Rare Case of Broad Ligament Haematoma after Normal Vaginal Delivery

مقدمه: Broad ligament haematoma is rare complication of normal vaginal delivery. It can be life threatening if not recognised and managed quickly as the patient can lose large amount of blood in short time. We report patient who developed this complication after vaginal delivery.• معرفی بیمار: 35-year-old woman G2P2 (NVD*2), was brought to Kamali hospital with one previous normal vaginal delivery and the history of abdominal trauma and Gastrointestinal perforation, controlled diabetes during pregnancy. The patient was admitted to the labour ward because of her Postterm pregnancy at 41 weeks and days gestation without onset of labour pain and bloody show or ROM. Her first stage of labour lasted for 20 hours and her second stage lasted for one hour. amniotomy was performed after 16 hours of beginning of the dilation and administration of Misoprostol, serum and syntocinon. living healthy female was delivered live infants who weighed 3500 followed by complete delivery of the placenta. After delivery, the women feeling unwell. She experienced progressive severe epigastric pain in left lower quadrant. Her physical examination revealed soft abdomen, with well contracted uterus, edematous vulva without bruising. There was no sign of haematoma in the vulva and the perineum. The vaginal examination was normal wihout any sign of laceration. Her postpartum haemoglobin was 10.1 g/dl dropping from 13.3 g/dl antepartum. An ultrasonography was requested urgently because of her continous pain. The ultrasound revealed just postpartum uterus and 48*50 mm clot in the uterus cavity and no evidence of free fluid in the abdoman.an abdominal and pelvic CT scan was performed and left broad ligament was seen. After hours her haemoglobin became 7.9 and 2.5 hours later became 5. These units pack cell and FFp and Fibrinogen were transfused. The operation of Historaphy and evacuation of hematomas, blockin of left uterus and left ovarian arteries were done and and wound drainage were palced.A full coagulation screen [prothrombin time (PT), fibrinogen, activated partial thromboplastin time (APTT), thrombin time were done to exclude bleeding disorders. All her investigations came back negative. She became Npo and the plan after surgery was to monitor patient’s pulse, blood pressure, temperature, respiratory rate, oxygen saturation, and urine output (after inserting Foley’s catheter) every hours for the first 48 hours, then every hours. Intravenous prophylactic antibiotics (Cefazolin and Gentamicin) Methergine and serum-oxytocin were prescribed. The woman recovered well and was discharged home• بحث نتیجه گیری:Broad ligament hematoma results from tear in the upper vagina,cervix, or uterus that extends into uterine or vaginal arteries.(1), most commonly following operative delivery, trauma, or surgery, but it may also occur following spontaneous vaginal delivery. Hematomas caused by tears during dilatation during D&C or D&E procedures are probably the most common causes of broad ligament hematomas. These can be dangerous as they may be silent and not cause obvious vaginal bleeding. The risk of hematoma formation may be increased with congenital coagulopathy.(2) Most patientsPresent with persistent postpartum pelvic pain, back pain, fullness or pressure in the recto-anal area, or an urge to push within the first few hours after delivery. Women usually complain of headaches, dizziness and eventually may become hypotensive, with sudden drop in haematocrit value(3). high level of suspicion is warranted. Clinical symptoms can be quite vague. Ultrasound imaging can confirm the diagnosis. The role of pelvic MRI in the evaluation of such type of hematomas is still under investigations. MRI scan should be used to evaluate patients with persistent postpartum localized pelvic pain without clinical findings.(4)Broad ligament hematoma may be treated either conservatively with blood transfusion, fluid resuscitation, and observation or with surgical exploration and evacuation. (5)Murali et al. reported on rare case of woman who developed broad ligament hematoma 24 hours after normal vaginal delivery. The patient had no history of congenital or acquired bleeding disorder, and the course of her pregnancy and labour were uneventful.(6)In another report there was woman who developed this complication within hrs of normal vaginal delivery. She is G2P1L1, 38 wks GA, in active labour. Pt was allowed for spontaneous progression of labour, following which she delivered vaginally. Within hrs patient looked clinically very pale with vitals being deranged and complains of inability to void urine, severe perineal pain. On basis of clinical examination and transabdominal ultrasound features diagnosis of right sided broad ligament haematoma was made. Based on patients haemodynamic instability surgical management in the form of obstetric hysterectomy was done.(7). Malhotra et al reported case of fetal death caused by bilateral broad ligament hematomas in the absence of any injury to the uterus, placenta, or the fetus following pelvic fractures sustained in pregnant woman during motor vehicle accident.(2)Duckett et al reported case of spontaneous broad ligament hematoma that occurred in nonpregnant woman after mowing the lawn. The patient had large fibroid uterus and the authors presumed that venous vascular injury occurred leading to the formation of the hematoma.(8) Muthulakshmi et al reported case of broad ligament hematoma following spontaneous vaginal delivery that was successfully treated by uterine artery embolization. (5)

کلیدواژه ها:

Broad Ligament Haematoma ، Vaginal Delivery.