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.
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
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
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
References:1.B.Muthulakshmi,I.Francis et al: Broad ligament
haematoma after a normal delivery: J Obstet Gynaecol. 2003
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.