In today’s episode, we’re pulling another one from our grab bag of pathology questions.
As always, I’m joined by Dr. Mike Natter from BoardVitals. If you are looking for some more help with your board prep, go to BoardVitals.com and check out everything they have to offer. Use the promo code BOARDROUNDS to save 15% off
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Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.
[02:04] Question of the Week
A 28-year-old woman presents to the emergency room with a painful lower abdominal mass two days after undergoing a C-section. Her pregnancy was significant for gestational diabetes, malposition, and macrosomia with a 4,558-gram baby. That’s a big baby.
There is a bloody discharge from her abdominal wound. Her physical exam reveals tachycardia, pallor, mild abdominal distension, and a tender mass at the left lower quadrant of the abdomen.
A CT scan reveals a hematoma at the abdominal wall. What is the most likely site of injury during the C-section that led to this hematoma?
(A) left renal artery
(B) left ovarian artery
(C) left colic artery
(D) abdominal aorta
(E) inferior epigastric artery
[02:59] Thought Process Behind the Correct Answer
This is a question that will test your anatomy basically. So left renal artery left ovarian left colic. Kidneys are in the back right. And the renal artery coming off of the aorta. Abdominal aorta just seems too far back right.
If a hopefully competent surgeon is in there taking the baby out, coming from interiorly unless they’re doing some new cool posterior C-section, I just don’t see left renal artery being affected there. So answer choice A is out.
Left ovarian artery is just too far to the left. And everything I know about C-sections, everything I’ve seen about C-sections being in them, is that it’s all so midline that a left ovarian artery, again just seems way too far out of the way.
The wound where the hematoma is on the abdominal wall. So a hematoma from a left ovarian artery would probably be more posterior, probably hiding a lot more than something that’s right there. So answer choice B is out too.
So another thing probably to think about here is the left colic artery. If it were abdominal aorta, that person wouldn’t be dead, so that’s not an issue. So answer choice D is out.
For answer choice E, inferior epigastric artery is a lot more central, superficial. And so this bleeding would be there. There would be a hematoma there that wouldn’t kill a person. So the correct answer here is E.“It’s important to not only know your anatomy in terms of the vessels but also the anatomy in reference to a C-section.”Click To Tweet
Basically, when you’re talking about a C-section, the left colic is also kind of deep. It comes off the aorta, which is going to try and get over to your left side of your colon. So these are things that are really far in a way from the site of where you’re cutting in order to do this C-section. Hence, answer choice C is out.
What they’re also getting at, if you notice, is the rectus sheath. It’s a rectus sheath hematoma, which is unfortunate, but it’s a possible complication of these C-sections and all the other arteries.
If it were abdominal aorta, and two days postop, she would have been dead in like minutes, maybe even seconds. You would see a retroperitoneal bleed, which is ecchymosis on the sides and the back. You would definitely not be seeing a hematoma in the anterior area.
Right off the bat, you know that this got to be an artery that’s going to be involved and or near the site of incision.
And it’s a relatively superficial branch. It’s unfortunately one of those things that can get in the way. And so you quickly just go ahead and ligate that and that usually solves the problem.
[07:10] If You’re Not Familiar with C-Sections
A first and second year medical student may be concerned not being familiar with a C-section. But based on your anatomy and based on the fact that you’ve opened up a cadaver at this point, you’ve studied from the textbooks and letters that you have a sense of kind of where everything is in the neighborhood.
Just keep that in mind. But it’s true that a lot of folks who are about to sit for the Step 1 exam may have not had any clinical exposure yet. So that’s a good point.“A C-section is a very benign kind of common surgery that most people are going to be aware of.”Click To Tweet
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