Sonographic detection of fluid collections and postoperative morbidity following Cesarean section and hysterectomy

Anesthesia Considerations for Placenta Accreta Spectrum

Anesthesiologists are critical members of the multidisciplinary team managing patients with suspected placenta accreta spectrum (PAS). Preoperatively, anesthesiologists provide predelivery consultation for patients with suspected PAS where anesthetic modality and invasive monitor placement is discussed. Additionally, anesthesiologists carefully assess patient and surgical risk factors to choose an anesthetic plan and to prepare for massive intraoperative hemorrhage. Postoperatively, the obstetric anesthesiologist hold unique skills to assist with postoperative pain management for cesarean hysterectomy. We review the unique aspects of peripartum care for patients with PAS who undergo cesarean hysterectomy and explain why these responsibilities are critical for achieving successful outcomes for patients with PAS. KEY POINTS: · Anesthesiologists are critical members of the multidisciplinary team planning for patients with suspected placenta accreta spectrum.. · Intraoperative preparation for massive hemorrhage is a key component of anesthetic care for patients with PAS.. · Obstetric anesthesiologists have a unique skill set to manage postpartum pain and postoperative disposition for patients with PAS who undergo cesarean hysterectomy..

Sonographic Detection of Surgical Site Fluid Collections and Postoperative Maternal Morbidity Following Cesarean Section

INTRODUCTION

 Surgical site infection (SSI) is one of the most common complications after cesarean and causes much burden on the mother as well as the health care system. SSIs are defined as infections of a surgical site up to 30 days after surgery. Ultrasonography of the surgical site may be a helpful tool to detect its complication. With this background, the following study was planned to evaluate the clinical significance of sonographically detected fluid collections and post-operative maternal morbidity following cesarean section (CS) and identify risk factors associated with their formation.

METHODS

This prospective observational study was conducted at the Department of Obstetrics and Gynecology, Lala Lajpat Rai Memorial Medical College, Meerut. A total of 1000 women, who had undergone CS were included. Sonographic examination of the cesarean site was done on the 3^rd or 4^th postoperative day to look for any fluid collection in the parities or pelvis. All cases were followed on the 8^th postoperative day and finally on the 30^th postoperative day to look for any SSIs i.e. surgical wound problems like wound infection, induration, and discharge from a surgical wound, or even wound dehiscence and postoperative morbidity.  Results: Out of the total cases (1000), abdominal wound fluid collection was noted in 490 (49%) women after CS. Thirty-two patients were lost to follow-up, so 458 patients were followed, of which collection was septated or loculated in 62 (13.6%) and diffused in 396 (86.5%). Out of 62 loculated and 396 diffused cases, 21 (33.87%) and 20 (5.05%) cases reported surgical site abdominal wound infection and needed resuturing, respectively and it was found to be highly significant (p<0.001).

CONCLUSION

Post-operative fluid collections are common after CS. But it is the pattern of the fluid collection that determines post-operative wound infection and morbidity. Thus ultrasound of the cesarean site may be an important tool to detect surgical site wound complications earlier and to decrease postoperative morbidity.

Imaging of Postpartum/Peripartum Complications

There are various complications that can occur in the postpartum period, including pain, bleeding, and infection. These include complications related to cesarean section, postpartum hemorrhage and hematomas, bladder injury, torsion and uterine dehiscence, and rupture. It is important the radiologist is aware of these entities and the associated imaging features to help guide timely and appropriate management.

Risk factors and clinical significance of abdomino-pelvic free fluid after cesarean section: a prospective study

Introduction: Post-partum hemorrhage is a major cause of maternal mortality. Ultrasonography is a safe, rapid, and noninvasive diagnostic tool which can be used to identify and measure the abdomino-pelvic free fluid in post-partum period.Objective: This study was conducted to evaluate the risk factors and clinical significance of abdomino-pelvic free fluid after cesarean section.Method: Demographic data, indication of cesarean section, duration of operation, volume of intraoperative blood loss, and instability in vital signs, blood transfusion, decreased Hb level, and decreased urine output were documented in 100 women with cesarean delivery 4 and 24 h after surgery. Abdomino-pelvic free fluid volume was estimated by ultrasound study.Result: Four hours after cesarean, minimal, moderate, and large amount of free fluid was seen in 38(38%), 45(45%), and 17(17%) patients respectively. The volume of free fluid was decreased generally as 73 (73%) of patients had minimal amount of free fluid 24 h after surgery. There was statistically significant relationship between volume of blood loss during cesarean and the volume of free fluid 4 h (and not 24 h) after surgery. There was no statistically significant relationship between duration of operation and the volume of free fluid 4 and 24 h after cesarean. There is statistically significant relationship between free fluid volume 4 h after surgery and hemodynamic instability.Conclusion: Ultrasonography detects even minimal amount of free fluid in post-cesarean patients but cannot predict their clinical course.

