Management of Panniculus Gangrene After Cesarean Hysterectomy for Placenta Accreta: A Case Report

Introduction

There is a strong association between cesarean sections and the complication of placenta accreta spectrum (PAS) disorders, and it is expected to increase with increasing cesarean rates globally [1]. PAS occurs when the placenta abnormally adheres to the myometrium of the uterine wall. This can result in potentially life-threatening maternal hemorrhage if not diagnosed during pregnancy or when manually removing the placenta during delivery, leading to high mortality rates [2]. PAS disorders are associated with significant morbidity; patients are more likely to be admitted to an intensive care unit, require mechanical ventilation, and have infections, with multi-organ failure leading to extended hospital stays [3]. In this case, the patient experienced a critical postpartum hemorrhage, which was complicated by sepsis and renal failure. Ultimately, she had a severe and rare complication known as panniculus skin gangrene. Panniculus fatty necrosis is an uncommon complication of obstetrics and gynecology procedures, and few cases have been published [4–6]. Abdominal wall skin and subcutaneous fat necrosis commonly occur following abdominoplasty due to insufficient perfusion [7]. Based on multiple comorbidities of the patient, negative-pressure wound therapy (NPWT) was applied successfully to manage wide skin and subcutaneous wound defects. Remarkably, NPWT achieved wound healing without skin grafting, indicating NPWT’s potential to improve outcomes in complex cases.

Case Report

A 40-year-old woman with twin pregnancy, para 5, had a history of iron deficiency anemia and had 4 previous low transverse cesarean sections. She was diagnosed with dichorionic diamniotic twin pregnancy during her first antenatal visit at 14 weeks of gestation and had been under the care of a feto-maternal obstetrician ever since. Her body mass index (BMI) was 21.57/kg/m2. Her antenatal workup showed anterior complete placenta previa of twin A with a history of mild to moderate antepartum hemorrhage at 30 weeks of gestation, and she completed a course of antenatal corticosteroids (dexamethasone). Also, she had a pelvic magnetic resonance imaging (MRI) at 28 weeks of gestation that showed no evidence of placenta accreta. She received multiple intravenous iron treatments to optimize her hemoglobin level. She underwent an elective low transverse cesarean section at 35 weeks of gestation.

During the cesarean section, it was found that she had a focal placenta accreta, as there was no sign of placental separation; manual removal of the placenta was conducted, and the placenta was delivered in fragments, which caused severe bleeding. The surgeons applied multiple hemostatic sutures, uterotonic medications, as well as tranexamic acid, and initiated a massive blood transfusion protocol. After various uterine compression efforts, hemostasis was achieved, and the uterus was preserved. The estimated blood loss during the surgery was 4 L, and the patient was transferred to the intensive care unit (ICU). However, within 4 hours of completing the cesarean section, she started to re-bleed and required inotropes and further blood transfusion. Therefore, an emergency hysterectomy was performed using the previous Pfannenstiel incision, during which 1 L of hemoperitoneum was extracted, and a total hysterectomy was performed, without complications. The uterus was sent to histopathology, which confirmed the diagnosis of placenta accreta. After the procedure, the patient was transferred back to the ICU, gradually taken off inotropes, successfully extubated, and underwent echocardiography (ECHO), which showed an ejection fraction of (EF) 55%. In the first 24 hours, she received 12 units of packed red blood cells, 6 units of cryoprecipitate, 6 units of platelets, and 6 units of fresh frozen plasma. Her condition improved by postoperative day 2, and transfer to the obstetrics ward was planned.

However, on postoperative day 3, her condition deteriorated abruptly, and she experienced fever, abdominal pain, distention, and developed acidosis. She had septic shock and disseminated intravascular coagulopathy due to a widespread E. coli infection (in the blood, urine, and peritoneal area) and non-occlusive bowel ischemia. She required reintubation, inotropes, and broad-spectrum antibiotics (meropenem and vancomycin). Vancomycin was discontinued after obtaining the result of E. coli bacterial culture sensitivity (Table 1).

By postoperative day 9, she developed acute ischemia in her upper and lower limbs, resulting in blackish discoloration and gangrene of the distal digits. She underwent debridement by the plastic surgery team and received daily wound care. Subsequently, her status was complicated by congestive heart failure (EF 35%) and renal failure, and she began hemodialysis on postoperative day 13. Repeated CT scans showed improvement in peritonitis and bowel ischemia. She received ongoing supportive care from a multidisciplinary team, including obstetrics and gynecology, general surgery, hematology, infectious disease, vascular surgery, plastic surgery, nephrology, and wound care.

