What is the management approach for ascites (accumulation of fluid in the peritoneal cavity) after a cesarean section (C-section)?

Management of Ascites After Cesarean Section

A diagnostic paracentesis should be performed immediately to determine the cause of ascites after cesarean section, with analysis including total protein concentration, serum ascites albumin gradient (SAAG), neutrophil count, and culture. 1

Diagnostic Approach

• Perform a diagnostic paracentesis as the first step in evaluating new-onset ascites, which is essential for determining the underlying cause 1
• Initial ascitic fluid analysis should include:
  • Total protein concentration and calculation of serum ascites albumin gradient (SAAG) 1
  • Ascitic fluid neutrophil count and culture to rule out infection 1
  • Consider additional tests based on clinical suspicion: cytology, amylase, brain natriuretic peptide (BNP), and adenosine deaminase 1
• Inoculate ascitic fluid into blood culture bottles at the bedside to improve detection of bacterial infection 1
• Perform abdominal ultrasound to evaluate the appearance of the liver, pancreas, and lymph nodes, as well as the presence of splenomegaly 1
• Blood tests should include urea and electrolytes, liver function tests, prothrombin time, and complete blood count 1

Management Based on Etiology

If Spontaneous Bacterial Peritonitis (SBP) is Diagnosed:

• SBP is diagnosed when ascitic neutrophil count is >250 cells/mm³ in the absence of an intra-abdominal surgically treatable source of sepsis 1
• Initiate immediate empirical antibiotic therapy:
  • Third-generation cephalosporins such as cefotaxime (2g IV every 8 hours) are most extensively studied and effective 1
  • Consider local bacterial resistance patterns when selecting antibiotics 1
• For patients with SBP and signs of developing renal impairment, administer albumin at 1.5 g/kg in the first six hours followed by 1 g/kg on day 3 1
• Consider a second diagnostic paracentesis at 48 hours to check treatment efficacy if response is inadequate or secondary bacterial peritonitis is suspected 1

If Cirrhotic Ascites is Diagnosed:

• Implement moderate dietary sodium restriction (5-6.5 g/day or 87-113 mmol sodium) 1
• Provide nutritional counseling on sodium content in diet 1
• Initiate diuretic therapy:
  • Start with spironolactone monotherapy (100 mg/day, can be increased to 400 mg/day) 1
  • If inadequate response, add furosemide (starting at 40 mg/day, can be increased to 160 mg/day) 1
• Monitor serum electrolytes, particularly during the first weeks of treatment 1
• For refractory ascites, consider therapeutic paracentesis:
  • For paracentesis <5 liters, use synthetic plasma expanders (150-200 ml of gelofusine or haemaccel) 1
  • For large volume paracentesis, administer albumin (8 g per liter of ascites removed) 1

If Malignant Ascites is Suspected:

• Request ascitic fluid cytology 1
• Further imaging studies may be required to identify the primary malignancy 2
• Management will depend on the type and stage of malignancy identified 2

Special Considerations After Cesarean Section

• Rule out surgical complications specific to cesarean section:
  • Bile leak or intestinal perforation during surgery
  • Chylous ascites from lymphatic injury
  • Urinary ascites from bladder or ureter injury 3
• Consider postpartum-specific causes:
  • HELLP syndrome or preeclampsia-related liver dysfunction
  • Acute fatty liver of pregnancy with residual hepatic dysfunction
  • Peritonitis related to endometritis 3, 2

Follow-up Care

• Monitor response to treatment with clinical assessment of ascites volume
• Repeat paracentesis if symptoms worsen or new symptoms develop 1
• For patients with cirrhosis and ascites, consider referral for liver transplantation evaluation, as it offers definitive treatment 4
• For recurrent ascites, evaluate for underlying cause and consider long-term management strategies based on etiology 4, 5

Complications to Monitor

• Renal impairment (hepatorenal syndrome in cirrhotic patients) 6
• Electrolyte imbalances, particularly hyponatremia 1
• Recurrent infections, especially in patients with low ascitic fluid protein (<1.5 g/dL) 1
• Malnutrition and muscle wasting due to dietary restrictions and chronic disease 1

The management of ascites after cesarean section requires prompt diagnosis through paracentesis and appropriate treatment based on the underlying cause, with close monitoring for potential complications that could affect maternal morbidity and mortality.