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Case report

Uterus-sparing surgical treatment of suture necrosis after caesarean section - case series report

Radojka Cerović Popović1, Jovana Ćupić1, Olga Mihaljević1, Kosta Pantović1, Miloš Radojević1,2
  • Clinic for Gynecology and Obstetrics, University Clinical Center of Serbia
  • University of Belgrade, Faculty of Medicine

ABSTRACT

Introduction: Delivery by caesarean section (CS) accounts for approximately 32% of all deliveries worldwide, and it may be associated with early and late complications. Although postpartum uterine suture necrosis is not a common condition, it is associated with high morbidity and mortality in puerperal women, as well as permanent loss of fertility in these patients. In this article, we present seven patients successfully treated conservatively, who were diagnosed with uterine suture necrosis, during puerperium, after caesarean section.

Case series report: We present 12 female patients in whom, in the period between February 1, 2019 and November 10, 2022, infection occurred after caesarean section was performed at the Clinic for Gynecology and Obstetrics of the University Clinical Center of Serbia (CGO, UCCS), and clinical suspicion of the presence of uterine suture necrosis arose. Of the total number of patients diagnosed with uterine suture necrosis, seven patients were successfully treated conservatively.

Conclusion: The uterus-sparing surgical treatment approach to uterine suture necrosis is a possible alternative to standard treatment, which may allow fertility preservation in patients who have not completed reproduction.


INTRODUCTION

Cesarean section (CS) is one of the most common major obstetric operations and accounts for approximately 32% of all deliveries worldwide. As with all surgical procedures, CS can be associated with early and late complications. These include bleeding, wound infection, endometritis, uterine suture necrosis, and postpartum hysterectomy, in the short term, as well as long-term problems such as placentation disorders in subsequent pregnancies, chronic pelvic pain stemming from adhesions in the lesser pelvis, as well as menstrual disorders [1],[2].

Uterine suture necrosis after CS is not a common condition. Its frequency is between 0.06% and 3.8% [2]. It is associated with high morbidity and mortality of puerperal women, primarily due to the development of intra-abdominal infection and systemic inflammatory response. The standard treatment is hysterectomy, which represents a problem in young female patients who want to preserve their fertility [1],[2].

Uterine suture necrosis requires a multidisciplinary approach and, depending on the severity of the clinical presentation, a uterus-sparing (debridement of the wound and re-stitching of the incision on the uterus) or a radical surgical approach (hysterectomy) is possible [2],[3].

In this article we present seven female patients with a diagnosis of uterine suture necrosis, in puerperium, after caesarean section, who were successfully treated conservatively.

CASE SERIES REPORT

At the Clinic for Gynecology and Obstetrics of the University Clinical Center of Serbia (CGO, UCCS), in the period between February 1, 2019 and November 10, 2022, 12 patients who developed an infection after cesarean section and had a clinical suspicion of uterine suture necrosis were hospitalized. Out of the total number of patients diagnosed with uterine suture necrosis, seven patients were successfully treated sparingly (Table 1), while the remaining five patients underwent total classic hysterectomy with preservation of the ovaries.

Table 1. Case reports of sparingly treated patients

Table 1. Case reports of sparingly treated patients

The average age of the patients was 32.4 years (the youngest patient was 21 years old, while the oldest was 49 years old). Caesarean sections in all seven patients whose uterine suture necrosis was treated with a uterus-sparing procedure were performed at the CGO of the UCCS, of which five were emergency procedures (due to premature detachment of the placenta and development of fetal asphyxia), while the other two were elective procedures (in which the indications were twin pregnancy and condition after CS). The clinical presentation of puerperal infection in the described patients appeared on the second postoperative day, at the earliest, and on the sixteenth postoperative day, at the latest. Only in one patient, due to intraoperative bleeding, the B-Lynch uterine suture was performed. Five of the seven patients had no previous pregnancies.

In six patients, the clinical presentation manifested with typical signs and symptoms of infection in the form of elevated inflammation parameters (increased serum CRP level, elevated body temperature, tachycardia) and abdominal pain with intestinal peristaltic disorder. In the remaining patient, the clinical presentation developed in the form of a hematoma at the uterine incision site, with consequent low hemoglobin values (hemoglobin value 103 g/L, then after 36 hours a drop to 75 g/L was observed), which resulted in the replacement of four doses of concentrated erythrocytes of the appropriate blood group.