On the 30th day after the operation, there was an increase in abdominal swelling with massive skin gangrene and fat necrosis of the entire pannus (Figure 1A, 1B). CT scans are valuable for excluding necrotizing fasciitis in the differential diagnosis of panniculus gangrene; they assess the fascia and the extent of gas and necrosis, which aids in decision-making for debridement and further wound management. The CT scan of the abdomen and pelvis showed a subcutaneous collection with multiple air pockets in the lower abdominal wall measuring 1.5×6.2×6.6 cm; it also showed extensive wound opening and rupture in the abdominal wall, along with diffuse fat stranding, free fluid, and multiple gas bubbles. There were abdominopelvic partially organized collections measuring 4.9×10.9×7.5, and there were no features of bowel ischemia, with an intact fascial layer (Figure 2A-2C).

The patient had an ultrasound-guided drainage procedure, which revealed an organized subcutaneous collection of hematoma, with only 1 mm of bloody fluid aspirated. Cultures from the wound and central line showed the presence of Candida auris, and the hematoma culture was positive for VRE Enterococcus faecium. The patient was treated with broad-spectrum antibiotics and antifungals (meropenem, Caspofungin, and linezolid) based on bacterial and fungal culture sensitivity tests (Tables 2, 3). Extensive skin and fat tissue debridement were performed by the Gynecology and Plastic Surgery teams, leaving huge skin and subcutaneous defects of the whole pannus. The size of the remaining subcutaneous defect was approximately 25×14×5 cm. After debridement, the wound was covered with a Promogram Collagen Matrix dressing, which serves as a conformable scaffold for cellular growth and helps maintain a moist wound environment. Following the application of the dressing, negative-pressure therapy was initiated using a sponge placed on the matrix, which was then secured with a semi-occlusive barrier. This setup creates an airtight dressing that is compatible with the application of subatmospheric pressure. The macro-deformation and decompression resulting from this therapy promote the drainage of excess fluid. The patient underwent daily dressing changes with NPWT set to moderate continuous mode at 50 mmHg to facilitate secondary intention closure. Pathological examination of the removed tissues confirmed that the subcutaneous tissues were infarcted. Due to the abdominal collection being undrainable and the patient’s condition being unsuitable for another surgery, she was monitored with 4 sequential CT scans to assess the response to antibiotics and antifungals. The first 2 scans were conducted at weekly intervals and showed a decrease in the size of the abdominal collection. This was followed by another 2 scans spaced 3 weeks apart, which demonstrated further reduction in the collection.

During her ICU stay, she received 21 units of packed red blood cells, 16 units of cryoprecipitate, 27 units of platelets, and 18 units of fresh frozen plasma. By postoperative day 60, she had undergone repeated blood cultures, resulting in the clearance of bacteremia and fungemia. Afterwards, she was discharged from the ICU and transferred to the ward. The heart failure was resolved. Considering the patient’s condition, which included end-stage renal disease (ESRD) requiring hemodialysis, the team discussed the increased risk of postoperative morbidity, including infections [8] associated with surgeries such as skin grafting. Given these factors, the patient and her medical team decided to continue with NPWT. She also received ongoing care from psychiatry, physiotherapy, and social worker services throughout the hospital stay.

The wound responded well to the NPWT, showing significant contraction and granulation, as illustrated in Figure 3, which was captured on postoperative day 80, 50 days after the debridement procedure. Because the patient lived in a rural area where no home wound care team was available, she continued hospitalization to receive daily dressing and NPWT. Over time, there was progressive re-epithelialization without the need for a skin graft, ultimately leading to complete healing of the wound. The patient was discharged on postoperative day 116, 86 days after abdominal wall debridement (Table 4). She was scheduled for home healthcare and follow-ups with plastic surgery, nephrology, and social workers to ensure continuity of care. She was seen in the gynecology clinic for follow-up. She had ESRD, requiring hemodialysis twice weekly, and she is still following up with occupational therapy and physiotherapy for the complication of peripheral limb ischemia. Figures 4 and 5 demonstrate 1-year follow-up after debridement.

Discussion

Panniculus fat liquefaction and necrosis with significant skin gangrene is a rare complication following obstetric and gynecological surgery. About 30% of patients with placenta accreta will experience infectious complications, such as abdominal wound infections, vaginal cuff cellulitis, peritonitis, pneumonia, and pyelonephritis [9]. In this case, peripheral limb ischemia gangrene and abdominal wall gangrene with fat necrosis occurred due to severe ischemia and inflammation of the blood vessels caused by hypovolemia and septic shock, leading to hypoperfusion of the skin and subcutaneous tissues of the abdomen and digits. In addition, pannus subcutaneous fat has a relatively low vascular supply; a histopathological study of resected panniculus showed that 42% of patients had associated artery calcification, and half had microscopic adipocyte necrosis [10]. It is likely that vascular calcification occurred, which could impede blood flow and potentially lead to fat necrosis. Both conditions may be associated with chronic inflammation resulting from sepsis and kidney failure. A similar issue has been reported in a patient with chronic kidney disease who experienced postoperative sepsis and skin and fat necrosis [11]; the experience of a patient with kidney failure suggests possible links but may not represent all patients. Overall health, comorbidities, and variations in surgical techniques can affect outcomes. Additionally, a subcutaneous hematoma may have contributed to the progression of subcutaneous fat necrosis, as seen in a previous case involving a morbidly obese patient after a total hysterectomy [4].

