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 blends with the pelvic sidewall. 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. Blood from the upper uterus, the ovary, and upper part of the broad ligament is collected by several veins which form the large pampiniform plexus within the broad ligament.
Broad ligament hematomas at the time of cesarean may result from either trauma or extension of the hysterotomy into the broad ligament. Hematomas may also accompany tubal ligation. Broad ligament hematomas can result in large volumes of blood loss by dissecting into the retroperitoneal spaces.
The source of a broad ligament hematoma can be venous, arterial, or both. Arterial bleeding usually results in a rapidly expanding hematoma. Venous bleeding typically results in slower expansion. Small stable hematomas do not require treatment and can be monitored. If the hematoma appears to be expanding, direct pressure should be applied to the site. Extended pressure may result in hemostasis of smaller vessels. Pressure will also limit blood loss while supplies are collected. When possible, bleeding vessels should be cauterized or suture ligated as necessary.
If the uterine artery or a branch is the bleeding source, uterine artery ligation is usually necessary. Special care is required when the ureter is nearby. 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. Exteriorizing the uterus may facilitate ligation and separation from the ureter. Surgeons often employ the same suture and needle used to close the hysterotomy. To place the ligature, the area surrounding the bleeding site is pinched between a thumb and one or two fingers. The needle is then passed through the anterior uterine wall, medial to the uterine artery, usually inferior to the bleeding site. As the needle is curved around posteriorly, the surgeon uses their nondominant hand to stretch out the broad ligament. The needle is brought through a relatively avascular area of the broad ligament. This suture is then tied 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 blood products are obtained. 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, consultation with Interventional Radiology for vessel embolization should be considered.
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
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