In all patients, transvaginal and transabdominal ultrasonography visually confirmed a deviation from the normal findings for the corresponding postpartum day, such as the presence of free fluid in the pelvis, hematoma (a formation of mixed echogenicity) in the area of the incision on the uterus, or a thinned uterine wall in the area of the incision. In three patients, dehiscence of the incision on the uterus was verified with computed tomography (CT).

Microbiological analyses (lochia swab and/or uterine swab) showed that Escherichia coli was isolated in four patients, methicillin-resistant Staphylococcus aureus (MRSA) was found in one patient, while, in two patients, the causative agent of infection was not identified with conventional microbiological methods.

Once the general health status of the patients during the early postoperative course after caesarean section started to deteriorate, all of them were examined, and a multidisciplinary decision was made to perform a relaparotomy and to proceed according to the findings, in six patients, while, in one patient, it was decided to continue the treatment with polyvalent antibiotic therapy, with intensive monitoring. In two patients, the decision to undergo surgery was made and the surgery itself was performed on the first postoperative day (within 24 – 48 h); in two other patients this was done on the second postoperative day (48 – 72 h), while it was the fourth, fifth and twelfth postoperative day, for the remaining three patients.

Due to the age of the patients and their desire to preserve fertility, in six patients the decision was made to try uterus-sparing surgical treatment instead of hysterectomy, and debridement and resuturing of the uterine wound was performed (as well as evacuation of the described hematomas in one patient). One patient was treated with conservative therapy (antibiotic and supportive therapy, with intensive monitoring). In the five remaining patients treated for infection during puerperium, the decision was made to perform hysterectomy, with preservation of the ovaries. The decision on radical treatment (hysterectomy) was made due to a more severe form of the systemic inflammatory response, a worse initial response to the application of therapy, and more extensive damage of the uterus by necrosis and infection.

Intraoperatively, in five patients, the presence of fibrin deposits at the site of the uterine incision was noted, the uterus was softer than normal, there were partially necrotic sections of the suture, there were adhesions between the genital organs and the parietal peritoneum and the sigmoid colon, and finally, the presence of turbid free fluid in the pelvis was noted. In contrast, a different finding was noted in two patients. In one patient, the presence of a hematoma in the region of the rectus abdominis muscles and the incision of the uterus, with a necrotic suture, was noted. The one remaining patient was not treated operatively.

After reoperation, the postoperative recovery of all patients was without further clinical complications. The patients were treated with polyvalent antibiotic therapy, with intensive monitoring. The shortest length of hospitalization in sparingly surgically treated patients was 11 days, while in the remaining five patients, it was more than 20 days, and the longest was 33 days. The patient who did not undergo reoperation was treated in-hospital for 28 days. After successful conservative treatment, the patients were discharged in good general health and, after the first check-up was performed by the surgeon, they were later followed up at the primary health care level.

DISCUSSION

In gynecology and obstetrics, uterine suture necrosis after caesarean section is a significant problem because it is associated with increased morbidity and mortality of puerperal women and their loss of reproductive function. According to Al Shahed et al, this type of complication after caesarean section poses a major clinical challenge in diagnosis and further management, mainly because of its nonspecific symptomatology. The most reported clinical symptoms were in the form of increased body temperature, abdominal pain, elevated inflammatory parameters, and sepsis, which was consistent with the clinical symptoms of the presenting patients [4]. In the presented series of cases, a sonographic examination of the pelvis was sufficient to determine the existence of a pathological process in the area of the uterine incision, while most of the other authors report that MR and CT were performed for the purpose of diagnosis [2],[4],[5]. Considering the fact that in most of the described cases the patients were of reproductive age, uterine suture necrosis was successfully treated conservatively, as the local intraoperative findings allowed reconstruction of the uterine wall. There are few data in literature on successful conservative treatment of suture necrosis after caesarean section, while the standard approach is hysterectomy [2],[4],[6].

Given that all patients presented with abdominal infection, they were treated with polyvalent antibiotic therapy, before and after relaparotomy. Patients previously started on broad-spectrum antibiotic therapy, with a multidisciplinary approach, intensive surveillance, and the presence of minor concomitant complications and comorbidities are considered to have a good prognosis [4],[7]. S. aureus, Klebsiella pneumoniae, and E. coli are reported as the most common causes of wound infections. In the presented patients, in most uterine swabs, E. coli was isolated, while S. aureus was isolated in the uterine swab of one patient [8]. In one of the patients, in whom the clinical presentation of uterine suture necrosis developed on the second postoperative day, a large number of E. coli was isolated from the uterine swab, which may be causally related to the occurrence of uterine suture necrosis. In the second patient, whose symptoms appeared on the second postoperative day, the causative agent of the infection was not isolated, while the diagnosis of suture necrosis was made at reoperation.

