Severe Complications of Uterine Dehiscence Post-Lower Segment Cesarean Section: A Case Report Emphasizing the Importance of Timely Diagnosis and Intervention

Introduction

Over time, the global rates of lower segment cesarean section (LSCS) have notably risen, starting from approximately 7% in 1990 to 21% presently, exceeding the World Health Organization’s recommended ideal LSCS rate of 10% to 15% [1,2]. Multiple LSCS can be performed safely; however, they can lead to complications in subsequent pregnancies. Uterine scar dehiscence is a rare condition, occurring in approximately 0.6% of cases worldwide [3]. It can result from various causes, including prior LSCS, uterine trauma, congenital anomalies, abnormal placentation, and inappropriate oxytocin administration [3,4]. Patients can present with postpartum hemorrhage, endomyometritis, and peritonitis, either immediately after childbirth or a few weeks later. Diagnosis relies on clinical suspicion and radiological imaging, such as ultrasonography and computed tomography (CT) scans [5]. Early diagnosis and treatment are crucial to minimize morbidity, especially in future pregnancies. Uterine scar dehiscence should be considered as a rare but important cause of postpartum localized or generalized peritonitis with sepsis, particularly when severe abdominal wound infection follows a LSCS [6].

The term uterine dehiscence is generally used to refer to the process of gradual myometrial rupture without a rupture of membranes. However, the term is used synonymously with the term uterine rupture. Uterine dehiscence is often described in the context of a LSCS scar, where it is also termed an incisional dehiscence [7]. Dehiscence can be partial or complete.

Uterine dehiscence following LSCS is a relatively rare [4] but critical complication, often linked to the development of puerperal sepsis. This condition carries significant risks, including the potential for infection-related complications, such as peritonitis and abscess formation, primarily arising from compromised uterine closure and scar tissue integrity [3,8]. Faulty myometrial approximation during LSCS can yield similar outcomes, underscoring the importance of precision during the procedure. Various factors can contribute to the weakening of the lower uterine segment or incisional wound, including technical suturing, suture material, emergency situations, and other causes. The delay in diagnosing and managing uterine dehiscence can have severe consequences, leading to substantial morbidity and mortality.

We report the case of a 28-year-old pregnant woman with 2 previous LSCS with puerperal sepsis accompanied by intra-abdominal abscess formation associated with uterine dehiscence. The patient experienced fever and abdominal pain, highlighting the pressing need for early recognition and prompt treatment. Laparotomy with drainage and diagnostic laparoscopy have proved to be effective interventions for managing these cases.

Case Report

Past Obstetrics History

PAST OBSTETRICS HISTORY:

A 28-year-old woman who was in her third pregnancy and had a history of LSCS 9 and 13 years ago and an appendectomy 2 years ago presented at 35+4 weeks of gestation to another facility with preterm labor. She received dexamethasone and terbutaline during a 4-day admission. She returned at week 37+5 in labor and underwent LSCS with tubal sterilization, receiving intravenous (i.v.) cefazolin.

The LSCS involved a double-layer technique for uterine incision closure. The uterine suturing was conducted using chromic catgut material. The first layer was secured with continuous locking using chromic catgut No. 1, followed by the second layer sewn continuously with chromic catgut No. 0. Adhesions around the right uterus and omentum were noted and removed. Tubal sterilization was performed. The surgical site was meticulously closed with nylon 3-0, and the entire procedure lasted 1.30 h. During surgery, a malfunction in the negative pressure air system in the operating room led to uncomfortable conditions in the second half of the procedure. A thin lower myometrial segment with severe adhesions was noted intraoperatively.

She was discharged on the third day but experienced persistent lower abdominal pain, fever, and foul-smelling vaginal discharge. After 2 hospital visits, she was referred to Siriraj Hospital due to high-grade fever, severe abdominal pain with guarding, diarrhea, nausea, and vomiting. Before referral, she received Cef-3, 2 g once a day, and metronidazole 500 mg i.v. infusion every 8 h. A whole abdomen CT scan identified uterine dehiscence, prompting further evaluation and management.