Efficiency of using a vaginal drain after hysterectomy: A systematic review

Objective Hysterectomy is the second most frequently performed surgical procedure for women of reproductive age topped only by caesarean section. Hysterectomies may be associated with a significant risk of ultrasonographically detected vault haematomas in up to 59% with consequent postoperative morbidity. The aim of this systematic review was to compare women who had a vaginal drain placed intraoperatively after a hysterectomy and the impact on peri and postoperative outcomes related to vault haematomas. Study Design Electronic searches of AMED, BNI, CINAHL, EMBASE, HBE, HMIC, Medline, PsycINFO and PubMed, Cochrane register of controlled trials (CCTR), Cochrane database of systematic reviews (CDSR) CINAHL and Google scholar were performed. A systematic review and meta-analysis of studies comparing women with and without a vaginal drain after a hysterectomy and the impact on different outcomes was carried out. Results Ten studies involving 1778 women, 811 with a vaginal drain and 967 without a drain, were included in the meta-analysis. This suggests that the use of a vaginal drain after hysterectomy may significantly reduce the incidence of vault haematoma (OR 0.22, 95% CI 0.08 - 0.57) and febrile morbidity (OR 0.54, 95% CI 0.40 to 0.73), non- significantly reduce the rate of usage of antibiotics (OR 0.80, 95% CI 0.46-1.42) and makes no difference to the length of hospital stay (MD 0.12, 95% CI -0.14 to 0.38). Conclusion The use of a vaginal drain after hysterectomy could reduce the incidence of vault haematoma and febrile morbidity.

Comparison of postpartum sonographic findings after uneventful vaginal and cesarean section deliveries

Objective: To prospectively determine the sonographic findings of the postpartum uterus 24 hours after vaginal delivery and cesarean section. Methods: Women who had uneventful vaginal delivery or cesarean section from July 2015 to May 2018 in a tertiary care hospital were prospectively included. Uterine lengths, endometrium, amout of free fluid, the distance between the uterine fundus-promontorium and uterine fundus-L5 were evaluated 24 hours after delivery. Results: The mean (min-max) endometrial thickness in the vaginal delivery and cesarean section groups were 13.3 (4-25) and 12.4 (4-29) mm, respectively. Fundus-cervix length was significantly higher in the vaginal delivery group compared to the cesarean section group (184.05 ± 16.8 vs 163.6 ± 6.7 mm, p <0.001). The measurements of anterior and anterior-posterior walls of the uterus, anteroposterior uterine length and uterine width were similar in both groups. Promontorium-fundus length was significantly higher in patients who delivered vaginally than those by cesarean section (123.3 ± 13.6 vs 108.7 ± 23.3 mm, p = 0.005). Conclusion: The measurement of L5-fundus distance is a simple and effective technique to evaluate the size of the uterus. Homogenous endometrium up to 30 mm in asymptomatic patients may be a normal finding 24 hours after delivery. The results of this study may be helpful in the decision-making process in cases of early postpartum hemorrhage or hemodynamic instability.

Objective: To prospectively determine the sonographic findings of the postpartum uterus 24 hours after vaginal delivery and cesarean section. Methods: Women who had uneventful vaginal delivery or cesarean section from July 2015 to May 2018 in a tertiary care hospital were prospectively included. Uterine lengths, endometrium, amout of free fluid, the distance between the uterine fundus-promontorium and uterine fundus-L5 were evaluated 24 hours after delivery. Results: The mean (min–max) endometrial thickness in the vaginal delivery and cesarean section groups were 13.3 (4–25) and 12.4 (4–29) mm, respectively. Fundus-cervix length was significantly higher in the vaginal delivery group compared to the cesarean section group (184.05 ± 16.8 vs 163.6 ± 6.7 mm, p <0.001). The measurements of anterior and anterior-posterior walls of the uterus, anteroposterior uterine length and uterine width were similar in both groups. Promontorium-fundus length was significantly higher in patients who delivered vaginally than those by cesarean section (123.3 ± 13.6 vs 108.7 ± 23.3 mm, p = 0.005). Conclusion: The measurement of L5-fundus distance is a simple and effective technique to evaluate the size of the uterus. Homogenous endometrium up to 30 mm in asymptomatic patients may be a normal finding 24 hours after delivery. The results of this study may be helpful in the decision-making process in cases of early postpartum hemorrhage or hemodynamic instability.

