From the Guidelines
For a complex cesarean delivery complicated by excessive bleeding and hemostatic procedures, prophylactic antibiotics should be limited to 24 hours, and exceptionally 48 hours, but never beyond, as stated in the 2019 guidelines on antibioprophylaxis in surgery and interventional medicine 1. The recommended regimen includes a broad-spectrum antibiotic such as cefazolin, with additional coverage for anaerobic bacteria if necessary.
- The choice of antibiotic should be effective against the main bacteria responsible for post-operative infection.
- The duration of prescription should be brief, to minimize the ecological risk of resistant organisms to any antibiotic.
- A single preoperative injection has proven effective for many interventions, and prescription beyond 48 hours is prohibited in all cases, as per the guidelines 1. Key considerations for the duration of prophylactic antibiotics include:
- The risk of surgical site infections and endometritis associated with prolonged surgery time, excessive blood loss, and additional surgical interventions.
- The potential for compromised tissue perfusion, bacterial contamination, and reduced immune function that can occur with significant hemorrhage.
- The need to balance the benefits of antibiotic prophylaxis with the risks of antibiotic resistance and adverse effects. The decision to discontinue antibiotics should be based on clinical assessment, including vital signs stability, absence of fever, and normalization of inflammatory markers, as well as consideration of the individual patient's risk factors and clinical situation, as suggested by the guidelines 1.
From the Research
Duration of Prophylactic Antibiotics
- The duration of prophylactic antibiotics after a complex cesarean section complicated by excessive bleeding and hemostatic procedures is not explicitly stated in the provided studies 2, 3, 4, 5, 6.
- However, the use of prophylactic antibiotics in women undergoing cesarean section has been shown to substantially reduce the incidence of episodes of fever, endometritis, wound infection, urinary tract infection, and serious infection after cesarean section 4.
- The reduction in the risk of endometritis with antibiotics was similar across different patient groups, including elective and non-elective cesarean sections 4.
- There is no specific guidance on the duration of prophylactic antibiotics in the context of complex cesarean sections with excessive bleeding and hemostatic procedures.
Hemostatic Procedures
- Various hemostatic procedures have been described, including uterotonic therapy, uterine compression sutures, balloon tamponade, blood-vessel ligation, and uterine artery embolisation 2, 5.
- A "step-by-step" minimally invasive hemostatic technique using intrauterine double-balloon tamponade combined with uterine isthmus vertical compression suture has been proposed for the control of placenta accreta and severe atonic hemorrhage during a cesarean section 5.
- The choice of hemostatic procedure may depend on the individual case and the underlying cause of the bleeding.
Complications and Management
- Complications after a complex cesarean section can include postpartum menorrhagia, enlarged uterus, and intra-abdominal adhesions 6.
- Management of these complications may involve explorative laparotomy, extensive lysis of adhesions, and total abdominal hysterectomy and bilateral salpingectomy 6.
- A better understanding of the management of adhesions for abdominal procedures is necessary to improve patient outcomes.