CT SCAN OF HER ENTIRE ABDOMINAL REGION REVEALED SIGNIFICANT FINDINGS: Identification of fluid accumulation with concomitant air bubble formation from the lower uterine segment raised concerns about potential uterine dehiscence at her prior LSCS scar site. Remarkable abscess formation, characterized by dimensions of 6.5×1.4×3.6 cm and 2.1×3.4×2.3 cm, were noted in the subhepatic region and the right paracolic gutter, measuring 4.6×2.9×15.2 cm and 4.7×4.5×5.6 cm, respectively (Figures 1, 2).

PRESENT OBSTETRICS HISTORY:

The patient, following a recent LSCS with tubal sterilization and adhesiolysis 9 days prior, was referred to Siriraj Hospital due to troubling symptoms, including pyrexia, abdominal discomfort, irregular vaginal discharge, and malodorous odor. A CT scan revealed fluid accumulation, air bubble formation, and substantial abscesses in the abdominal region.

Upon admission, the initial laboratory findings signaled septicemia linked with uterine dehiscence, characterized by an elevated white blood cell count, elevated alkaline phosphatase levels, and irregularities in coagulation. Swift interventions encompassed a targeted antibiotic regimen (gentamicin, ampicillin, clindamycin) and an exploratory laparotomy designed to address the septicemia and uterine dehiscence.

LABORATORY FINDINGS:

Her initial laboratory results upon admission had the following findings:

An elevated white blood cell count of 28 140/mm³, predominantly neutrophils (92%) with an absolute neutrophil count of 26 310/µL.

Elevated alkaline phosphatase levels of 122 U/L.

Coagulation anomalies, including a prothrombin time of 13.1 (10.7–12.6) s and an activated partial thromboplastin time of 27.9 (22–30) s.

Upon admission to Siriraj Hospital, urgent therapeutic measures were initiated, including the commencement of antibiotic therapy consisting of gentamicin (240 mg once daily), ampicillin (2 g every 6 h), and clindamycin (900 mg every 8 h).

Additionally, an exigent exploratory laparotomy was conducted following the diagnosis of septicemia associated with uterine dehiscence.

During the intraoperative exploration, various observations were made, including the detection of a 5-mL collection of pus in the subcutaneous tissue and intra-abdominal accumulations containing aged blood and pus, measuring 100 mL within the anterior lower abdomen and the right paracolic gutter. Examination of the uterus revealed a total lower uterine dehiscence spanning 10 cm, marked by fragility and the presence of necrotic tissue at the lower uterine segment and surgical margins, as well as within the parametrium (Figure 3). Other findings included a significant attachment of the bladder to the lower segment of the uterus, intraabdominal adhesions extending from the omentum to the right lateral abdominal wall, and unremarkable characteristics of the cervix and adnexae. A comprehensive surgical approach was undertaken, involving a total abdominal hysterectomy (Figures 4, 5), abdominal toileting, and a blood transfusion to address substantial blood loss. During this procedure, an estimated blood loss of 1500 cc was recorded, necessitating the transfusion of 2 units of packed red blood cells. Abdominal toileting was performed using 2 L of normal saline solution combined with povidone. Jackson drains were carefully placed within the right paracolic gutter and vaginal stump. The abdominal wall was meticulously closed layer by layer, with the skin securely closed using staples. Postoperatively, the patient’s antibiotic regimen was adjusted to ampicillin/sulbactam (3 g every 6 h). She was positioned in a semi-fowler position for 3 days, facilitating the adequate drainage of pus from the subhepatic region.

On the third day following the surgical procedure, it was deemed appropriate to remove the Jackson drain, as the volume of its contents had significantly reduced, measuring only 1 to 2 cc. Subsequent pus culture analysis confirmed the presence of E. coli, which exhibited susceptibility to ampicillin/sulbactam.

However, the patient experienced a recurrent pattern of fever and abdominal discomfort upon the removal of the Jackson drain, along with disruption of the abdominal wound (Figure 6). In response to these concerns, a repeat CT scan was performed, revealing the persistence of pus collection in the subhepatic region and the right paracolic gutter, although with a reduction in size (Figure 7).

To address this evolving condition, a plastic surgeon was consulted to oversee wound care, which incorporated the use of vacuum dressings (Figure 8). These dressings were meticulously replaced every 3 days to ensure optimal wound management. Simultaneously, an interventional radiologist was engaged to perform percutaneous drainage under ultrasound guidance (Figure 9). The antibiotic regimen was modified to ertapenem (1 g i.v., once daily).

