Hematoma espontáneo del ligamento ancho luego de un parto vaginal normal: reporte de caso / Spontaneous hematoma of the broad ligament after a normal vaginal delivery: case report / Hematoma espontâneo do ligamento largo após um parto vaginal normal: apresentação de um caso clínico

La hemorragia posparto es una de las principales causas de muerte materna con una elevada morbimortalidad. El hematoma del ligamento ancho representa una entidad inusual, de difícil diagnóstico y alta sospecha clínica. Se presenta el caso clínico de una paciente con un hematoma del ligamento ancho espontáneo luego de un parto vaginal. Se optó por una conducta activa con laparotomía y antibioticoterapia obteniendo una buena evolución con egreso hospitalario a los 30 días. Se realiza la discusión del caso luego de revisar la bibliografía disponible.

Postpartum hemorrhage is one of the main causes of maternal death with high morbidity and mortality. The broad ligament hematoma represents an unusual entity, difficult to diagnose, in which clinical suspicion is determinant. The clinical case of a patient with a spontaneous broad ligament hematoma after a vaginal delivery is presented. An active management with laparotomy and antibiotic therapy was chosen, obtaining a satisfactory evolution with hospital discharge at 30 days. The case is discussed, after reviewing the available bibliography.

A hemorragia pós-parto é uma das principais causas de morte maternal com alta morbidade e mortalidade. O hematoma do ligamento largo representa uma entidade incomum, de difícil diagnóstico e alto suspeita clínica. A presentamos o caso clínico de uma paciente com hematoma espontâneo do ligamento largo, após parto vaginal. Foi optada por conduta ativa com laparotomía e antibioticoterapia, obtendo boa evolução com alta hospitalar após 30 dias. O caso é discutido depois de revisar a bibliografia disponível.

Acute abdominal pain due to internal herniation of the sigmoid colon, fallopian tube and left ovary, a rare presentation of Allen Masters syndrome.

In 1955, Allen and Masters describe a painful syndrome which associates traumatic delivery to laceration found on the posterior leaf of the broad ligament. Herniation through this defect is a rare entity, accounted for about 4-7% of all internal hernias. Normally, it involves the small bowel. The authors present the case of a multiparous woman admitted at emergency for constipation and abdominal pain. The CT scan showed an extremely rare case of internal hernia of the sigmoid colon, fallopian tube and left ovary through a large defect of the broad ligament. The patient underwent a full laparoscopic surgery that allowed the reduction of the hernia and the suture of the defect with very good outcome.

[ALLEN-MASTERS SYNDROME AS A CAUSE FOR CHRONIC PELVIC PAIN: DIAGNOSIS, TREATMENT AND LONG TERM FOLLOW-UP].

Chronic pelvic pain is one of the main causes for repeated ambulatory and hospital visits. The main findings on exploratory laparoscopy performed for these complaints are endometriosis and adhesions, while in more than 50% of cases, no cause for the pain is found. In 1955, Allen and Masters reported pain associated with traumatic labor. They reported retroverted and hyper-mobile uterus in all women and during operation, tears in the posterior serosa of the broad igament. A few therapeutic options have been discussed, including repair of the tears, but without long term follow-up and significant relief of symptoms. Tightening of the utero-sacral ligaments following peritoneal resection of the Douglas as a long effective treatment was initially suggested in France in 1972. In 1997, von Theobald showed that it could be conducted by laparoscopy with long term follow-up. We report 3 cases of women diagnosed with Allen-Masters Syndrome, the surgical treatment performed and the long follow-up of these patients. We also discuss the ways to diagnose the syndrome and the preferred modality of treatment.

