Paravesical and broad ligament hematoma after vaginal delivery

Introduction and case presentation

Hematomas are amongst the most feared complications of delivery. The insidious nature of hematomas may delay the diagnosis and may cause severe hemorrhagic shock and even death [5]. Lacerations of the uterine artery or vessels of the broad ligament can cause retroperitoneal puerperal hematoma, which is very rare in obstetrical practice [6].

A 20-year-old nulliparous Turkish woman gave birth to a 2600 g healthy baby. The delivery was assisted by a midwife in a delivery room. Due to prolonged second stage, fundal pressure was applied by the midwife to shorten the second stage of the delivery. After delivery, the patient was noted to have deep cervical lacerations and 1^st degree perineal lacerations, which were repaired.

Six hours after the delivery, the patient became pale and began to vomit in the obstetric ward. The blood pressure was measured as 90/50 mm Hg with concomitant tachycardia. Upon inspection, there was no obvious bleeding from vagina and ecchymosis or hematoma in vulva. There was a visible mass on the right side of the abdomen, and the uterus could not be palpated due to this painful mass. On ultrasound examination, the mass arose from the right side of the vagina to the right side of the uterus up to the bifurcation of the iliac arteries; and was diagnosed as a retroperitoneal hematoma. Upon conducting vaginal examination, there was a huge paravaginal hematoma on the right side, which had no connection with the episiotomy. The cervix could not be reached. Immediate laparotomy was decided upon rapid deterioration of the patient’s hemodynamic status. The Hb and Htc levels were measured as 6.3 g/dL and 18.7% before laparotomy, respectively.

Upon exploration of the abdomen via Pfannenstiel incision, a huge hematoma was observed, beginning from the uterovesical space and extending towards the right side of the retroperitoneal space, up to the bifurcation of the iliac artery (Figures 1 and 2A). The hematoma was evacuated as much as possible, but our attempts to find the source of bleeding were not successful (Figure 2B). We decided to ligate the bilateral internal iliac artery (Figure 3). After the abdominal operation, we evacuated the paravaginal hematoma vaginally (Figure 4). Following evacuation of the hematoma, the patient received four units of packed red blood cells (PBRc) and soon became hemodynamically stable. She was discharged 6 days post-operation without any problem.

Figure 1

Laparatomy via Pfannenstiel incision and inspection of the huge paravesical hematoma.

Figure 2

(A) Demonstration of the paravesical hematoma by exteriorization of the uterus, (B) evacuation of the paravesical and right broad ligament hematoma.

Figure 3

Ligation of the internal iliac artery.

Figure 4

Evacuation of the paravaginal hematoma.

Discussion

In this rare retroperitoneal hematoma case, a possible explanation for the origin of bleeding could be the extension of a cervical tear, which caused the laceration of the descending branches of the right uterine artery. This may have led to the paravaginal hematoma, which extended through the paravesical space, and finally caused the hematoma in the paravesical space and between the layers of broad ligament. The contiguity of the paravaginal space as well as the paravesical, parametrial, and pararectal spaces may have facilitated the spread of the blood (or exudate) from one compartment to another [3].

The diagnosis of retroperitoneal hematoma may be challenging. Abdominal pain is not a “sine qua non” symptom; the patient may present with signs of hypovolemia [2] as in our case. It is also challenging to define the actual borders of hematoma and amount of blood loss [2]. In the presented case, rapid worsening of blood pressure was the alarming finding that prompted the decision to perform a laparotomy. The hematoma in the paravesical space and between the layers of broad ligament was evacuated. The search for the source of bleeding was not fruitful, which made it necessary to ligate the internal iliac arteries on both sides.

Case series on the management of retroperitoneal hematomas after vaginal delivery reported various methods, including conservative approach [3] and surgical interventions, such as laparotomy and evacuation of the hematoma [3, 7], pelvic arterial embolization [4], and even hysterectomy [5]. It is reasonable to manage puerperal hematomas with pelvic arterial embolization [4] if the patient is hemodynamically stable and the necessary equipment and staff are available. If both of these conditions are not met, as in this case, then laparotomy is indicated.

Muthulakshmi et al. [4] diagnosed a case with broad ligament hematoma after vaginal delivery as early as 3.5 h and managed with uterine artery embolization (UAE). UAE may be appealing as a minimal invasive technique; however, the recovery period was not very pleasing in this case. Fourteen units of blood were transfused in that case, and the patient was discharged on the 16^th day post-operation.

Singh et al. [7] reported a case with ischiorectal hematoma after vaginal delivery. In this case, the hematoma passed the levator ani barrier and extended to the supralevator area involving the broad ligament and retroperitoneal area. The source of bleeding could not be found and the hematoma was drained. Afterwards, surgicell^® (Ethicon) packs were applied to the retroperitoneal space and gauze roll packs were inserted into the vagina. Ten units of blood were administered to the patient.

Ligation of internal iliac artery has been successfully used in postpartum hemorrhages for more than five decades. It provides an 85% reduction in pulse pressure and a 50% reduction in blood flow in the distal vessels [1], including uterine artery, middle rectal artery, and internal pudendal artery. Ruptures of these arteries may lead to vulvovaginal, paravaginal, or retroperitoneal hematoma. Internal iliac artery ligation plays a major role in the management of retroperitoneal hematoma as well as almost all kinds of severe puerperal hematomas. In such cases, the source of bleeding cannot usually be found due to retracted and ruptured nature of arteries in the hematoma formation within in a distorted anatomy in a hemodynamically unstable patient with limited source settings. Internal iliac artery ligation is a rapid technique that requires no specific setup but only surgical skill.

Finally, retroperitoneal hematomas after vaginal delivery are very rare and can be life-threatening. Hence, the obstetrician should be aware of all kinds of complications after vaginal delivery, including rare ones (e.g., puerperal retroperitoneal hematomas). They should also be able to ligate the internal iliac arteries in case of hemodynamic instability, in order to save the patient’s life, especially in hospitals where an interventional unit is not available.