Obesity and poor glucose control can increase the risk of wound infection and fatty tissue necrosis. Research has shown that these factors are associated with other abdominal wall fat necrosis cases in obstetrics and gynecology [4–6]. Although this patient had a normal BMI, she developed a large pannus because of her twin pregnancy. Also, she had a normal glucose tolerance test (GTT) during pregnancy, and there was no evidence of diabetes in the postpartum period or during her hospital stay.

In this case, the pelvic MRI showed no evidence of placenta accreta. However, according to a meta-analysis by D’Antonio et al, MRI is highly accurate in detecting PAS disorders, with a sensitivity of 94.4% (95% CI 86.1% to 97.9%) and a specificity of 84.0% (95% CI 76.0–89.8%) [12]. False-negative results in MRI for placenta accreta can have significant implications. It is important to note that this patient’s condition was managed as a high-risk pregnancy, considering the potential risk of hemorrhage. Preoperatively, 6 cross-matched blood units were made available. The patient was followed by a fetal medicine consultant in obstetrics at a tertiary care center, where a massive transfusion protocol, an experienced gynecologist skilled in cesarean hysterectomy, and an ICU were readily accessible. In a cohort study [13], 11% of patients (n=6) had false-negative MRIs; all these patients underwent hysterectomies, with half requiring admission to the ICU. One patient had severe postpartum hemorrhage, which was complicated by massive blood transfusion and sepsis. Factors that influence the interpretation of MRI results include the timing of the MRI study, especially if it is conducted beyond 24 to 30 weeks of gestation. In this case study, the patient underwent an MRI at 28 weeks of gestation. Another factor that could affect the accuracy of the MRI is motion from the fetus or the mother. This is particularly relevant in fast spin echo sequences, which provide better tissue contrast and signal-to-noise ratios but can be affected by artifacts caused by motion, potentially obscuring the evaluation of the placenta [14].

Placenta accreta can lead to severe bleeding during delivery, and when treated conservatively, may necessitate multiple surgeries and ICU admission. Early diagnosis is essential in mitigating these risks and improving patient outcomes. To reduce bleeding during incidental intraoperative diagnosis of placenta accreta spectrum (PAS), several approaches can be considered. These include performing focal placental resection when dealing with a localized area of accreta, using a tourniquet both prophylactically and therapeutically around the uterine isthmus after fetal extraction, and applying intrauterine balloon tamponade. Additionally, adjuvant internal iliac embolization may also be recommended [15]. Determining the primary source of sepsis is challenging; it may stem from an indwelling Foley catheter (E. coli), or possibly from a deep wound surgical site infection (E. coli) [16], or a combination of both. Methods to lower the likelihood of perioperative infections in cases of placenta accreta, alongside standard antibiotic prophylaxis, involve multiple strategies. Recent studies indicate that performing a vaginal preparation with a 4% chlorhexidine gluconate scrub prior to cesarean deliveries and hysterectomies yields better results than using povidone–iodine. Currently, there is no evidence suggesting that vaginal preparation raises the risk of serious vaginal bleeding in patients with previa or placenta accreta spectrum (PAS) [16,17]. Promoting early ambulation and early removal of the Foley catheter can also help reduce the risk of postoperative infections.

Following the debridement of abdominal fat and subcutaneous tissues, the patient received NPWT, significantly reducing wound complications. NPWT has been recognized worldwide since 1997, when Morykwas et al published the first positive results of vacuum-assisted closure, an innovative foam NPWT system for wound management [18]. This advanced therapy facilitated efficient exudate management and minimized edema, enhancing tissue healing. Further, NPWT promotes faster recovery by reducing microbial loads and minimizing the risk of post-surgical infections; it is also considered an alternative to skin grafting when there are contraindications. NPWT eliminated the need for skin grafting in a patient with panniculus gangrene who underwent abdominal hysterectomy and facilitated recovery, with complete healing in 82 days [4], while another post-cesarean section patient also had a similar outcome in a comparable time [5]. NWPT promotes accelerated wound healing while minimizing associated complications, which is a significant advancement in wound care.

Conclusions

The presented case of placenta accreta complications illustrates how postpartum hemorrhage, ischemia, and septic shock can result in long-term morbidity, such as ESRD and a rare complication – pannus gangrene with fat necrosis. The key role of supportive care in the patient’s recovery cannot be overstated. The effective coordination of the multidisciplinary team’s activities played a key role in addressing the complex complications and facilitating the patient’s steady recovery. The skills of each specialist helped to stabilize her condition, reverse multi-organ failure, and implement new wound care practices, such as NPWT. Gauze-based NPWT effectively treats immense skin and subcutaneous wound defects without requiring skin grafting.