Imaging after Cesarean Delivery: Acute and Chronic Complications

Abstract

Cesarean delivery is a commonly performed operation and accounts for nearly one-third of all births in the United States. Although it is a safe procedure, cesarean delivery has a variety of acute and chronic complications that prompt imaging with ultrasonography (US), computed tomography, and magnetic resonance imaging. Acute complications include hematomas in specific locations that are unique to the procedure, as well as a variety of infections. A bladder flap hematoma occurs in the space between the bladder and the lower uterine segment, whereas a subfascial hematoma is an extraperitoneal collection located in the prevesical space posterior to the rectus muscles and anterior to the peritoneum. Puerperal infections after cesarean delivery include abscesses, wound infections and dehiscence, uterine dehiscence and rupture, and pelvic thrombophlebitis. The prevalence of chronic complications related to the healed cesarean delivery scar is unknown, but the scar may result in technical limitations for pelvic US due to the adhesions between the anterior lower uterine segment and the anterior abdominal wall. The cesarean delivery scar also leaves the patient susceptible to several unique diagnoses. A cesarean scar "niche" is a tethering of the endometrium that can serve as a reservoir for intermenstrual blood and fluid. Intrauterine devices can be malpositioned in the cesarean delivery scar, and endometrial implants can develop in the abdominal wall years after surgery. These patients are also at increased risk for implantation abnormalities including cesarean scar ectopic pregnancy, retained products of conception, and placenta accreta. Familiarity with the normal postoperative findings following cesarean delivery is necessary to recognize acute and chronic complications, which are being encountered with increasing frequency.

Hemorrhagic uterine necrosis after surgical vessel ligation and B-Lynch suture in persistent post-cesarean uterine atony: case report and review of literature

“…Intrauterine gas may be seen in the early postpartum period and may persist for as long as 3 weeks as a physiologic finding in the absence of other clinical symptoms. [11][12][13] In our case the uterine enlargement did not change in three weeks, as seen on ultrasounds and on CT scans, and the gas content was also intraparietal as well as inside the uterine cavity. The CT attenuation of the myometrium was irregular as previously seen in the literature.…”

Multidetector CT appearance of the pelvis after cesarean delivery: normal and abnormal acute findings

“…Its rate ranges from 3%-5% in Africa to 33% in the United States and 43.9% in Brazil with a reported worldwide global estimation of 15% (1). Complications such as hematomas, infection, abscesses, uterine dehiscence or rupture, pelvic thrombosis or thrombophlebitis may occur at an overall rate of 14.5%.…”

“…During the first day after CS, it can be difficult to distinguish normal early postsurgical modification from possible uterine and pelvic complications. To date, only a few articles described the normal and acute abnormal CT findings of the female pelvis after CS (1)(2)(3)(4)(5). The aim of this article is to review the surgical technique of CS, and describe the expected normal and abnormal CT findings after CS as well as describe the most common acute complications.…”

“…The most frequently performed surgical technique is the low transverse CS via a Pfannenstiel or Joel-Cohen skin incision (2-3 cm above the symphysis pubis); this type of uterine incision is usually recommended because it is related with less postoperative pain and blood loss, and it has the lowest risk for rupture in subsequent pregnancies (1,5,6). In this procedure, the fascia is opened and the rectus muscles are separated, followed by entrance into the peritoneum.…”

“…CT is the modality of choice for imaging postsurgical or intra-abdominal complications, such as hematomas, abscess, uterine dehiscence and rupture, and pelvic thrombophlebitis (1). Moreover, CT is usually employed to rule out active arterial bleeding in case of postpartum hemorrhage (5,8).…”