In the analyzed series of cases, in the patient whose early postoperative recovery was complicated primarily by the development of clinical and ultrasonographic presentation of uterine hematoma at the site of the caesarean section, no difference in the dynamics of the drop in hemoglobin levels in the blood count was observed, as compared to the other patients presented. This may be due to the small number of cases or the rather wide range (500 – 1,000 ml) of estimated blood loss during caesarean section.

Placement of a B-Lynch suture during cesarean section is associated with a higher rate of uterine suture necrosis and, consequently, postpartum hysterectomy [9]. In the presented series of cases, in one patient with a twin pregnancy, during cesarean section, it was decided to reinforce the sutures with B-Lynch compression sutures, due to profuse intraoperative bleeding and uterine hypotonia. During the third postoperative day, because of the deterioration of the patient’s general health status, the maintenance of low values of coagulation parameters despite the compensation of concentrated erythrocytes (four doses), as well as due to the gynecological examination and ultrasound findings indicating the existence of a clearly delineated swelling corresponding to a hematoma, it was decided to perform a relaparotomy, based on vital indications, and to proceed according to the findings. Intraoperatively, the presence of uterine suture necrosis, which occurred in the area of the inflamed hematoma, was demonstrated.

One of the innovative therapeutic approaches to treating uterine defects as well as the resulting peritonitis is intrauterine negative pressure therapy (IU-NPT). Negative pressure mimics local debridement, it reduces local edema, prevents bacterial contamination, and serves to drain secretions from the wound, stimulate blood flow, and stimulate tissue regeneration [10].

CONCLUSION

Uterine suture necrosis must be considered as a possible differential diagnosis after the onset of the first symptoms of intra-abdominal infection, in puerperium, after a caesarean section, mainly because it is associated with higher morbidity and mortality in puerperal women. A multidisciplinary approach, together with radiological diagnostics, is of great help in establishing the diagnosis. Hysterectomy is the definitive surgical treatment, if the patient’s condition deteriorates severely.

A uterus-sparing approach, in the form of surgical reconstruction of the uterine wall, can be one of the options when the patient’s general health status and local intraoperative findings allow it, for the purpose of attempting to preserve fertility in female patients who have not completed reproduction.

  • Conflict of interest:
    None declared.

Informations

Volume 4 No 1

March 2023

Pages 82-88
  • Keywords:
    uterine suture necrosis, caesarean section, infection, conservative treatment, fertility
  • Received:
    11 December 2022
  • Revised:
    30 January 2023
  • Accepted:
    03 February 2023
  • Online first:
    25 March 2023
  • DOI:
  • Cite this article:
    Cerović-Popović R, Ćupić J, Mihaljević O, Pantović K, Radojević M. Uterus-sparing surgical treatment of suture necrosis after caesarean section: Case series report. Serbian Journal of the Medical Chamber. 2023;4(1):82–8. doi: 10.5937/smclk4-41703
Corresponding author

Olga Mihaljević
26 Dr Koste Todorovića Street, 11000 Belgrade, Serbia
E-mail:This email address is being protected from spambots. You need JavaScript enabled to view it.


  • 1. Kawakita T, Landy HJ. Surgical site infections after cesarean delivery: epidemiology, prevention and treatment. Matern Health Neonatol Perinatol. 2017 Jul 5;3:12. doi: 10.1186/s40748-017-0051-3. [CROSSREF]

    2. El-Agwany AS. Conservative Management of Infected Postpartum Uterine Dehiscence after Cesarean Section. J Med Ultrasound. 2018 JanMar;26(1):59-61. doi: 10.4103/JMU.JMU_5_18. [CROSSREF]

    3. Kadija S, Stefanović A, Cerović Popović R, Radojević M, Likić-Lađević I, Sparić R, et al. Uspešan konzervativan tretman nekroze šava na uterusu nakon carskog reza – serija slučajeva. Zbornik radova 61. Ginekološka akušerska nedelja GAS SLD, 2017 Jun: 197-201. [HTTP]

