Discussion:
Dehiscence of a cesarean scar incidence varied between 0.3–1.9% of all cases and uterine hemorrhage did not occurs in majority of cases[3, 6, 7]. Therefore, other symptoms such as infection in wound and dehiscence sites should be considered in evaluation of postpartum pain after CS. In addition, coinfection by brucellosis of other microbial agents should be considered in differential diagnosis. Other studies demonstrated that multiparty, infection, and an incision placed too low in the lower uterine segment are the risk factors for dehiscence in LSCS[3].
Infections and subsequent spillage of pathogenic organisms into the peritoneum are the cause of weakening in uterine scar tissue and occurred the peritonitis or abscess formation. Similar consequence observed in the myometrium during LSCS, which the gradual spread of intra-uterine pathological organisms into the peritoneal cavity is occurred and caused facial dehiscence[4, 11]. Among diagnostic methods, 3D ultrasound is better method for detection of dehiscence than routine transvaginal ultrasound that is applicable for fluid collection or hematoma in the scar area[6].
The uterine culture in current case, did not show any microbial infection, but the wound culture was positive twice that E. coliin the first time and negative Coagulase Staff in second time. Therefore, she received a broad spectrum antibiotic cover to healing their wound and control her fever. However, due to long time fever, and history of unpasteurized dairy, premature delivery and intrauterine infection brucellosis tests were checked. However, other articles showed that delayed cesarean wound healing may be due to infection[7]
According to literatures multiparty, infection, and an incision placed too low in the lower uterine segment are related risk factors for dehiscence of the lower segment uterine scar following CS[3]. In current case, uterine fascia dehiscence may be related to brucellosis infection and the persistent fever despite adequate antimicrobial therapy was the cause of delayed wound healing. Nevertheless, in this case, due to antibiotics prophylaxis after CS, the sepsis did not occur, but the brucellosis infection may be the main cause of high fever and delayed healing. Brucellosis as a common and threatening infection in pregnant women could cause localized body system complications, osteoarticular system and severe obstetrics outcomes such as spontaneous abortion, premature delivery, intrauterine infection or intrauterine fetal death (IUFD)  in pregnant women with brucellosis[8-10]. The same condition conducted in current patients and our cases pregnancy terminated at 29th week of gestational age. Nevertheless, the fetus was not infected to brucellosis and was normal.
In the presented cases the laparotomy conducted two times and in the first time the subcutaneous lesion collection was evacuated at 4th day after CS and another laparotomy operation was conducted at 11th day after CS and adhesions were released. Nevertheless, the uterine of our case was preserved, but the consequences of this complication is unknown for a future pregnancy.
Uterine scar separation should be executing in patients with a fascial dehiscence after CS delivery and patients should be counseled for hysterectomy at laparotomy time for especial situations.[12] Moreover, transvaginal sonography of the scar region is necessary in patients with CS history to screening the latent scar dehiscence in combination with uterine wall thinning before planning further pregnancy. In cases who were suspected to uterine dehiscence, combined laparoscopic - vaginal or vaginal sonography is useful for repair the defect.[1]
Conclusion :
Uterine fascia dehiscence in lower uterine segment incision is a rare but is a potentially dangerous for mothers. This outcome should be considered in patients with history of CS who were deciding for future pregnancy. However, preterm deliveries due to PPROM and high uncontrolled fever after CS, are conditions that practitioners should considering the uterine dehiscence to their differential diagnoses. Nevertheless, the occurrence of dehiscence due to brucellosis infection is questionable and require more evaluation.
References :
1. Klemm P, Koehler C, Mangler M, Schneider U, Schneider A. 2005. Laparoscopic and vaginal repair of uterine scar dehiscence following cesarean section as detected by ultrasound. Journal of perinatal medicine;33(4):324-31.
2. Ramadan MK, Kassem S, Itani S, Sinno L, Hussein S, Chahin R, et al. 2018. Incidence and Risk Factors of Uterine Scar Dehiscence Identified at Elective Repeat Cesarean Delivery: A Case-Control Study. J Clin Gynecol Obstet;7(2):37-42.
3. Wagner MS, Bédard MJ. 2006. Postpartum uterine wound dehiscence: a case report. Journal of obstetrics and gynaecology Canada : JOGC = Journal d’obstetrique et gynecologie du Canada : JOGC;28(8):713-5.
4. Haridas M, Tenneti VJD, Joshi A. 2021. Uterine Dehiscence: A Rare Cause of Postpartum Puerperal Sepsis. Cureus;13(9):e18264-e.
5. Larsen JV, Janowski K, Krolilowski A. 1995. Secondary post partum haemorrhage due to uterine wound dehiscence. The Central African journal of medicine;41(9):294-6.
6. Sengupta Dhar R, Misra R. 2012. Postpartum Uterine Wound Dehiscence Leading to Secondary PPH: Unusual Sequelae. Case Rep Obstet Gynecol;2012:154685-.
7. Baba T, Morishita M, Nagata M, Yamakawa Y, Mizunuma M. 2005. Delayed postpartum hemorrhage due to cesarean scar dehiscence. Archives of gynecology and obstetrics;272(1):82-3.
8. Liu Z, Wei D, Li Y, Zhou H, Huang D, Guan P. 2020. Different Clinical Manifestations of Human Brucellosis in Pregnant Women: A Systematic Scoping Review of 521 Cases from 10 Countries. Infect Drug Resist;13:1067-79.
9. Alsaif M, Dabelah K, Featherstone R, Robinson JL. 2018. Consequences of brucellosis infection during pregnancy: A systematic review of the literature. International Journal of Infectious Diseases;73:18-26.
10. Bosilkovski M, Arapović J, Keramat F. 2020. Human brucellosis in pregnancy - an overview. Bosn J Basic Med Sci;20(4):415-22.
11. Sholapurkar SL. 2018. Etiology of Cesarean Uterine Scar Defect (Niche): Detailed Critical Analysis of Hypotheses and Prevention Strategies and Peritoneal Closure Debate. J Clin Med Res;10(3):166-73.
12. Treszezamsky AD, Feldman D, Sarabanchong VO. 2011. Concurrent postpartum uterine and abdominal wall dehiscence and Streptococcus anginosus infection. Obstetrics and gynecology;118(2 Pt 2):449-51.