0:01

So this is actually the same patient.

0:03

She represented or was admitted

0:05

and came for a CT scan a day or so

0:08

later because she wasn't improving.

0:09

She still had a postpartum fever, even though

0:12

she was being treated for endometritis.

0:15

So they got a CT scan here,

0:17

and I'll let you look.

0:18

Here is the beginning of the uterus up here.

0:20

We have a fluid collection

0:21

starting right here as well.

0:26

And if you just look at these axial images, it

0:31

can be a little tricky to figure out exactly

0:32

what's going on in this particular patient.

0:35

We can definitely see some air in

0:37

the endometrium that corresponds or

0:39

correlates with our ultrasound images.

0:41

We have a fluid collection anteriorly, and

0:43

I put this little arrow here because this

0:45

is probably the exact same fluid collection

0:47

that we were seeing on the ultrasound, and

0:49

you can see why you couldn't see it that

0:50

well because there's lots of air within it.

0:53

But one thing I like to say is whenever

0:54

you're looking at a uterus-type of

0:56

problem on a CT scan, axial is really

0:59

not going to be your best friend.

1:00

I go to the sagittal.

1:02

So if we go to the sagittal

1:03

sequence on this patient,

1:07

again, you can see an enlarged uterus,

1:09

which we expect she is postpartum

1:11

slightly below the umbilicus, so maybe

1:13

a little bit larger than we expect.

1:15

Endometrium is going to be right here.

1:17

You can see there are foci of gas within it.

1:19

leading right out to the C-section scar.

1:21

We expect the C-section to be right around

1:23

here, and we see that it's full of air.

1:26

That probably isn't normal.

1:28

The other thing that you can see is if

1:30

you follow these foci of gas, they come

1:33

right out into this fluid collection.

1:35

And so this is a dehiscent C-section scar.

1:38

So she has endometritis.

1:39

She has dehiscence of her C-section scar.

1:42

And then this is her bladder right here, but

1:44

we have this gas-containing fluid collection.

1:48

Again, it all meets.

1:49

You can scroll up and down and see

1:50

these all meet gas-containing fluid

1:52

collection anterior to the uterus.

1:53

So she has an abscess.

1:55

So not only the endometritis,

1:56

she has an abscess.

1:58

And then to make things even worse, you

2:00

can see that there is a defect right here.

2:03

In the anterior abdominal wall through which

2:05

mesentery and small bowel loops have protruded.

2:08

So she has dehiscence of her endometrial

2:11

scar in the uterus, I guess, which

2:13

hadn't quite scarred yet, hadn't healed

2:15

dehisced, complicated by an abscess,

2:17

complicated by bowel dehiscence as well.

2:20

So this is uncommon.

2:23

Thankfully, this discontinuity can be

2:27

felt by physical exam on a bimanual exam,

2:29

but that's if the patient is going to be able

2:31

to tolerate that kind of pressure on them.

2:34

And then obviously this is

2:35

going to be a surgical repair.

2:36

This is not going to be a drained abscess.

2:38

This eviscerated bowel needs to be put back in.

2:40

This needs to be cleaned out and

2:43

this needs to be sewn back together.

2:45

So this is a rare complication from a C

2:47

section birth, but something to keep in mind.

2:49

It may not just be endometritis.

2:51

You have to think about dehiscence, abscess

2:53

formation, and at the worst, eviscerated bowel.

2:56

These aren't going to be ultrasound diagnoses

2:58

necessarily, and you're probably going to

2:59

need CT imaging to put all of this together.

3:02

And that's what's going to happen when

3:03

the clinical situation just doesn't match

3:06

with what is going on with the patient,

3:07

when they're not getting better when

3:08

they should with those IV antibiotics.