Materials and Methods
This retrospective case-control study was performed in a single academic
medical centre from March 2014 to October 2020. Women with uterine
rupture or dehiscence were included in the study group and compared to
women who had a successful TOLAC (the control group). Demographic and
obstetrical data, as well as any record of infection during or within a
month after a prior CD were investigated.
Rupture of the uterus was defined as complete disruption of the previous
Cesarean scar with communication between the uterine and abdominal
cavities. Dehiscence of the scar was defined as incomplete disruption
that included ruptured uterine muscle with intact serosa as the only
layer keeping the foetus in the uterus. All cases of rupture and
dehiscence were identified during CD.
The electronic medical records (EMR), were reviewed for demographic
characteristics (age, BMI, gravity, and parity) and for medical
information (regarding phase of delivery at first CD, surgical
technique, and inter-delivery interval), and neonatal birth weight.
Infection was defined as either intrapartum with maternal temperature
above 38°C during or up to 24 hours after delivery.
Postpartum fever was defined as maternal temperature above
38°C, 24-48 hours after delivery, and SSI was defined
according to the 2018 ACOG criteria and included endometritis, infected
hematoma or infection of surgical wound up to 30 days from the previous
CD.14 The diagnosis of SSI was determined based on the
ICD-9 codes, analysis of laboratory data of wound cultures,
non-prophylactic antibiotic prescriptions, and the clinical impression
written by the medical team in the EMR.
Based on a uniform protocol, all patients undergoing CD received
standard infection-prevention measures, including preoperative
intravenous (IV) antibiotic prophylaxis with one to two grams of
cefamezine based on maternal weight, surgical length and blood loss. For
patients allergic to penicillin, clindamycin and gentamicin were
administered.15
Intrapartum fever was treated with a combination of ampicillin and
gentamicin, while patients with intrapartum fever undergoing CD also
received IV metronidazole. Postpartum fever and endometritis were
treated with IV Augmentin up to 48 hours from the last fever, according
to protocols suggested by ACOG.16 Patients with large
infected abdominal hematomas or any other severe infection were treated
with a triad of ampicillin, gentamicin and IV metronidazole until
improvement was noted or positive cultures allowed more specific
treatment, according to institutional guidelines.
We compared three groups and subgroups: 1) All patients with rupture or
dehiscence compared to controls (no rupture or dehiscence), 2) Rupture
versus dehiscence, and 3) Rupture versus controls. We evaluated each
group in terms of the type of infection as a risk-factor for rupture or
dehiscence: intrapartum chorioamnionitis, postpartum endometritis, or
SSI.