A 25 year old G1P0 who was 24 weeks pregnant was admitted with suspected acute abdomen. There was no history of trauma and she was stable from an obstetric point of view with unremarkable blood results. Her abdominal symptoms were progressive and she underwent diagnostic laparoscopy.
After atraumatic Hassan entry at the umbilicus a significant haemoperitoneum including old clot was found, estimated around 800mls, with a Haemaccue drop to 70g/L from 117 g/L on initial presentation. Exploration revealed normal appearing ovaries and tubes but defects were noted in the broad ligaments with ongoing fresh bleeding.
Access was difficult due to the gravid uterus and conversion to midline laparotomy proceeded. Bilateral full thickness defects of the broad ligaments were noted with multiple exposed bleeding vessels which were sutured to achieve haemostasis. A Blake drain was left in and the abdomen closed.
The patient remained stable and discharged home on day 11 post surgery. At this stage the pregnancy continues with no apparent foetal effects on ultrasound assessment.
Very few cases of atraumatic rupture of the broad ligament in pregnancy have been reported, and none previously with ongoing pregnancy after diagnosis. In humans, one case was assumed to be secondary to horse carriage riding a week prior to symptoms and the other was associated with cocaine abuse (1). Broad ligament injury after trauma is equally rare with a single case reported post pelvic fracture associated with a severe MVA (2). In addition, there have been a few case reports of spontaneous broad ligament tear intrapartum.
One study on 31 pregnant mares that died of broad ligament haematoma peripartum suggested arterial injuries most commonly happen in the proximal uterine artery. Atrophy of smooth muscle cells with fibrosis of the arterial wall was one of the predisposing factors found on pathology examination (3).