Cesarean scar abscess: A case report and a review of the literature

doi:10.4236/ojog.2012.23050

Paper Menu >>

Journal Menu >>

Open Journal of Obstetrics and Gynecology, 2012, 2, 244-246 OJOG

http://dx.doi.org/10.4236/ojog.2012.23050 Published Online September 2012 (http://www.SciRP.org/journal/ojog/)

Cesarean scar abscess: A case repor t and a review of

the literature*

Takako Taguchi1, Seiji Mabuchi1#, Toshio Kimura2, Tadashi Kimura1

1Department of Ob s tetrics and Gynecology, Osaka University Graduate School of Medicine, Suita, Japan

2Department of Gynecology, Ashiya Municipal Hospi t a l , Ashiya, Japan

Email: #[email protected]d.osaka-u.ac.jp

Received 4 May 2012; revised 8 June 2012; accepted 20 June 2012

ABSTRACT

Cesarean section and the resultant Cesarean scar are

known to be associated with obstetric complications

in subsequent pregnancies. Cesarean scar is also as-

sociated with gynecological conditions that can ad-

versely affect the patient’s quality of life. We describe

a very rare case of Cesarean scar abscess that deve-

loped 8 years after a Cesarean delivery, which was

managed by emergency hysterectomy.

Keywords: Cesarean Section; Cesarean Scar Dehiscence;

Abscess

1. INTRODUCTION

The increasing rates of Cesarean section and its compli-

cations are global issues in developed countries. Cesa-

rean section and the resultant Cesarean scar in the lower

uterine segment are known to be associated with obstet-

ric complications in subsequent pregnancies, such as

uterine rupture; Cesarean scar pregnancy (CSP); placenta

previa; and placenta accreta, increta, or percreta. Cesar-

ean scars are also associated with gynecological condi-

tions that can ad versely affect the patient’s quality of life,

e.g., abnormal uterine bleeding, chronic pain, or secon-

dary infertility [1].

We herein describe a very rare case of Cesarean scar

abscess that developed 8 years after a Cesarean delivery,

which was m a naged by emergency hysterectomy.

2. CASE REPORT

A 44-year-old Japanese woman (gravida 1, para 1) visited

our hospital complaining of abdominal pain that had

lasted for 2 weeks accompanied by uterine bleeding. Her

obstetric history included a lower uterine segment trans-

verse Cesarean section 8 years earlier. Her medical his-

tory was unremarkable. Physical examinations including

pelvic examination revealed a body temperature of 39˚C,

marked bloody cervical discharge with an odious smell,

cervical motion tenderness, and lower abdominal ten-

derness, but no rebound tenderness. Transvaginal ultra-

sonography showed a normal-sized uterus with an 8 × 7

cm spherical mass in the lower uterine segment, which

was located on the scar cau sed by the previous Cesarean

section. The inner part of the mass was irregular (both

hyperechogenic and anechogenic). Both ovaries were

normal, and there was no intraperitoneal fluid. Labora-

tory tests revealed an elevated white blood cell count

(12,120/mm3), an elevated C-reactive protein level (14.9

mg/dl), and a negative pregnancy test result. She was

admitted, and initial treatment with antibiotics was per-

formed on the same day. A subsequent pelvic magnetic

resonance imaging (MRI) examination revealed an 11 ×

10 × 9 cm exophytic tumor in the lower uterine segment.

Both transvaginal ultrasonography and pelvic MRI sug-

gested that the tumor was connected to the uterine cavity

through a small defect in the lower anterior wall of the

uterus, which might have been a Cesarean scar defect. A

diagnosis of Cesarean scar abscess was suspected. As her

infectious symptoms progressed and she did not want to

preserve her fertility, we offered her abdominal hyste-

rectomy. Exploratory laparotomy revealed a 12 × 10 × 10

cm elastic mass arising from the lower anterior uterine

wall, which was adherent to the right pelvic sidewall, and

total abdominal hysterectomy was performed (Figure 1).

