Broad Ligament Haematoma

Broad ligament haematoma is a collection of blood between the layers of the broad ligament, from a tear of the uterine artery or its branches at the side of the uterus. It follows caesarean section (lateral extension of the incision), cervical laceration, uterine rupture, operative vaginal delivery and gynaecological surgery. It is rare and matters because large haematomas conceal litres of blood and cause shock, infection and ureteric injury.

• Risk factors: caesarean section in the second stage, lateral incision extension, forceps, cervical tear, uterine rupture, coagulopathy, anticoagulants.
• Blood spreads along the retroperitoneum and can reach the kidney and diaphragm.
• Early recognition and surgical control are the key.

Women have lower abdominal and flank pain, a lateral pelvic or abdominal mass, shifting of the uterus to the opposite side, rising pulse and falling blood pressure, with little vaginal bleeding. Ileus and difficulty passing urine are common.

• Tender lateral mass beside the uterus.
• Shock out of proportion to external loss.
• Differential diagnosis: uterine rupture, vaginal or pelvic haematoma, retroperitoneal bleeding from another source, uterine atony, ovarian vein thrombosis, ureteric injury with urinoma.
• Complications: haemorrhagic shock, DIC, infection and abscess, ureteric obstruction, ileus, anaemia, hysterectomy, maternal death.

The diagnosis is made by ultrasound or CT, with repeated haemoglobin measurement.

• Pulse, blood pressure, urine output; abdominal and bimanual examination for a lateral mass and uterine displacement.
• Haemoglobin every 4 to 6 hours, platelets, clotting screen, fibrinogen, creatinine, group and cross-match 4 units.
• Ultrasound for the mass and free fluid; contrast CT for size, extent and active bleeding, and for ureteric dilatation.
• Do not delay resuscitation for tests.

The principle is resuscitation, haemostasis and drainage of large or infected haematomas.

• Supportive: two large-bore cannulae; Ringer's lactate 1 to 2 litres rapidly; early blood transfusion with fresh frozen plasma 15 mL/kg and cryoprecipitate 10 units for fibrinogen below 2 g/L; urinary catheter with hourly output; oxygen; warm the patient; high dependency care.
• Pharmacological: tranexamic acid 1 g IV over 10 minutes, repeated once after 30 minutes if bleeding continues; oxytocin 10 IU IM and 20 IU in 1 litre Ringer's lactate at 125 mL per hour for 4 hours; calcium gluconate 1 g IV after every 4 units of blood; cefazolin 2 g IV plus metronidazole 500 mg IV before surgery, then amoxicillin-clavulanate 1.2 g IV 8-hourly for 5 days for a large haematoma; paracetamol 1 g IV 6-hourly (maximum 4 g in 24 hours); morphine 2.5 to 5 mg IV titrated; ferrous sulphate 200 mg oral 8-hourly for 3 months.
• Procedures: conservative care with serial scans for a small stable haematoma below 5 cm; selective uterine artery embolisation for active bleeding in a stable woman; laparotomy with opening of the broad ligament, ligation of the uterine artery and its branches, evacuation of clot, drain placement, and identification of the ureter; hysterectomy for uncontrolled bleeding; ultrasound guided drainage for an infected collection.
• Red flags: shock, expanding mass, falling haemoglobin, oliguria, fever above 38 degrees Celsius, flank pain, bowel obstruction.
• Follow-up: haemoglobin 6-hourly until stable; ultrasound at 1 week and 6 weeks; review at 6 weeks; counselling for later births.