Efficiency of using a Foley catheter as a pelvic drain in vaginal hysterectomy

OBJECTIVES

Vaginal hysterectomy can be associated with a significant risk of vault haematomas with consequent postoperative morbidity. The aim of this study was to assess the use of a Foley Catheter as a vaginal drain in premenopausal women undergoing a vaginal hysterectomy and the impact on different outcomes including development of vault haematoma, length of hospital stay, antibiotics usage, readmissions to the hospital and febrile morbidity in the immediate postoperative period.

STUDY DESIGN

This study was conducted at a tertiary teaching hospital and was a retrospective cohort study of women undergoing a vaginal hysterectomy. The study compared 52 women in the study group with a Foley catheter drain to 51 age matched controls without a drain who underwent surgery for similar indications. Outcomes were compared using the Chi square test and student t-test.

RESULTS

Comparing women with a drain to those without demonstrated a statistically significant difference with worse outcomes for all parameters in women without a drain: evidence of vault haematomas (0 vs 8; p = 0.0025); length of hospital stay over 2 days (3 vs 15; p = 0.001); discharge with antibiotics for vault haematomas (5 vs 0; p = 0.028) and readmission rates (0 vs 7; p = 0.005). There was no statistical difference in the number of women with temperatures over 38 °C (4 vs 2; p = 0.3) in either group.

CONCLUSION

A Foley catheter used as a pelvic drain following a vaginal hysterectomy reduces postoperative complications associated with vault haematomas with shorter hospital stay, lower antibiotic usage and lower readmission rate.

Vaginal vault drainage after complicated single-port access laparoscopic-assisted vaginal hysterectomy

Study objective:

To evaluate the feasibility and safety of vaginal vault drainage after complicated singleport access laparoscopic-assisted vaginal hysterectomy (SPA-LAVH).

Design:

Retrospective cohort study.

Setting:

Ulsan University Hospital (tertiary teaching hospital), South Korea.

Patients:

A total of 359 women underwent SPA-LAVH for the following conditions: benign uterine tumor, preinvasive uterine lesion, and microinvasive cervical cancer.

Interventions:

The participants included 124 women with vault drains and 235 women without drains.

Measurements:

Surgical outcomes, perioperative complications and morbidity, postoperative febrile morbidity.

Results:

There were no differences in background features between drain and no-drain groups. In surgical outcomes, mean uterine weight (364.2 ± 184.9 g vs. 263.7 ± 138.6 g; p < 0.001), operation time (87.4 ± 21.5 min vs. 73.0 ± 17.6 min; p < 0.001), blood loss (225.3 ± 122.2 mL vs. 150.4 ± 95.2 mL; p < 0.001), and hemoglobin decline (1.97 ± 0.96 g/dL vs. 1.42 ± 0.89 g/dL; p < 0.001) were significantly larger for the drain group compared with the no-drain group. However, with regard to postoperative morbidity and complications, there were no group differences in the transfusion rates (6.5% vs. 3.8%; p = 0.300), intraoperative complications (2.4% vs. 1.3%; p = 0.420), perioperative complications (2.4% vs. 0.9%; p = 0.345), and febrile morbidity ≥ 37.5°C (8.9% vs. 11.5%; p = 0.477), although the drain group was more prone to the development of pelvic fluid collection and febrile morbidity than the no-drain group.

Conclusion:

Vaginal vault drainage could be a safe alternative that allows for the management of postoperative morbidity and retains the advantages of minimally invasive surgery after complicated SPA-LAVH.

[Ultrasound appearance of the area of uterine closure in asymptomatic patients at 48 hours of uneventful cesarean section]

OBJECTIVE

It seeks to assess the appearance of the hysterorrhaphy area and seeks hematoma in asymptomatic patients at 48hours of their cesarean.

METHOD

It is common to see, ultrasound or CT scan, collection of images next to the hysterorrhaphy area in symptomatic patients after cesarean. Their interpretation remains difficult which led us to propose a prospective study looking for an evocative image collection or hematoma in asymptomatic patients at 48hours of their cesarean. It was directed suprapubic and transvaginal pelvic ultrasound with study area hysterorrhaphy and inter-uterine bladder space.

