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5/1/2013

Management of Broad Ligament Extension and Hematoma during a Cesarean Delivery

The broad ligaments consist of anterior and posterior leaflets of peritoneum which cover the lateral uterine corpus and upper cervix and extend from the lateral walls of the uterus to the pelvic sidewalls. The broad ligament is bounded superiorly by the round ligament, inferiorly by the cardinal and uterosacral ligaments, and laterally by the infundibulopelvic ligament where it joins the pelvic sidewall. The mesosalpinx of the Fallopian tube is contiguous with the broad ligament.

The primary blood supply to the uterus comes from the uterine and ovarian arteries. These blood vessels anastomose near the upper lateral aspect of the uterus.  Several veins which form the large pampiniform plexus within the broad ligament collect blood from the upper uterus, the ovary, and the upper part of the broad ligament. .

Trauma to or extension of the hysterotomy at the time of cesarean can lead to broad ligament hematomas. Hematomas may also accompany tubal ligation.  When broad hematomas enter the retroperitoneal spaces, large volumes of blood loss can occur.

Broad ligament hematoma can have a venous or arterial source, or even both. Arterial bleeding usually results in a rapidly expanding hematoma, while venous bleeding typically expand more slowly. Small stable hematomas do not require treatment and can undergo Observation.  When hematomas appears to expand, the clinician should apply direct pressure to the site. Smaller vessels may achieve hemostasis with extended pressure, or at least limit blood loss while the appropriate supplies are collected.    When possible, the clinician can cauterize or suture ligate bleeding vessels. .  

If the uterine artery or a branch is the bleeding source, a uterine artery ligation may be necessary.  The surgeon should take care to avoid the ureter, which crosses under the uterine artery 1-2 cm lateral to the uterus at the level of the internal cervical os. The ureter also courses near the base of the infundibulopelvic ligament.  Exteriorizing the uterus from the abdomen may facilitate ligation and separation from the ureter.  Surgeons often employ the same suture and needle used to close the hysterotomy.  The surgeon passes the needle through the anterior uterine wall, medial to the uterine artery, usually inferior to the bleeding site.  While curving the needle posteriorly, the surgeon uses their nondominant hand to stretch out the broad ligament, and brings the needle through a relatively avascular area within the broad ligament, and then ties the suture securely.  A second uterine artery ligation may be necessary superior to the bleeding site. If the hematoma continues to expand rapidly, pressure should be held while the team obtains blood products. 

Consider consulting an experienced surgeon to assist with opening the retroperitoneal space to ligate individual bleeding vessels. In rare cases, hysterectomy and/or oophorectomy will be necessary. 

When continued bleeding is suspected postoperatively, the team can consider consultation with Interventional Radiology for vessel embolization.

Further Reading:

Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstet Gynecol. 2017 Oct;130(4):e168-e186. doi: 10.1097/AOG.0000000000002351. PMID: 28937571.

Cunningham F, Leveno KJ, Bloom SL, et. al, Obstetrical Hemorrhage. Williams Obstetrics, 25e New York, NY: McGraw-Hill; 2018, Chapter 41.

Initial Approval:  May 2013; Revised March 2017, November 2018, Major revision May 2021; Revised November 2022

 

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