Remarkably, the patient displayed a significant reduction in fever and an overall improvement in her condition. She regained her ability to consume food and beverages without experiencing discomfort. After a comprehensive 7-day regimen of percutaneous drainage and vacuum dressings, the decision was made to remove the percutaneous drainage following an ultra-sound examination that confirmed the absence of any residual pus or content within the paracolic gutter. After 7 days of vacuum dressing, the abdominal wound displayed healthy healing (Figure 10) and was then carefully sutured with nylon 3-0.

The patient underwent a thorough 2-day observation period, during which no complications emerged. Ertapenem was subsequently transitioned to oral augmentin for a 7-day duration. The patient returned to the hospital 7 days later for the removal of sutures, without complications.

Discussion

This case report highlights the critical importance of recognizing and addressing uterine scar dehiscence, a rare yet potentially serious complication following cesarean sections. The case highlights how this condition, often mistaken for uterine rupture, can lead to severe consequences, such as puerperal sepsis and intra-abdominal abscesses. It is important to maintain a high index of suspicion for uterine scar dehiscence, particularly in women with a history of cesarean deliveries who present with symptoms such as abdominal pain, fever, or malodorous discharge. Timely diagnosis is essential for initiating appropriate management and preventing further complications.

The rising global LSCS rates have led to an increase in associated complications. Infections, such as wound infections and endometritis, are common after cesarean deliveries. Other risks include thromboembolism, anesthetic complications, and fetal trauma, although these are generally lower than in vaginal deliveries. Long-term risks for mothers include the potential need for future cesarean deliveries, which can increase surgical risks and complications with each subsequent procedure. Adhesion formation from cesarean deliveries can complicate future surgeries and raise injury risks. Additionally, the risk of abnormal placental placement, such as placenta accreta, rises with each cesarean delivery, potentially leading to severe hemorrhage and fertility issues, particularly with multiple cesarean sections [9,10]. Other complications include puerperal infections, endometritis, wound disruption, thrombophlebitis, chronic pelvic pain, adhesions, uterine scar dehiscence, and placental anomalies [8,11].

Some studies identified several factors that increase the risk of uterine scar dehiscence, including preterm delivery, lack of progress in the first stage of labor, and having multiple previous cesarean deliveries [12]. Furthermore, an analysis revealed that previous laparoscopic and abdominal myomectomies are linked to uterine rupture during pregnancy, with hysteroscopic myomectomy being associated with earlier gestational ages [13].

Postpartum uterine dehiscence, although rare, is characterized by the reopening of the incision line after a LSCS, with incidence rates ranging from 0.2% to 1.5% for low transverse incisions and about 4% to 9% for classical incisions [11]. Risk factors for this condition include diabetes, emergency surgery, closure technique, puerperal infection, and hematoma at the incision site [14]. The condition’s pathophysiology typically begins with a severe infection in the uterine layers, leading to necrosis of the weakest part, often the cesarean incision [15]. Improper closure techniques, such as tight locking sutures, can also contribute to myometrial ischemic necrosis [16]. Symptoms of early uterine dehiscence range from postpartum bleeding to mild pelvic pain and suprapubic sensitivity [11]. In cases of late uterine dehiscence, symptoms include sepsis, anemia, fever, tachycardia, suprapubic tenderness, and vaginal tenderness, due to the spread of infection to the peritoneal cavity [15].

Uterine scar dehiscence can lead to peritonitis, and treatment varies depending on the severity of infection. Antimicrobial treatment is usually sufficient if the infection is limited, but surgical intervention is necessary if there is uterine incisional necrosis. In some cases, peripartum hysterectomy can be required [17].

Infection associated with uterine dehiscence can manifest with symptoms such as fever, tachycardia, anemia, and signs of sepsis, along with suprapubic and vaginal tenderness. Diagnosis and treatment often involve exploratory laparotomy, and conservative resuturing can be an option, especially when there is no severe wound infection [18]. Choden et al [19] presented a case of uterine wound dehiscence with pelvic abscess following a cesarean section, characterized by symptoms of paralytic ileus and surgical site infection. Spontaneous cesarean scar dehiscence only 4 months after previous cesarean delivery was reported [20]. This case underscores the importance of thorough evaluation and readiness to address such complications during pregnancy, particularly in women with previous cesarean scars.