RESULTS

The suprapubic ultrasound examination was performed in 31 asymptomatic patients after collecting their written consent. Twenty-eight patients also received an endovaginal examination. The studied area was easily identified by visualizing the path of hysterotomy and hyperechoic aspect of the hysterorrhaphy. In 28 cases there were no abnormal image in front of the hysterorrhaphy area. In 3 cases, an evocative image of a haematic collection was displayed and measured a maximum of only 49mm long axis with a weak Doppler signal. The exam was very well tolerated by patients, especially by transvaginal route. Also the duration of ultrasound never exceeded 58seconds and remained fastest vaginally.

CONCLUSION

This preliminary work to a prospective double cohort (symptomatic patients and asymptomatic patients) has clarified the technique to use and focus in the search for a collection next to the hysterorrhaphy area. Ultrasound examination postoperatively, especially vaginally, is very fast, well tolerated with satisfactory image quality. Finally in this cohort of asymptomatic patients, it was very unusual for a collection, confirming the credit to be given to this type of image in case of symptoms after cesarean.

Abdominal and pelvic ultrasound findings within 24 hours following uneventful Cesarean section

OBJECTIVES

To describe prospectively the normal abdominal and pelvic ultrasound features within 24 h following uneventful Cesarean section.

METHODS

Transabdominal ultrasound examination was performed between 1 and 3 h, and again at 24 h, following lower-segment Cesarean section (LSCS). The myometrium, endometrium, and amount and distribution of free peritoneal fluid were studied in 30 women with singleton pregnancies who underwent LSCS delivery.

RESULTS

Examinations were performed easily in all cases except one who was morbidly obese (body mass index > 40 kg/m(2)). At 1-3 h after delivery, mean +/- SD endometrial thickness was 13 +/- 2 mm. Mean uterine length, from the fundus to the cervical external os, was 160 +/- 15 mm. Measurement of uterine length in the mid-sagittal plane of the pelvis was impossible in eight cases (27%) owing to pain. No abnormal intrauterine findings were observed. Mean uterine width was 110 +/- 10 mm. Mean distance between the sacral promontory and uterine fundus was 104 +/- 11 mm. Mean thicknesses of the anterior and posterior walls of the uterus were 40 +/- 5 mm and 39 +/- 7 mm, respectively. No fluid was seen in Morrison's or Douglas' pouches. There was a consistent and significant reduction between the measurements performed at 1-3 h and those at 24 h after LSCS, except for the distance between the fundus and external os.

CONCLUSIONS

Ultrasound examination is feasible after Cesarean section. Images are obtained easily, even when scanning through the scar. In normal pregnancies, there is no fluid in the abdomen or pelvis. These results could help clinicians in the decision-making process in cases of early postpartum hemorrhage or hemodynamic instability following LSCS.

Extensive fever workup produces low yield in determining infectious etiology

OBJECTIVE

The study was undertaken to evaluate the use of a fever workup in women undergoing benign gynecologic procedures.

STUDY DESIGN

A retrospective chart review was performed at Jackson Memorial Hospital between 1994 and 2000. Information was abstracted from hospital and clinic records. Fever criteria was defined as 1 temperature equal to or greater than 101.5, or 2 equal to or greater than 100.4, at least 4 hours apart within a 24-hour period. Patients undergoing additional intraoperative procedures leading to increased febrile morbidity were excluded. Data abstracted included patient demographics, procedure, complications, antibiotic use, and extent of fever workup. Statistical analysis used was 2-sample t tests, Wilcoxon rank test, chi2 test, and multivariate logistic regression. Alpha level = .05.

RESULTS

The charts of 505 patients were reviewed, and 147 patients met fever criteria. All patients underwent surgery for benign conditions, abdominal hysterectomy being the most common (90%). The study population was divided into 2 groups: the noninfectious group and infectious group. These groups were determined by wound infection, pelvic abscess, blood or urine culture, ultrasound, and chest roentgen. Both groups were found to be similar with respect to demographics, surgical procedures, and postoperative complications, with the exception of body mass index (28.4 vs 31.7) and length of hospital stay (3.9 vs 5.3). Results from fever workups included positive results blood cultures (9.7%), urine culture (18.8%), and chest roentgens (14%) in this study population. We found no association between positive urine analysis and urine culture. When comparing both groups, a statistically significant difference was found with regard to maximum temperature elevation, number of days febrile, and postoperative day of maximum temperature (P < .05).

CONCLUSION

The extensive fever workup was not frequently positive in this study population. Its use and cost-effectiveness should be questioned. Therefore, the fever workup should be tailored to the individual patient.