Discussion

This case has two main clinical implications. First, ISMAD can occur in the early postpartum period after cesarean delivery, even in a woman without a relevant medical or family history or evidence of connective tissue disease. ISMAD predominantly affects middle-aged men, with a systematic review reporting a mean age of 55.7 years and a male predominance of 80.6% [2]. In contrast, our patient was a young woman who developed ISMAD during the early postpartum period following cesarean delivery. Although a previous case of ISMAD occurring shortly after childbirth has been reported [7], to the best of our knowledge, the present case is the first reported occurrence of ISMAD following cesarean delivery. The patient’s age, sex, obstetric status, and temporal association with cesarean delivery therefore distinguish this case from the typical population affected by ISMAD and further highlight its rarity. Second, the diagnosis may be easily overlooked because the clinical picture can mimic more common postoperative complications. In the present case, anemia, abdominal distension, and pelvic hemoperitoneum made postoperative bleeding a plausible initial consideration. However, the sudden onset of upper abdominal pain and the contrast-enhanced CT findings revealed a visceral arterial dissection that required a different diagnostic and management approach.

ISMAD is increasingly recognized because of the widespread use of high-resolution CT. Nevertheless, it remains uncommon and is reported predominantly in middle-aged men. Systematic reviews have shown that many patients can be managed conservatively, particularly when intestinal ischemia and arterial rupture are absent [1-3]. The postpartum setting is markedly different from the typical patient population. Pregnancy and the postpartum period are associated with dynamic hemodynamic, hormonal, and coagulation changes, but the exact mechanism by which childbirth or cesarean delivery might contribute to ISMAD remains uncertain. Therefore, any causal relationship should be interpreted cautiously.

The key diagnostic lesson of this case is the importance of avoiding premature diagnostic anchoring after cesarean delivery. Postpartum abdominal pain is common, and postoperative bleeding, ileus, endometritis, urinary tract complications, and gastrointestinal disorders are often considered first. However, severe, abrupt, persistent, or anatomically unusual pain should prompt evaluation for less common but potentially serious vascular conditions. Contrast-enhanced CT is particularly useful because it can simultaneously evaluate postoperative hemorrhage, active extravasation, the mesenteric vessels, bowel perfusion, and other intra-abdominal complications.

Management of ISMAD should be based on symptoms, hemodynamic status, vascular morphology, distal perfusion, and the presence or absence of intestinal ischemia. Conservative management generally includes blood pressure control, bowel rest or dietary modification when clinically needed, analgesia, close clinical observation, and follow-up imaging. Endovascular or surgical treatment is usually reserved for patients with persistent or worsening abdominal pain, bowel ischemia, arterial rupture, aneurysmal progression, or failure of conservative therapy [4-6]. In the present case, conservative treatment was considered appropriate because there was no contrast extravasation, the distal superior mesenteric artery branches were patent, and there were no imaging signs of bowel ischemia.

The postpartum case previously reported after childbirth was also managed conservatively and had no recurrence during long-term follow-up [7]. To our knowledge, the present case is the first reported case of ISMAD after cesarean delivery. This distinction is clinically relevant because cesarean delivery introduces postoperative factors that can obscure the diagnosis, particularly anemia and hemoperitoneum. The diagnosis should therefore be considered not only in spontaneous postpartum abdominal pain but also in postoperative patients when the symptoms are disproportionate or not fully explained by routine postoperative findings.

Follow-up imaging is important after conservative treatment. Morphologic improvement or remodeling of the dissected segment can occur over time, but surveillance is needed to confirm stability and detect potential complications such as progression, aneurysmal dilatation, or branch compromise [8]. In this patient, follow-up contrast-enhanced CT at 12 months showed that the lesion had become less conspicuous, supporting the appropriateness of the initial conservative strategy.

This report has several limitations. First, it describes a single patient, and the mechanism of ISMAD after cesarean delivery cannot be determined from this case alone. Second, because the cesarean delivery was performed at the referring hospital, detailed intraoperative information, including the presence of adhesions, peritoneal or mesenteric abnormalities, the extent of intra-abdominal manipulation, and the closure technique, was unavailable. Therefore, we could not assess whether any specific surgical maneuver or mechanical factor contributed to the development of ISMAD, and the temporal association with cesarean delivery should not be interpreted as evidence of causality. In addition, because postpartum ISMAD is extremely rare, the optimal duration and frequency of follow-up imaging remain uncertain. Despite these limitations, this case provides a practical message for clinicians: when postpartum abdominal pain is atypical, severe, persistent, or disproportionate to the expected postoperative course, contrast-enhanced CT can be decisive in identifying uncommon vascular causes and preventing delayed diagnosis.