Uterine Wound Dehiscence in Post-Cesarean Section Patients with Postpartum Hemorrhage
Yes, uterine wound dehiscence is a recognized and potentially life-threatening cause of postpartum hemorrhage after cesarean section, though it remains relatively uncommon. 1, 2
Definition and Clinical Significance
Uterine dehiscence is characterized by disruption of the endometrial and myometrial layers with an intact serosal layer, distinguishing it from complete uterine rupture where all layers are disrupted. 1 This complication can occur both in early postpartum hemorrhage (within 24 hours) and late postpartum hemorrhage (24 hours to 6 weeks or even months after delivery). 1, 2, 3
When to Suspect Dehiscence
A bladder flap hematoma >5 cm on imaging should immediately raise suspicion for uterine dehiscence. 1 This is a critical diagnostic clue that should prompt further evaluation, as smaller hematomas (<4 cm) are often clinically insignificant. 1
Key Clinical Presentations:
- Heavy vaginal bleeding unresponsive to uterotonic agents 2, 4
- Late postpartum hemorrhage occurring weeks to months after cesarean section 2, 3
- Associated findings may include fever, abdominal pain, and signs of infection or peritonitis 5
Diagnostic Approach
Imaging Modalities in Order of Utility:
MRI is superior to CT and ultrasound for detecting the myometrial defect with intact serosal layer due to its superior soft-tissue contrast. 1 However, there is an important pitfall: in the immediate postpartum period, the cesarean section incision can be T1 and T2 hyperintense and may mimic dehiscence. 1
CT with IV contrast should be used in hemodynamically stable patients when conventional medical treatment fails. 1 CT can detect bladder flap, subfascial, or perivaginal space hematomas and their relationship to adjacent organs. 1
Critical Imaging Pitfalls:
- Do not interpret hypodense edema at the cesarean incision site as dehiscence in the first postpartum week - there is low correlation between clinical and radiologic findings of dehiscence during this period. 1
- Presence of gas in the myometrial defect extending from the endometrium to the parametrial tissue along with hemoperitoneum suggests complete uterine rupture rather than dehiscence. 1
Management Algorithm
For Hemodynamically Stable Patients:
- Obtain CT with IV contrast to localize bleeding source and assess for dehiscence 1
- Consider MRI if CT findings are equivocal and patient remains stable 1
- Evaluate for associated complications including pseudoaneurysm, retained products of conception, or infection 1, 6
For Hemodynamically Unstable Patients:
Proceed directly to emergency laparotomy - imaging delays are not justified when the patient is unstable with ongoing hemorrhage. 2, 4, 3 At laparotomy, options include:
- Uterine wound debridement and resuture if fertility preservation is desired and tissue is viable 4
- Subtotal or total hysterectomy for life-threatening hemorrhage or extensive necrosis 2, 3
Associated Complications
Uterine dehiscence may coexist with:
- Uterine artery pseudoaneurysm - seen in conjunction with cesarean scar dehiscence causing secondary postpartum hemorrhage 6
- Endomyometritis and localized peritonitis - infection can complicate dehiscence and present as abdominal wound sepsis 5
- Severe abdominal wound infection - may be the presenting sign of underlying uterine wound dehiscence 5
Long-Term Implications
Severe abdominal wound infection after cesarean section associated with uterine wound dehiscence poses a grave risk to the mother in future pregnancies. 5 This underscores the importance of early recognition and appropriate surgical management to minimize long-term morbidity.
Timeline Considerations
Late postpartum hemorrhage due to poor incision healing can occur as late as 3 months after cesarean section or even later. 3 The traditional definition of late postpartum hemorrhage (24 hours to 6 weeks) may be too restrictive, and obstetricians should maintain vigilance for this complication beyond the conventional puerperal period. 3