abdominal pain, positive peritoneal signs and palpable abdominal tumor of 25-30 cm diameter. On laparotomy, 1 liter of non coagulated blood and a large retroperitoneal haematoma caused by ruptured of right ovarian artery was found. Peritoneal cavity was cleaned and revised. A 10-centimeter segment of bleeding vessel was resected. The suture of the both remaining ends bleeding vessel was performed.It can be noted that in all 3 cases cited above, including the one reported locally, the haematomas occurred after uneventful spontaneous delivery. Obstetricians should be aware of the possibility of broad ligament haematomas after spontaneous deliveries.

References:1.B.Muthulakshmi,I.Francis et al: Broad ligament haematoma after a normal delivery: J Obstet Gynaecol. 2003 Nov;23(6):669-70.

2. You, Whitney B MD*; Zahn, Christopher M MD: Postpartum Hemorrhage: Abnormally Adherent Placenta, Uterine Inversion, and Puerperal Hematomas:[Do We Need to Advocate for Vaginal Delivery?]: Clinical obstetrics and gynaecology:Volume 49(1), March 2006, pp 184-197.

3. Banaś T: Intraperitoneal hemorrhage due to the rupture of right ovarian artery in the second day of puerperium: Ginekol Pol - 01-SEP-2004; 75(9): 729-32.

4. Williams obstetrics 22nd edition: Chapter 35. Obstetrical Hemorrhage.

 

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