0:01

This patient was a 26-year-old who was

0:04

transferred to our institution one day after

0:06

C-section with this non-contrast CT scan.

0:10

So, on review of this, you can see she must

0:12

have had a CAT scan relatively shortly before

0:14

this one because both kidneys are excreting

0:17

contrast, and this right kidney is hydronephrotic

0:22

and that is because she has

0:24

this very large pelvic hematoma.

0:28

So, contrast is thankfully getting to the bladder

0:30

but you really don't see that right here.

0:32

ureter at all.

0:33

We see a little bit of gas down here.

0:35

It's hard to even tell where the uterus itself

0:37

is, but you have this mixed-density process over

0:41

here that is causing a right hydronephrosis.

0:43

So, this is highly concerning

0:44

for a hematoma after C-section.

0:47

So, that's great; we have the

0:48

diagnosis, but that's not good enough.

0:50

We need to know why there's such a big hematoma

0:52

because that's unusual after C-section.

0:56

I'm going to show you just her sagittal

0:57

imaging too, real quick, before we

0:59

jump to more post-contrast imaging.

1:02

And you can see here, this is

1:03

not, this is her uterus here.

1:06

So, this is an enlarged uterus.

1:07

She is only, at this point, one to two days

1:09

postpartum, but we do have air in the

1:11

endometrium, which again might be normal.

1:13

She's only one day post-C-section at

1:15

this point, but this uterus is too big.

1:19

And again, we have lots of

1:20

heterogeneous material down here.

1:22

And this whole structure down here, this

1:23

is a very large, very large hematoma.

1:27

So, the patient was transferred to

1:29

our institution, and we got a CTA.

1:32

Again, we'll come back up a little bit higher.

1:35

You can see this kidney

1:36

still is excreting contrast.

1:38

She got transferred pretty quickly, but they're

1:39

still trying to excrete the prior contrast.

1:42

We're going to concentrate over here, right?

1:44

There should be no vessels, no

1:46

normal vessels in this area.

1:47

This is the hematoma, and you can

1:48

see this very squiggly line here.

1:52

What should that necessarily be?

1:55

Get a little bit lower,

1:58

and then you can see this puddling right here.

2:01

So, this is active extravasation.

2:03

We're on the arterial phase here, so

2:04

it's probably an arterial problem.

2:07

We did get a venous phase, which I'm not

2:08

showing you, but that puddle just got a

2:10

little bit bigger, a little bit denser.

2:12

So, this is a pseudoaneurysm after a C-section.

2:18

These are very uncommon, but you do have to

2:20

think about them, especially when you have a

2:22

larger-than-expected hematoma after a C-section.

2:26

Treatment for this is either going to be

2:27

hysterectomy, especially if the patient

2:29

isn't stable, or you can go to vascular

2:32

interventional radiology, and they can embolize

2:35

it, which is what ended up happening here.

2:37

They ended up treating it with gel foam.

2:40

and were able to stop the bleeding.

2:42

Here's some imaging from her procedure.

2:45

This is a fourth-order selection, and you

2:47

can see after they inject contrast, you can

2:49

see the pseudoaneurysm filling right there.

2:53

So they did successfully embolize this

2:55

with gel foam, which is non-permanent so

2:57

they could preserve, or hopefully preserve,

2:59

her fertility for future pregnancies.

3:02

So, C-section pseudoaneurysm is a rare

3:04

complication, but it's important to

3:05

keep in mind in the back of your head.

3:07

Usually, this is most commonly going to

3:09

happen due to a weakening or tearing

3:10

within the wall, and then they're going

3:12

to present with vaginal bleeding, and

3:14

if it's bad enough, hypotension as well.