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.
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