Cesarean delivery is one of the most commonly performed abdominal surgical procedures in the world, accounting for 45%-60% of all deliveries in China [13]. It is associated with infections, including wound infections and endometritis[14], as well as pelvic abscess formation, which is a rare complication. In our hospital, we presented 23 cases of rapid abscess formation involving 12 patients with wound dehiscence.
The patient’s presenting symptoms of fever, abdominal pain and wound dehiscence initially prompted us to consider infection and led us to sonographic and subsequent radiological investigations to learn the underlying abscess. Twenty-three patients all presented with abscesses located at the lower anterior wall of the uterus, posterior fornix, uterine fundus, and retrorectal space. In one patient, we were able to use a vascular clamp to directly access the uterine cavity from the wound dehiscence and see the cervical mucus on the incision in the abdominal wall. Three patients all presented with uterine dehiscence in the lower uterine segment at the site of the uterine scar and pelvic abscesses on MRI(Fig. 1). Others presented with more gas and liquid in the abscesses. In Dana’s report, they also showed the results of abscesses on CT imaging [10].
In 13patients, the cyst was located anterior to the uterus, 9 of whom were complicated by wound dehiscence, so debridement was the best treatment. Because many cysts are located anterior to the uterus, the pus can drain from the incision after debridement. Until removal of foreign matter and necrotic tissue (which may serve as a culture medium for bacteria)is completed, wounds will heal, begin to granulate and consequently epithelialize[16]. After the pus was drained, the pelvis recovered. Unfortunately, only one patient underwent secondary closure and removal of the pelvic abscess by laparotomy surgery. In our study, another patient underwent US drainage twice due to abscesses located at the pouch of Douglas. It has been reported that the success rates of CT- and US-guided drainage are 83.3% and 92%, respectively, with tuboovarian abscesses in gynecology [17–18]. Interestingly, in Chen’s study, they reported two patients with pelvic abscesses of a 5–6 cm single cyst in diameter without wound dehiscence who were treated with laparoscopic surgery because they all had difficulty performing CT- and US-guided drainage [19]. It is possible that laparoscopic surgery is a good treatment for patients with pelvic abscesses. However, in our study, other patients with pelvic abscesses of a 5–6 cm single cyst in diameter without wound dehiscence were all treated with antibiotics.
A total of 65% (13/20) of patients had a positive discharge culture. The most common pathogens in the discharge were Streptococcus (30.7%), Enterococcus spp. and Escherichia coli, which is consistent with studies from Great Britain, where Streptococcus was the most common pathogen[20–23]. However, due to the long time and widespread use of broad-spectrum antibiotics, pelvic abscess pathogens may also originate from fungi[24–26]. Based on the guidelines developed by the CDC, the treatment of pelvic abscess is empirical and involves the use of broad-spectrum antimicrobial agents to cover likely pathogens [6, 27–29]. In our study, nine patients were treated with Tienam due to failure of anther antimicrobial agents. Interestingly, when we performed drainage and debridement, the temperature would slowly return to normal. This was also reported in John’s study [30]. Therefore, in the clinic, we should locate the infection and not just switch the antimicrobial agents.
Our study has several limitations. The primary limitation is that pelvic abscesses could not be located as early as possible. Most patients’ pelvic abscesses were discovered when the fever persisted despite good antibiotics for a long time. The second limitation was the retrospective nature of this research. Third, the treatment of every patient with pelvic abscess had its own characteristics, so there is no standard guideline for locating the abscesses.