Spontaneous broad ligament rupture following uncomplicated vaginal delivery: A case report.

A 37-year-old woman, gravida 2, para 1, was admitted to the labor unit in spontaneous labor, 7 cm dilated, at 39 + 4 weeks of gestation. She had a history of one previous normal vaginal delivery, and the course of her current pregnancy was unremarkable. Labor progressed normally, and the patient spontaneously delivered a 3255 g female infant. There were no vaginal or perineal tears, and the placenta was delivered intact with minimal blood loss. Four days later, she presented to the emergency room with severe, constant abdominal pain that had begun nine hours earlier. She had no relevant surgical or medical history. She was hemodynamically unstable and drowsy. Heart rate was 123 bpm and blood pressure 94/58 mmHg initially, which then dropped to 59/33 mmHg. Intravenous fluid resuscitation was initiated immediately. Uterine tone was adequate with normal postpartum lochia. The abdomen was distended and sensitive to palpation. Hemoglobin level was 8.4 g/dL. Urgent formal ultrasound performed at the bedside revealed an empty uterus. There was significant free fluid in the abdomen, along the liver edge. A CT scan revealed massive internal bleeding with suspicion of uterine rupture. Because the patient was in hemorrhagic shock, she was immediately taken for laparotomy with simultaneous resuscitative measures and blood transfusion on flow. A midline incision was made, and exploratory laparotomy revealed a tear in the left broad ligament. Extending from beneath the insertion of the utero-ovarian vessels to the cervix ( Fig. 1 ). Bleeding from the uterosacral ligament vessels was noted and controlled with hemostatic sutures. Injury to the liver and spleen was excluded. Total estimated blood loss at this time was 3 l. A total of 5 units packed red blood cells and 2 units fresh frozen plasma were administered. Fig. 1 Anterior view of the left broad ligament rupture. Fig. 1 Anterior view of the left broad ligament rupture. The patient recovered completely following the procedure and after a 1-day admission to the intensive care and 5 days to the ward she was discharged home. No postoperative complications were observed during follow-up. Given the spontaneous nature of the broad ligament rupture in the absence of trauma or instrumental delivery, close monitoring was advised in future pregnancies. While evidence remains limited, an elective cesarean section might be considered, to reduce the risk of recurrence. These considerations and recommendations were thoroughly explained to the patient during her hospitalization and follow-up.

A broad ligament rupture after a normal vaginal delivery is highly uncommon, yet can be life-threatening. Timely diagnosis and appropriate management are crucial to ensuring favorable outcomes. Collaboration between obstetrics and gynecology teams, diagnostic imaging specialists, and vascular surgeons is vital for the rapid and effective treatment of patients in shock. In the future, angiographic identification of the hemorrhagic source and subsequent embolization may provide an alternative to surgery, which remains the standard approach for locating the hemorrhage site and achieving hemostasis. Clear guidelines on the appropriate mode of delivery following a broad ligament rupture are lacking. Given the potential risks, an elective cesarean section may be a prudent option to prevent the possibility of another laceration. Careful antenatal follow-up and delivery planning in a specialized center are advised.

The broad ligament of the uterus is a double-layer fold of peritoneum that attaches the lateral portions of the uterus to the lateral pelvic sidewalls. It is divided into three parts: the mesometrium (the largest portion), the mesosalpinx (mesentery of the fallopian tubes), and the mesovarium (which connects the ovaries to the broad ligament). The broad ligament contains blood vessels, nerves, and lymphatics, and it is also a common site for endometriosis [ 1 ]. Broad ligament hematoma and rupture are rare and may occur as a result of operative vaginal or cesarean deliveries or spontaneously due to uterine artery or vessels rupture. Rapid labor, cesarean section, instrumental deliveries, and trauma have been reported as predisposing factors for broad ligament rupture [ 2 , 3 ]. These hematomas typically result from upper vaginal, cervical, or uterine lacerations extending into the uterine or vaginal arteries. Spontaneous rupture of the uterine artery has been associated with maternal mortality during labor, possibly due to substantial blood pressure fluctuations during delivery. Hormonal changes in pregnancy, especially the influence of estrogen, may also contribute by making blood vessels more susceptible to rupture through the suppression of intimal proliferation in response to vascular injury [ 4 ]. It is noteworthy that a substantial amount of hematoma can accumulate between the folds of the broad ligament, extending into the natural cleavage lines of connective tissue, before manifesting as shock. [ 1 ] The primary symptoms of broad ligament rupture include hypovolemic shock and severe abdominal pain, without active vaginal bleeding. In the majority of cases, patients present with acute hemodynamic instability within hours of delivery [ [4] , [5] , [6] ]. However, in this case, the delayed presentation suggests that bleeding occurred at a slower rate. While rare, broad ligament rupture should be considered in the presence of these signs [ 6 ]. Early detection allows for timely intervention, which may involve fluid resuscitation, blood transfusions, and surgical procedures like hematoma evacuation and vessel ligation [ 7 ]. Several cases of broad ligament hematomas were described in the 1960s and 1970s [ 2 ]. Few cases of spontaneous broad ligament rupture have been reported in women not in labor [ 8 , 9 ]. Zhu et al. reported a case of a woman pregnant with twins who was diagnosed with spontaneous rupture of a broad ligament vein [ 10 ]. Additionally, Soleymanimajd et al. published a case in England of a spontaneous broad ligament tear during early labor [ 11 ]. This case highlights the rare occurrence of broad ligament rupture following a routine vaginal delivery, emphasizing the need for awareness and effective management of this uncommon obstetric complication. Although infrequent, broad ligament rupture can pose serious risks and may lead to significant maternal morbidity and mortality if not promptly identified and treated. Timely intervention was crucial in managing this case. The considerable blood loss underscores the potential for broad ligament rupture to result in significant maternal morbidity. Prompt resuscitative efforts, including blood transfusions, were essential for maintaining hemodynamic stability and ensuring a smooth postoperative recovery. No apparent cause for the broad ligament rupture was identified. The patient's relatively uneventful vaginal delivery, without the need for instrumental assistance, along with the intraoperative findings, suggest that the hematoma and subsequent rupture likely resulted from a spontaneous vessel rupture, probably during labor or delivery. Despite the absence of fetal macrosomia in this case, fetal size may still have been a contributing factor to the broad ligament rupture.

Hemoperitoneum is an uncommon but potentially life-threatening complication in the postpartum period, particularly following an apparently uncomplicated vaginal delivery. Its nonspecific clinical presentation can delay diagnosis and appropriate management, increasing the risk of severe maternal morbidity or mortality. Among the uncommon etiologies, rupture of the broad ligament is an exceptional finding. This structure, composed of a double fold of peritoneum, contains vital vascular and neural elements and is rarely the site of spontaneous rupture in the absence of trauma or surgical intervention. Although broad ligament hematomas have been described following instrumental deliveries or cesarean sections, spontaneous rupture without any apparent predisposing factors remains extremely uncommon. We report a case of massive hemoperitoneum due to spontaneous broad ligament rupture several days after a normal vaginal delivery. We emphasize the diagnostic challenges and the importance of timely surgical intervention.