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C-Section Pseudoaneurysm

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This patient was a 26-year-old who was

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transferred to our institution one day after

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C-section with this non-contrast CT scan.

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

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have had a CAT scan relatively shortly before

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this one because both kidneys are excreting

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contrast, and this right kidney is hydronephrotic

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and that is because she has

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this very large pelvic hematoma.

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So, contrast is thankfully getting to the bladder

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but you really don't see that right here.

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ureter at all.

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We see a little bit of gas down here.

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It's hard to even tell where the uterus itself

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is, but you have this mixed-density process over

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here that is causing a right hydronephrosis.

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So, this is highly concerning

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for a hematoma after C-section.

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So, that's great; we have the

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diagnosis, but that's not good enough.

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

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because that's unusual after C-section.

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I'm going to show you just her sagittal

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imaging too, real quick, before we

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jump to more post-contrast imaging.

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And you can see here, this is

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not, this is her uterus here.

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So, this is an enlarged uterus.

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

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postpartum, but we do have air in the

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endometrium, which again might be normal.

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

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this point, but this uterus is too big.

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And again, we have lots of

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heterogeneous material down here.

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And this whole structure down here, this

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is a very large, very large hematoma.

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So, the patient was transferred to

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our institution, and we got a CTA.

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

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You can see this kidney

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still is excreting contrast.

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She got transferred pretty quickly, but they're

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still trying to excrete the prior contrast.

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We're going to concentrate over here, right?

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There should be no vessels, no

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normal vessels in this area.

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This is the hematoma, and you can

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see this very squiggly line here.

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What should that necessarily be?

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Get a little bit lower,

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and then you can see this puddling right here.

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So, this is active extravasation.

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We're on the arterial phase here, so

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it's probably an arterial problem.

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

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showing you, but that puddle just got a

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little bit bigger, a little bit denser.

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

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These are very uncommon, but you do have to

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think about them, especially when you have a

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

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Treatment for this is either going to be

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hysterectomy, especially if the patient

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isn't stable, or you can go to vascular

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interventional radiology, and they can embolize

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it, which is what ended up happening here.

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They ended up treating it with gel foam.

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and were able to stop the bleeding.

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Here's some imaging from her procedure.

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This is a fourth-order selection, and you

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can see after they inject contrast, you can

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see the pseudoaneurysm filling right there.

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So they did successfully embolize this

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with gel foam, which is non-permanent so

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they could preserve, or hopefully preserve,

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her fertility for future pregnancies.

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So, C-section pseudoaneurysm is a rare

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complication, but it's important to

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keep in mind in the back of your head.

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Usually, this is most commonly going to

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happen due to a weakening or tearing

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within the wall, and then they're going

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to present with vaginal bleeding, and

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if it's bad enough, hypotension as well.

Report

Faculty

Kathryn McGillen, MD

Assistant Professor of Radiology, Medical Director of Ultrasound

Penn State University Milton S Hershey Medical Center

Tags

Vascular

Uterus

Iatrogenic

Gynecologic (GYN)

CT

Body

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