A Rare Combined Hematoma of the Retzius Space and Broad Ligament Complicating Short Second-Stage Labor: A Case Report

In the complex geography of the human body, the pelvis is a crowded room filled with muscles, bones, and a dense network of blood vessels. Among these vessels are delicate, valveless networks that act like a sponge, filling with blood to support the growing weight of a pregnancy. When a woman gives birth, these tissues stretch and shift. Usually, the process is gradual, allowing the body to adapt. However, when labor moves with sudden, intense speed, the force can tear these fragile vessels before the body has time to adjust. This can lead to a hidden danger: a collection of blood that forms deep inside the body, away from the skin and far from the usual signs of bleeding. Unlike a cut on the arm that weeps visibly, this internal bleeding can pool in the empty spaces between organs, creating a silent, expanding mass that presses on the bladder and other structures. Because the blood does not flow out of the body, a patient might look pale and weak while appearing to have only a minor injury, making it one of the most deceptive and dangerous complications in childbirth.

A recent report from a hospital in Shandong, China, details a rare instance of this hidden crisis, where a woman suffered a massive internal bleed in two distinct areas of her pelvis simultaneously. The patient was a thirty-three-year-old mother who had just given birth to her second child. While the first part of her labor lasted nearly nineteen hours, the final stage, when the baby is pushed out, happened with startling speed, taking only twenty-seven minutes. This rapid expulsion, known in medical terms as a short second-stage labor, created a sudden, violent stretching of the pelvic tissues. Three hours after the delivery, the woman began to feel a deep, unrelenting pain in her lower abdomen and found she could not urinate. Although she had no significant bleeding from the vagina, her blood pressure dropped, and her heart raced. Tests revealed that her blood count had fallen sharply, a clear sign that she was losing a large volume of blood internally, even though it was not visible to the eye.

When doctors performed an ultrasound, they discovered the source of the trouble: a huge pocket of blood, measuring fourteen point four centimeters by nine point two centimeters by nine point zero centimeters, had formed in the space behind the pubic bone and in front of the bladder. This area, known as the Retzius space, is a potential gap that usually contains only a thin layer of tissue. In this case, the rapid labor had torn the delicate venous plexus in this space, causing blood to leak out and fill the cavity. But the story did not end there. Further investigation showed that the bleeding had also spread into the broad ligament, a fold of tissue that supports the uterus on the side. The result was a dual-compartment hematoma, a massive collection of blood occupying two separate but connected spaces within the pelvis. This specific combination of injuries is exceptionally rare, and the fact that it occurred in such a short labor suggests that the sudden mechanical force was the direct cause.

The medical team faced a difficult decision on how to stop the bleeding. A common treatment for postpartum hemorrhage involves a procedure called arterial embolization, where a catheter is threaded through an artery to block the source of the bleed. However, the doctors realized this approach would likely fail in this case. The bleeding was not coming from a single, high-pressure artery that could be plugged; instead, it was a slow, widespread ooze from many tiny, torn veins. Blocking an artery would not stop the blood leaking from these venous networks. Furthermore, the sheer size of the blood clot was pressing on the bladder and causing severe pain, a problem that a minimally invasive procedure could not fix. The only way to save the patient was to open the abdomen, remove the clots, and stitch the bleeding vessels directly.

During the surgery, the team found exactly what the scans had predicted. Between the abdominal muscles and the pelvic lining, they encountered a massive accumulation of blood clots. As they carefully cleared the area, they saw the raw, torn veins in the retropubic space, oozing blood from multiple points. They also found a specific, distinct bleeding spot deep in the broad ligament, located beneath a major ligament that holds the ovary. The surgeons used absorbable stitches to tie off the bleeding vessels and applied a special sponge to help stop the slow oozing in the wider areas. They then repaired the torn tissue layers and placed a drainage tube to ensure no new blood could collect in the empty space. In total, they removed about thirteen hundred milliliters of clotted blood, and the patient received a transfusion of six units of red blood cells to replace what she had lost.

The outcome was a complete recovery. The patient's pain vanished quickly, her blood pressure stabilized, and she was able to urinate normally again within two days. She was discharged five days after the surgery with no further complications. This case highlights a critical lesson for medical care: when a woman experiences unexplained weakness, severe lower abdominal pain, and trouble urinating after a very fast delivery, doctors must suspect a hidden internal bleed even if there is no external blood. The rapid nature of the labor likely tore the delicate venous networks in two places at once, creating a situation where only open surgery could provide the necessary view to stop the bleeding and relieve the pressure. While the authors note that this is a single case and more data is needed to form universal rules, the success of this operation demonstrates that recognizing the signs of this rare, concealed emergency and acting with open surgery can be the difference between a life-threatening crisis and a full recovery.