    4. Al Shahed S, Al Shehri A, Bader H, Habash Y, Al Zahrani A. Case report of uterine necrosis after cesarean section, Int J Med Res Health Sci. 2021, 10(S1):1-8. [HTTP]

    5. Nigam A, Gupta N, Elahi AA, Jairajpuri ZS, Batra S. Delayed Uterine Necrosis: Rare Cause of Nonhealing Wound. J Clin Diagn Res. 2016 Dec;10(12):QD01-QD02. doi: 10.7860/JCDR/2016/20943.9058. [CROSSREF]

    6. Courbiere B, Jauffret C, Provansal M, Agostini A, Bartoli JM, Cravello L, et al. Failure of conservative management in postpartum haemorrhage: uterine necrosis and hysterectomy after angiographic selective embolization with gelfoam. Eur J Obstet Gynecol Reprod Biol. 2008 Oct;140(2):291-3. doi: 10.1016/j.ejogrb.2008.03.012. [CROSSREF]

    7. Bharatam KK, Sivaraja PK, Abineshwar NJ, Thiagarajan V, Thiagarajan DA, Bodduluri S, et al. The tip of the iceberg: Post caesarean wound dehiscence presenting as abdominal wound sepsis. Int J Surg Case Rep. 2015;9:69-71. doi: 10.1016/j.ijscr.2015.02.013. [CROSSREF]

    8. Njoku CO, Njoku AN. Microbiological Pattern of Surgical Site Infection Following Caesarean Section at the University of Calabar Teaching Hospital. Open Access Maced J Med Sci. 2019 May 14;7(9):1430-1435. doi: 10.3889/oamjms.2019.286. [CROSSREF]

    9. Luo L, Wan J, Chen X, Zhang H, Zhang M, Chen Q. Uterine necrosis, infection, and subinvolution: complications observed after combined application of modified B-Lynch suture and vascular ligation. J Int Med Res. 2021 May;49(5):3000605211010730. doi: 10.1177/03000605211010730. [CROSSREF]

    10. Wulfert CH, Müller CT, Abdel-Kawi AF, Schulze W, Schmidt-Seithe H, Borstelmann S, et al. Intrauterine negative-pressure therapy (IU-NPT) to treat peritonitis after caesarean section. Innov Surg Sci. 2020 Oct 1;5(1-2):67-73. doi: 10.1515/iss-2020-0014. [CROSSREF]


REFERENCES

1. Kawakita T, Landy HJ. Surgical site infections after cesarean delivery: epidemiology, prevention and treatment. Matern Health Neonatol Perinatol. 2017 Jul 5;3:12. doi: 10.1186/s40748-017-0051-3. [CROSSREF]

2. El-Agwany AS. Conservative Management of Infected Postpartum Uterine Dehiscence after Cesarean Section. J Med Ultrasound. 2018 JanMar;26(1):59-61. doi: 10.4103/JMU.JMU_5_18. [CROSSREF]

3. Kadija S, Stefanović A, Cerović Popović R, Radojević M, Likić-Lađević I, Sparić R, et al. Uspešan konzervativan tretman nekroze šava na uterusu nakon carskog reza – serija slučajeva. Zbornik radova 61. Ginekološka akušerska nedelja GAS SLD, 2017 Jun: 197-201. [HTTP]

4. Al Shahed S, Al Shehri A, Bader H, Habash Y, Al Zahrani A. Case report of uterine necrosis after cesarean section, Int J Med Res Health Sci. 2021, 10(S1):1-8. [HTTP]

5. Nigam A, Gupta N, Elahi AA, Jairajpuri ZS, Batra S. Delayed Uterine Necrosis: Rare Cause of Nonhealing Wound. J Clin Diagn Res. 2016 Dec;10(12):QD01-QD02. doi: 10.7860/JCDR/2016/20943.9058. [CROSSREF]

6. Courbiere B, Jauffret C, Provansal M, Agostini A, Bartoli JM, Cravello L, et al. Failure of conservative management in postpartum haemorrhage: uterine necrosis and hysterectomy after angiographic selective embolization with gelfoam. Eur J Obstet Gynecol Reprod Biol. 2008 Oct;140(2):291-3. doi: 10.1016/j.ejogrb.2008.03.012. [CROSSREF]

7. Bharatam KK, Sivaraja PK, Abineshwar NJ, Thiagarajan V, Thiagarajan DA, Bodduluri S, et al. The tip of the iceberg: Post caesarean wound dehiscence presenting as abdominal wound sepsis. Int J Surg Case Rep. 2015;9:69-71. doi: 10.1016/j.ijscr.2015.02.013. [CROSSREF]