Síndrome de Allen Master: causa excepcional de abdomen agudo en el embarazo / Allen Master syndrome: exceptional cause of acute abdomen in pregnancy

Se presenta un caso de abdomen agudo en una gestante de 20 semanas, por una torsión anexial. Ante la ausencia de signos ecográficos compatibles con patología en los primeros momentos y el empeoramiento clínico, se solicitó una RMN que permitió la aproximación diagnóstica y facilitó la indicación urgente de cirugía abdominal. En el curso de la laparotomía se diagnosticó una hernia interna del anexo, con marcado componente vascular a través de un defecto del ligamento ancho, que obligó a la anexectomía. Tras el diagnóstico y el tratamiento realizado, la gestación continúa con buenos resultados materno-fetal. Estos orificios han sido presentados excepcionalmente como causa de hernias internas digestivas, urológicas y anexiales, siendo controvertido su origen, congénito, inflamatorio o traumático. Se repasan las pruebas complementarias indicadas en el manejo diagnóstico del dolor abdominal en el embarazo, incluyendo las últimas recomendaciones de la European Society of Urogenital Radiology-ESUR.

A case of acute abdomen in a pregnant 20 weeks is presented with an adnexal torsion. In the absence of pathologic ultrasound signs with in the early stages and clinical worsening, was requested an MRI that allowed the diagnostic approach and the indication for urgent abdominal surgery. During laparotomy was observed an internal adnexal hernia through a defect in the broad ligament, with marked vascular component which forced the adnexectomy. After the diagnosis and treatment performed, the pregnancy continues with good maternal and fetal outcomes. These defects were presented exceptionally as a cause of digestive, urological and adnexal internal hernias. The origin remains controversial, congenital, inflammatory or traumatic. Complementary tests in the diagnostic management of abdominal pain in pregnancy are reviewed, including the latest recommendations of the European Society of Urogenital Radiology-ESUR.

Allen-Masters syndrome: do the classic risk factors also apply in patients with endometriosis?

AIM: To evaluate whether the classic risk factors for Allen-Masters syndrome, such as body mass index (BMI) and spontaneous births, are in fact responsible for the condition in patients with endometriosis. METHODS: A total of 26 women who underwent a laparoscopic procedure due to chronic pelvic pain, Allen-Masters syndrome and endometriosis from 2009-2011 were enrolled in this study from an endometriosis competence center specializing in minimally invasive surgery. This was a retrospective cohort study (Canadian Task Force classification II-2). RESULTS: Only eight of the 26 patients (30.77%; 95% confidence interval [CI], 14.33-51.79%) had the classic risk factors (BMI >25 kg/m(2) and/or at least one spontaneous birth). The mean age in the study group was 32.08 years (SD ± 5.45). The patients had a mean BMI (kg/m(2) ) of 19.61 (SD ± 3.07). The means for the patients' clinical data were 0.88 (SD ± 1.53) pregnancies, 0.81 (SD ± 1.23) for parity, 0.27 (SD ± 0.60) for cesareans and 0.54 (SD ± 0.99) for spontaneous births. The revised American Society for Reproductive Medicine (rASRM) stage showed a median of grade III. The left side of the posterior compartment was more often affected (73.1% of cases) than the right side in all patients. CONCLUSION: In all, 69.23% of the cases (95% CI, 48.21-85.67%) were not explained by the classic risk factors. In view of the absence of other diseases and otherwise unremarkable parameters, we consider mechanical damage of the lesser pelvis not to be solely responsible for AMS. Further observations in patients with AMS, with and without endometriosis, may be able to contribute to research into the actual etiology of the condition.

Strangulated hernia through a defect in the broad ligament: a sheep in wolf's clothing.

Small bowel obstruction due to an internal hernia is an uncommon finding and, when caused by a defect in the broad ligament, it is exceptionally rare. This condition should be considered when evaluating all female patients presenting with de novo small bowel obstruction. We report an unusual case of intestinal obstruction from an internal hernia through the left broad ligament in a middle-aged patient with no prior surgical history and discuss the relevant literature and treatment. Although an oncologic diagnosis should be entertained, a small bowel obstruction arising in the pelvis may involve the broad ligament in parous patients. An internal hernia through the broad ligament should be considered in the differential diagnoses of female patients presenting with intestinal obstruction.

