What are the complications of a pelvic abscess following a cesarean section (C-section) complicated by placenta accreta and excessive bleeding (hemorrhage)?

From the Guidelines

A pelvic abscess following cesarean delivery complicated by placenta accreta and excessive bleeding requires prompt treatment with broad-spectrum antibiotics and drainage, as this condition can lead to severe sepsis and significant morbidity and mortality 1.

Initial Management

Initial management should include intravenous antibiotics such as piperacillin-tazobactam 4.5g every 6 hours, or a combination of cefepime 2g every 8 hours plus metronidazole 500mg every 8 hours.

• The choice of antibiotics should be guided by local resistance patterns and the severity of the infection.
• Imaging with CT or ultrasound should guide drainage procedures, and percutaneous or surgical drainage of the abscess is essential and should be performed as soon as possible.

Antibiotic Therapy and Drainage

Antibiotic therapy should continue for 7-14 days, with transition to oral antibiotics once the patient shows clinical improvement (afebrile for 24-48 hours with normalized white blood cell count).

• Close monitoring for sepsis is crucial, including vital signs, laboratory markers, and clinical assessment.
• The patient may require additional supportive care including IV fluids, pain management, and possibly blood transfusions if anemia is present from the previous hemorrhage.

Importance of Multidisciplinary Care

The management of placenta accreta spectrum and its complications, including pelvic abscess, requires a multidisciplinary approach, involving experienced obstetricians, maternal-fetal medicine subspecialists, pelvic surgeons, urologists, interventional radiologists, obstetric anesthesiologists, critical care experts, and neonatologists 1.

• Delivery in highly experienced maternity centers that have this type of coordinated care team and the ability to garner additional expertise and resources in cases of severe hemorrhage appears to improve outcomes 1.

From the Research

Pelvic Abscess after Cesarean Section

• Pelvic abscess is a rare but potentially life-threatening complication after cesarean section, especially in cases complicated by placenta accreta and excessive bleeding 2, 3, 4.
• The condition can present with symptoms such as lower abdominal pain and fever, several days after the cesarean section 2, 3.
• Diagnosis is often made using imaging techniques, which can reveal the presence of a pelvic abscess that may not be amenable to drainage through interventional radiology 2, 3.

Treatment Options

• Laparoscopic drainage is a viable treatment option for pelvic abscess after cesarean section, allowing for effective drainage and recovery from infection 2, 5.
• CT-guided drainage with a percutaneous approach is another treatment option, which can be effective in managing severe pelvic abscess formation after cesarean section 3.
• Antibiotic therapy is often used in conjunction with drainage procedures, but may not always be effective in resolving the infection 3, 4, 5.
• In some cases, radiologically-guided drainage of the abscess may be necessary to achieve continuous recovery 4.

Considerations for Management

• The decision to drain or not to drain a pelvic abscess should be based on individual patient factors, such as the size of the abscess, white blood cell count, and presence of underlying conditions like endometrioma 6.
• Early laparoscopic or image-guided drainage may be considered in women who prioritize fertility, have a large pelvic abscess, or exhibit signs of severe sepsis 6.
• The lack of high-quality evidence for many aspects of pelvic abscess treatment highlights the need for well-designed, large multicenter randomized controlled trials to determine the most effective treatment strategies 6.