Broad Ligament Hematoma Following Uncomplicated Spontaneous Vaginal Delivery - A Case Report and Review of Literature

Broad ligament hematomas are an uncommon complication of pregnancy and delivery. Even less common are broad ligament hematomas following uncomplicated spontaneous vaginal deliveries. This case demonstrates the rare finding of a broad ligament hematoma following an uncomplicated spontaneous vaginal delivery and its subsequent complications during postpartum care. This particular case of broad ligament hematoma occurred immediately postpartum and presented as hemodynamic instability and abdominal pain. The patient underwent imaging which revealed hemoperitoneum, free fluid and clotted blood products in the left adnexa measuring 11x6x5 cm, and no active bleeding. Initial management included transfusion of blood products which transiently stabilized the patient. Due to further decompensation, she was ultimately taken to the OR for exploratory laparotomy where a left broad ligament hematoma with rupture of the posterior broad ligament was identified. 2.1 liters of hemoperitoneum were evacuated, the posterior broad ligament was repaired, and cystoscopy was performed. She received a total of 5 units pRBCs, 4 units FFP, and 1 pack of platelets during her admission. Her postoperative course was further complicated by ileus and fascial dehiscence requiring repair in the OR. She was discharged home on postpartum day 5 in stable condition. In order to provide context to this case, a review of literature of broad ligament hematoma following vaginal delivery was performed. Exclusively case reports were found presumably due to low incidence. 11 total case reports met criteria and were analyzed to provide context to the case report, including aspects such as patient characteristics, presentation, diagnosis, management, proposed etiologies, and morbidities. Findings showed that broad ligament hematomas can occur following vaginal deliveries in a wide range of patients and can present in a variety of ways - from asymptomatic to hemodynamic instability, bleeding, or pain. Management was also varied and included expectant management, transfusions alone, IR intervention, and surgical intervention including hysterectomy. Patients often required significant quantities of blood products. Proposed etiologies included spontaneous vessel rupture, shearing trauma, extension of lacerations or episiotomy, fundal massage, intrauterine pressure catheter placement, operative vaginal delivery, placenta accreta spectrum, intra-amniotic infection, connective tissue disorders, and inherent weakness of vessels and structures. In summary, this case highlights a rare but serious postpartum complication that can occur even after uncomplicated vaginal delivery. For hospitalists, maintaining a high index of suspicion for intra-abdominal hemorrhage is critical, as early recognition and intervention can reduce morbidity.