Conservative Surgical Management of Uterine Incisional Necrosis and Dehiscence After Primary Cesarean Delivery Due to Proteus mirabilis Infection: A Case Report and a Review of Literature

Abstract

We hereby describe the conservative surgical management of a case of infected uterine incisional necrosis and dehiscence after primary cesarean delivery, and report our brief review on risk factors, physiopathology and the management of this postpartum complication. We encountered a 25-year-old woman presenting to our emergency department (ED) with severe suprapubic pain and high grade fever. She had an urgent cesarean delivery performed 10 days prior to presentation due to fetal distress. At the ED, CT scan of pelvis was ordered and showed an intraperitoneal collection anterior to the uterus at the level of the uterine cesarean scar. Exploratory laparotomy showed a uterine rupture at the previous incision site. We performed resection of necrotic edges, peritoneal lavage, approximation of uterine edges with separate interrupted sutures, placement of a suction drain in the cul-de-sac and a passive drain inside the uterine cavity through the cervix and vagina. Postpartum uterine scar rupture secondary to infection and necrosis is a rare but serious complication of cesarean delivery. Conservative management by drainage and resection of necrotic edges in addition to intravenous antibiotics may be considered as an option before resorting to hysterectomy in selected young patients. A low threshold to diagnose this complication is warranted.

Conservative management of uterine necrosis following bilateral uterine vessels ligation and B-Lynch suture: Long term follow up

“…[8][9][10][11][12][13] Reports regarding conservative management of uterine necrosis are sparse, but in a recent publication, necrosis was diagnosed preoperatively by CT 10 days after caesarean section, and the woman was managed by laparotomy, excision of the necrotic margins of the ruptured uterine incision, and suturing after draining the pus. 14 In the present woman, there was no dehiscence of the uterine incision, and the necrosis involved the body of the uterus. Pregnancy after uterine compression sutures was reported to be in the range of 32% 6 to 44%, 15 and there are no reports of pregnancy after conservative management of uterine necrosis.…”

Conservative surgical management of immediate post-caesarean uterine dehiscence and pelvis abscess due to proteus mirabilis infection: a rare complication of puerperal endomyometritis

“…10 In this case, the culture detected Proteus mirabilis however the wound was surgically repaired with broad spectrum antibiotic cover and there is only one paper reporting Proteus mirabilis as a single agent responsible of this complication, Badr et al where conservative management with uterine debridement and suturing was done with uneventful postoperative period. 11 Hence, in well-selected patients, debridement and resuture of the uterine incision is an acceptable alternative to hysterectomy for uterine incisional necrosis. Missing diagnosis and delaying treatment may result in septic shock leading to hysterectomy increasing the morbidity and mortality.…”

The Impact of Spontaneous Labor Before Elective Repeat Cesarean Delivery on Pregnancy Outcome: A Prospective Cohort Study

“…13 Furthermore, concerns about uterine scar dehiscence/rupture, with related subsequent fetal compromise, were the major motives for performing URCD, particularly in view of previous studies demonstrating increased rates of uterine dehiscence/rupture in labor with advancement of gestational age, 19,20 and with additional evidence that ruptures can occur after latent uterine activity or abdominal pain in mothers with multiple uterine scars. [21][22][23] The exact mechanism underlying how labor before ERCD can affect maternal outcome, remains enigmatic. Some have implicated the high incidence of abnormal placentation in association with MRCD, where unplanned delivery (due to labor) is associated with heavier bleeding and worse outcome.…”

“…Some authors have been skeptical about whether or not, spontaneous labor constitutes an emergency, 18 while others have ascertained that labor was the most common indication for URCD 13 . Furthermore, concerns about uterine scar dehiscence/rupture, with related subsequent fetal compromise, were the major motives for performing URCD, particularly in view of previous studies demonstrating increased rates of uterine dehiscence/rupture in labor with advancement of gestational age, 19,20 and with additional evidence that ruptures can occur after latent uterine activity or abdominal pain in mothers with multiple uterine scars 21–23 …”