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Management of Broad Ligament Extension and Hematoma during a Cesarean Delivery

5/1/2013 - Paul J. Wendel, MD

Editor:  Regan Theiler, MD

 

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 blends with the pelvic sidewall. The fallopian tubes, ovaries, and round ligaments are found within the upper portion of the broad ligaments and have their own separate mesentery. The mesosalpinx of the Fallopian tube is contiguous with the broad ligament.

The primary blood supply to the uterus is via the uterine and ovarian arteries. These blood vessels anastomose near the upper lateral aspect of the uterus. The uterine wall is occupied by many venous sinuses. Blood from the upper uterus, the ovary, and upper part of the broad ligament is collected by several veins which come together within the broad ligament to form the large pampiniform plexus.

Broad ligament hematomas may occur at the time of cesarean delivery as a result of either trauma or extension of the uterine incision into the broad ligament. Hematomas within the mesosalpinx may also occur during or following tubal ligation. Small stable hematomas usually require no treatment and can simply be monitored. Enlarging broad ligament hematomas may dissect into the large presacral space or the retroperitoneal spaces along the lateral pelvic sidewalls.

The source of a broad ligament hematoma can be venous, arterial, or both. Arterial bleeding usually results in a rapidly expanding hematoma and may appear bright or dark red. Venous bleeding typically results in slow expansion and may appear dark red or bluish. If the hematoma appears to be expanding, direct pressure should be applied to the site and the hematoma evaluated for further expansion. Obvious bleeding sites should be identified, and suture ligated as necessary. If the hematoma continues to expand, uterine or ovarian artery ligation should be considered.

Ureteral compromise is a concern if either vessel requires ligation. The ureter crosses under the uterine artery 1-2 cm lateral to the uterus at the level of the internal cervical os and is also at risk near the base of the infundibulopelvic ligament. If bleeding persists and the hematoma is rapidly expanding within the retroperitoneal space, the retroperitoneal space should be opened to identify and ligate individual bleeding vessels. If continued bleeding is suspected postoperatively, consultation with Interventional Radiology for vessel embolization should be considered. In selected cases, where all other measures have failed to control the bleeding, a hysterectomy may be indicated.

Further Reading:

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

 

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