Failure to diagnose and treat uterine scar dehiscence promptly can result in long-term complications, including heavy menstrual bleeding abnormalities. Additionally, future pregnancies in affected individuals carry a risk of scar rupture, necessitating careful assessment and vigilance.

In one study, magnetic resonance imaging (MRI) showed the appearance of uterine dehiscence in patients after LSCS and differentiated between complete and partial dehiscence [7]. Over 82 months, 55 patients who had undergone pelvic MRI after cesarean section were included. Five patients exhibited indications of incisional dehiscence on MRI. Among these, 2 had confirmed complete dehiscence during surgery, while 3 displayed signs of partial dehiscence. The optimal imaging plane was found to be perpendicular to the incision. The findings suggest that MRI features can effectively identify complete uterine dehiscence and can outperform CT scans in this context [7].

The number of prior cesarean deliveries is the primary risk factor for uterine dehiscence. Unrepaired dehiscence can lead to symptoms even outside of pregnancies and can require repair. Dehiscence should also be addressed before subsequent pregnancies. The preferred management strategy involves planned delivery before the onset of labor, with careful symptom monitoring. Additionally, ultrasonography should be used to assess lower uterine segment thickness in women with prior cesarean deliveries. This evidence-based review is relevant for health-care professionals involved in managing uterine dehiscence in pregnancy and subsequent pregnancies [21].

The present case aligns with previous reports on postpartum uterine dehiscence, which often manifests with symptoms such as abdominal pain, fever, and vaginal discharge. The diagnosis typically involves imaging studies, such as CT scans, to confirm uterine dehiscence and assess for associated complications, such as abscess formation. Laboratory findings indicating infection, as seen in this case, further support the diagnosis. Clinical course management is consistent with existing literature, emphasizing the importance of antimicrobial treatment for limited infections and surgical intervention for cases involving uterine incisional necrosis. Peripartum hysterectomy can be required in severe cases to prevent complications such as peritonitis.

This case underscores the significance of using meticulous suturing techniques when closing the uterine incision during LSCS. Ensuring a secure uterine wound closure is imperative to reduce the risk of complications, such as uterine scar dehiscence. The proper selection of suture material plays a pivotal role in upholding the integrity of uterine closure. Careful consideration should be given to choosing appropriate suture material that provides the requisite strength and support, thereby minimizing the risk of wound dehiscence.

Adequate postoperative drainage is a critical aspect of patient care. This case emphasizes the importance of maintaining effective drainage mechanisms to prevent the accumulation of fluids or pus, which can lead to complications such as infections and wound disruption. Patients with a history of multiple prior obstetric procedures, including LSCS and other surgeries, can be at an increased risk of complications. The presence of adhesions and altered anatomy can make subsequent surgeries more complex.

This case highlights the crucial role of a smoothly operating surgical environment. Unforeseen glitches, like the air system malfunction described in this scenario, can disrupt the comfort and productivity of the surgical team, potentially leading to complications.

Performing an emergency LSCS, especially in cases with thin myometrial segments, can elevate the risk of wound rupture and postoperative complications. Considerations of urgency and patient condition are essential in decision making. The experience and proficiency of the surgical team, particularly the surgeon, significantly influence the outcome of complex procedures, like LSCS. Surgical skill, decision making, and teamwork are crucial factors in patient outcomes and complication prevention.

Conclusions

This report emphasizes the significance of recognizing uterine scar dehiscence, despite its rarity, as a potential diagnosis in women with previous cesarean deliveries who develop symptoms such as abdominal pain, hemorrhage, or abdominal sepsis during subsequent pregnancies. Early recognition and prompt intervention are essential to ensure timely management and improve outcomes for the mother and fetus or unborn infant. Diagnostic modalities, such as CT scans and ultrasonography, play crucial roles in confirming the diagnosis, but suspicion should prompt expedited exploratory laparotomy without delay. Timely diagnosis and treatment are paramount to minimize morbidity, particularly in the context of future pregnancies.