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41. Broad Ligament Haematoma
Keywords
Supralevator haematomaBroad ligament haematomaRetroperitoneal haematomaPostpartum haemorrhage (PPH)Bilateral internal iliac ligationSelective arterial embolization41.1 Introduction
During pregnancy the uterus, vagina and vulva have rich vascular supplies. Any significant trauma during birth process may result in formation of a haematoma. Puerperal genital haematomas are relatively uncommon causes of PPH but can lead to serious morbidity and even maternal death [1]. The reported incidence of significant postpartum haematoma is around 1 in 500–700 deliveries [2].
Supralevator haematomas also known as broad ligament haematomas are rare, with widely varying incidence of between 1:500 and 1:20,000 deliveries [3]. As the symptoms are nonspecific and size dependent and bleeding is often concealed, most of them are difficult to diagnose.
41.2 Types of Puerperal Genital Haematomas
- 1.
Infralevator Haematomas
- (a)
Location—Below the levator ani muscle
- (b)
Include the vulva, perineum and lower vagina, episiotomy site
- (c)
More common than supralevator variety
- (d)
Occur following vaginal birth/instrumental deliveries/big baby/any other obstetric trauma
- (a)
- 2.
Supralevator Haematomas
- (a)
Location—Above the levator ani muscle, in the leaves of broad ligament
- (b)
Mostly due to an extension of cervical tear, forniceal tear or uterine incision and uterine rupture
- (c)
Less common than infralevator haematomas
- (d)
Can be associated with spontaneous vaginal birth, but commonly occur following instrumental vaginal deliveries, difficult caesarean section or vaginal birth after caesarean (VBAC), etc.
- (a)
Broad ligament haematoma occurs secondary to lacerations/tear in the upper vagina, cervix or uterus that extends into uterine or vaginal vessels or vessels of the broad ligament. The engorged vessels of pregnancy bleed profusely in the space between the leaves of broad ligament accommodating significant blood collection.
Extension of cervical tear or primary colporrhexis (vault rupture)
LSCS scar rupture
Spontaneous rupture of paravaginal venous plexus adjacent to the vault
The diagnosis is usually delayed, as there are no obvious symptoms like pain or vaginal bleeding. Sometimes unexplained shock with features suggestive of internal haemorrhage immediately following delivery raises the suspicion. Maternal mortality chances are high if the diagnosis is delayed. So strong suspicion, good clinical examination and prompt treatment are the key words in the management.
Spontaneous vaginal birth
Episiotomy
Caesarean section
Precipitate labour
Instrumental vaginal delivery (commonly forceps)
Assisted breech delivery
Twins
Prolonged second stage of labour
Big baby
Vaginal birth after caesarean (VBAC)
Hereditary clotting deficiencies
Vulvar varicosities
Fifty percent of these haematomas are diagnosed immediately, while the other 50% are discovered within 24 h [7]. The arterial origin haematomas are rapidly expanding and appear bright or dark red, while the slow expanding haematomas are of venous origin and appear dark red or bluish in colour [7]. It may be concealed with no obvious vaginal bleeding.
41.2.1 Symptomatology
Symptoms can be quite vague and usually develop within a few hours of delivery. They depend upon the size of the haematoma (amount of blood loss), the rate at which its formation occurs and the type of haematoma.
Haematomas are usually diagnosed when patient presents with haemorrhagic shock or even death, due to its insidious nature [7]. The speed of diagnosis depends on the extent of the bleeding, its associated consequences and the level of awareness and suspicion of the medical staff.
41.2.2 Clinical Presentation
Features of hypotensive shock.
Disproportionate pallor to the visible blood loss.
Persistent throbbing pelvic pain/back pain may be there.
Inability to pass urine.
Pressure in the recto-anal area/fullness.
An urge to push within the first few hours after delivery.
Headache, dizziness, restlessness.
A broad ligament haematoma can present with abdominal pain, but often it first presents with signs of hypovolaemia, including cardiovascular collapse.
General Exam—signs of shock, e.g. pallor, sweaty, cold, clammy, dizzy, elevated pulse, decreased blood pressure.
A swelling/mass may be felt just above the inguinal ligament.
The uterus gets pushed upward/laterally to the opposite side of the broad ligament haematoma.
Occlusion of the vaginal canal by a bulge
A boggy mass/swelling felt through the fornix
P/R Exam—Presence of the soft boggy mass.
41.2.3 Differential Diagnosis
Intraperitoneal haemorrhage
Rectus sheath haematoma
Ovarian mass/pelvic mass
An abscess
41.3 Investigations
41.3.1 Blood Tests
Sudden fall in haematocrit levels is suggestive of internal haemorrhage. A full blood count and coagulation screen are most important to determine baseline values. Crossmatching and replacing adequate blood units as per the clinical picture is crucial.