Pathology of lethal peripartum broad ligament haematoma in 31 Thoroughbred mares.

REASONS FOR PERFORMING STUDY: Broad ligament haemorrhage in peripartum mares is a life-threatening disease and there are few reports on the aetiology and pathogenesis of broad ligament haematoma. OBJECTIVES: To obtain information regarding the sites for the early diagnosis and pathogenesis of broad ligament haematoma of mares. METHODS: Thirty-one mares that died of broad ligament haematoma peripartum were examined pathologically for bleeding sites. The arterial distribution of 5 young mares with several parities served as negative controls. RESULTS: Age and/or multiparity were the predisposing factors for the disease. Arterial injuries were most commonly observed in the uterine artery (24 of 31 mares). Among these, the proximal uterine artery that lies within 15 cm of the bifurcation of the iliac artery was the most frequent site for rupture (18 mares). The lesions occurred preferentially at the bifurcations, lateral part of curvatures and abrupt flexures of the artery. The morphology of the injuries was classified into 3 types: ruptures with and without longitudinal fissures, and transections. Histologically, the arterial wall adjacent to the rupture showed atrophy of smooth muscle cells with fibrosis of the tunica media and disruption and/or calcification of the internal elastic lamina. CONCLUSIONS: Arterial injuries that led to broad ligament haematoma in peripartum mares occurred most frequently in the proximal uterine artery, and atrophy of smooth muscle cells with fibrosis of the arterial wall was as one of the predisposing factors in aged and multiparous mares. POTENTIAL RELEVANCE: Monitoring small aneurysms, mural tearing, medial fibrosis at the proximal uterine artery by transrectal echography could provide useful information for the early diagnosis and possible prevention of broad ligament haematoma of peripartum mares.

Right-sided low inguinal pain in young women.

Young women with right iliac fossa pain are commonly referred to general surgeons as possible acute appendicitis. The differential diagnosis that includes pelvic visceral disease may be very difficult to determine clinically, especially when the history and physical signs are equivocal. We believe that diagnostic accuracy may be improved by eliciting precisely the site of abdominal pain. Right-sided low inguinal pain may be referred from the female pelvic viscera in the same way as testicular pain may be referred to the groin, as these viscera derive their autonomic nerve supply from the T10-L2, mainly T12-L1, spinal segments in both sexes. There are no previous reports of the value of the symptom of right-sided low inguinal pain in differentiating pelvic visceral disease from acute appendicitis in young women. This paper reports a prospective study of the discriminant value of this symptom in such patients.

[Pelvic pain related to pelvic ligament support]. / Algies pelviennes liées à des troubles de la statique pelvienne.

In the context of organic pelvic pain, alongside post-infectious pain or pain related to endometriosis, ruptured ligaments of the pelvic fascia are an important cause of the pelvic congestion syndrome well known to classical authors. Surgical treatment combines two procedures: suture of the tear and exclusion of the pouch of Douglas.

Hysterectomy at the time of cesarean section: analysis of 108 cases.

One hundred eight cases of cesarean hysterectomy are analyzed. Important differences in operative complications and postoperative morbidity between elective and emergency cases are emphasized. Elective cases had a higher incidence of urinary tract injury but a much lower incidence of excessive blood loss, blood transfusion, and febrile morbidity. Transfusion was required in 19% of all operations, including 66.6% of emergency cases and 11.8% of elective operations. Febrile morbidity occurred in 30.5% and morbidity of all types in 35.2% of patients. A close correlation is demonstrated between operating time and febrile morbidity. No maternal mortality occurred in this series. Operative injury to the urinary tract, adnexal bleeding, broad ligament hematomas, vaginal cuff bleeding, and adequate identification of the cervix are problems that must be dealt with when performing a cesarean hysterectomy. Details of operative technique are described that address these problems and minimize blood loss and postoperative morbidity.