8. Njoku CO, Njoku AN. Microbiological Pattern of Surgical Site Infection Following Caesarean Section at the University of Calabar Teaching Hospital. Open Access Maced J Med Sci. 2019 May 14;7(9):1430-1435. doi: 10.3889/oamjms.2019.286. [CROSSREF]

9. Luo L, Wan J, Chen X, Zhang H, Zhang M, Chen Q. Uterine necrosis, infection, and subinvolution: complications observed after combined application of modified B-Lynch suture and vascular ligation. J Int Med Res. 2021 May;49(5):3000605211010730. doi: 10.1177/03000605211010730. [CROSSREF]

10. Wulfert CH, Müller CT, Abdel-Kawi AF, Schulze W, Schmidt-Seithe H, Borstelmann S, et al. Intrauterine negative-pressure therapy (IU-NPT) to treat peritonitis after caesarean section. Innov Surg Sci. 2020 Oct 1;5(1-2):67-73. doi: 10.1515/iss-2020-0014. [CROSSREF]

1. Kawakita T, Landy HJ. Surgical site infections after cesarean delivery: epidemiology, prevention and treatment. Matern Health Neonatol Perinatol. 2017 Jul 5;3:12. doi: 10.1186/s40748-017-0051-3. [CROSSREF]

2. El-Agwany AS. Conservative Management of Infected Postpartum Uterine Dehiscence after Cesarean Section. J Med Ultrasound. 2018 JanMar;26(1):59-61. doi: 10.4103/JMU.JMU_5_18. [CROSSREF]

3. Kadija S, Stefanović A, Cerović Popović R, Radojević M, Likić-Lađević I, Sparić R, et al. Uspešan konzervativan tretman nekroze šava na uterusu nakon carskog reza – serija slučajeva. Zbornik radova 61. Ginekološka akušerska nedelja GAS SLD, 2017 Jun: 197-201. [HTTP]

4. Al Shahed S, Al Shehri A, Bader H, Habash Y, Al Zahrani A. Case report of uterine necrosis after cesarean section, Int J Med Res Health Sci. 2021, 10(S1):1-8. [HTTP]

5. Nigam A, Gupta N, Elahi AA, Jairajpuri ZS, Batra S. Delayed Uterine Necrosis: Rare Cause of Nonhealing Wound. J Clin Diagn Res. 2016 Dec;10(12):QD01-QD02. doi: 10.7860/JCDR/2016/20943.9058. [CROSSREF]

6. Courbiere B, Jauffret C, Provansal M, Agostini A, Bartoli JM, Cravello L, et al. Failure of conservative management in postpartum haemorrhage: uterine necrosis and hysterectomy after angiographic selective embolization with gelfoam. Eur J Obstet Gynecol Reprod Biol. 2008 Oct;140(2):291-3. doi: 10.1016/j.ejogrb.2008.03.012. [CROSSREF]

7. Bharatam KK, Sivaraja PK, Abineshwar NJ, Thiagarajan V, Thiagarajan DA, Bodduluri S, et al. The tip of the iceberg: Post caesarean wound dehiscence presenting as abdominal wound sepsis. Int J Surg Case Rep. 2015;9:69-71. doi: 10.1016/j.ijscr.2015.02.013. [CROSSREF]

8. Njoku CO, Njoku AN. Microbiological Pattern of Surgical Site Infection Following Caesarean Section at the University of Calabar Teaching Hospital. Open Access Maced J Med Sci. 2019 May 14;7(9):1430-1435. doi: 10.3889/oamjms.2019.286. [CROSSREF]

9. Luo L, Wan J, Chen X, Zhang H, Zhang M, Chen Q. Uterine necrosis, infection, and subinvolution: complications observed after combined application of modified B-Lynch suture and vascular ligation. J Int Med Res. 2021 May;49(5):3000605211010730. doi: 10.1177/03000605211010730. [CROSSREF]

10. Wulfert CH, Müller CT, Abdel-Kawi AF, Schulze W, Schmidt-Seithe H, Borstelmann S, et al. Intrauterine negative-pressure therapy (IU-NPT) to treat peritonitis after caesarean section. Innov Surg Sci. 2020 Oct 1;5(1-2):67-73. doi: 10.1515/iss-2020-0014. [CROSSREF]


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