Retzius space haematoma with retroperitoneal dissection after spontaneous vaginal delivery: an unusual presentation of ruptured paravesical plexus managed by bilateral internal iliac artery ligation

IntroductionAbdomino-pelvic hematomas during pregnancy, labor or postpartum are severe and rare hemorrhagic complication that result from rupture in the pelvic vessels. Principles of surgical management of pelvic hematomas and postpartum hemorrhage are well known and documented and are of high clinical interest.AimWe report a rare case of hematoma following vaginal delivery.Case studyA patient with a Retzius space hematoma after vaginal delivery presented with hemodynamic instability and abdominal distension with suprapubic bulge in the postpartum period. Ultrasound examination showed a heterogeneous mass between bladder and uterus suspicious of hematoma with another retroperitoneal one associated with right hydronephrosis.ResultsExploratory laparotomy was performed that revealed a hematoma in the Retzius’ space with infiltration of the wall of the bladder with extension to the paracolpos space and the right broad ligament to the retroperitoneal space. The bleeding source was suspected to be the blood vessels in the wall of the bladder that were hemostatically sutured. Bilateral uterine artery ligation with bilateral internal iliac artery ligation were done to control hematoma and atony and vertical vertical compression sutures were done for uterine atony. The hemorrhage was found to be secondary to rupture in the paravesical venous vessels.DiscussionHematoma in the Retzius’ space is a rare complication. It needs urgent diagnoses and management. Few cases were reported in the literature. The condition may pose diagnostic problems, as pelvic bones let only a limited examination, but requires an undelayed handling. This was illustrated by determining a complete extent of the hematoma only intraoperative. The authors made an accurate diagnosis and applied a necessary treatment in an urgent situation. The technique of the vessel ligation was a demanding, but optimal solution.ConclusionsThis article focuses attention at an uncommon obstetrical situation and delivers actual and practical advice for management.