Idiopathic retroperitoneal hematoma after normal vaginal delivery: a case report and literature review

Introduction and importance: Retroperitoneal hematoma is a rare but life-threatening obstetric emergency associated with high maternal morbidity and mortality. Diagnosis is difficult because of nonspecific symptoms and limited access to advanced imaging in low-resource settings. Case presentation: A 30-year-old multiparous woman was admitted on postpartum day 3 with persistent diarrhea, abdominal pain, severe anemia, hypotension, and tachycardia after the spontaneous vaginal delivery of a stillborn fetus. There was no history of abdominal trauma or visible postpartum hemorrhage. Initial ultrasonography was normal. The patient was initially treated for suspected gastroenteritis and postpartum infection. Despite supportive treatment and a partial blood transfusion, she developed progressive anemia, persistent hemodynamic instability, and worsening abdominal symptoms. Repeat ultrasonography on postpartum day 18 revealed a large right retroperitoneal hematoma. Emergency laparotomy showed a massive retroperitoneal hematoma extending from the cecal region to the right renal compartment. Hematoma drainage and abdominal packing were performed. The postoperative course was complicated by refractory hemorrhagic shock in the context of a severe blood shortage, leading to death 4 hours after surgery. Clinical discussion: Persistent postpartum anemia without external bleeding should raise suspicion for concealed internal hemorrhage. Ultrasonography remains useful in low-resource settings because of its accessibility and repeatability, but it may initially fail to detect retroperitoneal bleeding. Conclusion: Idiopathic retroperitoneal hematoma after vaginal delivery is a rare, underreported obstetric emergency. Early diagnosis, serial reassessment, repeated imaging, and adequate blood transfusion are essential to improving maternal outcomes.