Grossly, the mass contained bloody purulent discharge

and was connected to the uterine cavity by a thin piece of

tissue. A pathological examination showed a bundle-like

mass of muscle tissue without any findings of degene-

rated leiomyoma. The cavity of the tumor and the tissue

connecting it to th e uterus were lined with colu mnar cells

resembling those found in the endocervical epithelium.

Culturing of the abscess contents produced Enterobacter

cloacae. The diagnosis of Cesarean scar abscess was

confirmed. The patient received intravenous antibiotics

for 2 days after the surgery and was discharged.

*Conflicts of Interest Statement: The authors declare that no conflicts

of interest exist.

#Corresponding author.

OPEN ACCESS

T. Taguchi et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 244-246 245

Figure 1. Photographs of Cesarean scar abscess. (A) A photo

taken from the back of the uterus; (B) A photo taken from the

left side of the uterus.

3. DISCUSSION

Cesarean scar abscess, a rare late complication of Cesa-

rean section, is caused by infection of the “diverticulum”

at the site of the Cesarean scar. Its precise incidence is

unknown; however, to the best of our knowledge, only

two cases have been reported in the English literature

[2,3] (Table 1). The following mechanisms have been

reported to lead to the formation of Cesarean scar ab-

scesses: The formation of scar dehiscence, a myometrial

discontinuity at the site of a previous Cesarean scar, is

caused by unknown mechanisms. A lack of coordinated

muscular contractions around Cesarean scar dehiscence

allows the accumulation of menstrual debris and diver-

ticulum formation. The accumulation of menstrual blood

in the diverticulum can result in intermittent bleeding

and/or abdominal pain and can also promote infection

[2,3].

In previous reports, abnormal uterine bleeding and

lower abdominal pain were observed in 82% [4] and

46.3% [5] of women with Cesarean scar dehiscence, re-

spectively. Moreover, recent reports have demonstrated a

clear association between scar dehiscence and secondary

infertility. According to a report by Gubbini et al., se-

condary infertility was ob s erved in 35% of women with a

history of irregular bleeding associated with a Cesarean

scar defect [6]. It is hypothesized that the persistence of

menstrual blood in the cervix negatively influences mu-

cus quality, obstructs sperm transport through the cervi-

cal canal, affects sperm quality, and/or interferes with

embryo implantation. Collectively, these reports suggest

that a significant number of patients with scar dehiscence

suffer symptomatic complications that require treatment.

Since there are no treatment guidelines based on a

good level of evidence, the treatment for Cesarean scar

dehiscence should be chosen on an individual basis de-

pending on the presence of clinical symptoms and

whether the patient wishes to preserve their fertility.

In recent transvaginal ultrasound studies, Cesarean scar

dehiscence was observed in 57.5% - 100% of women

with a history of Cesarean section [7], which is a much

higher rate than the incidence of CSP or uterine rupture,

the most catastrophic complications of Cesarean section.

Therefore, a policy of routine surgical management

would not be cost effective, and hence, difficult to justify.

However, as recent reports have suggested that surgical

reconstruction of Cesarean scar dehiscence might resolve

the patient’s clinical symptoms and restore their fertility,

surgical treatment might be beneficial and should be

considered in symptomatic cases. So far, many surgical

techniques have been proposed to correct Cesarean scar

dehiscence. Of these, wedge excision of the Cesarean

scar dehiscence either by laparotomy or laparoscopy [8]

and a resectoscopic treatment called “isthmoplasty” were

reported to be successful [1]. As wedge excision of a

Cesarean scar can result in postoperative adhesion, which

might affect the patient’s fertility, a hysteroscopic app-

roach might be the first-choice treatment for patients

who wish to preserve their fertility. In cases involving

patients who do not want to preserve their fertility or

cases involving a large diverticulum, hysterectomy

mig ht b e the optimal treatment. As shown in Table 1, as

Table 1. Summary of the reported cases of Cesarean scar abscess.

Author [Ref] Diaz-Garcia, et al. [2] Ou, et al. [3] Present case

Characteristics

Age 36 41 44

Number of C/S 1 2 1

Time after C/S (year) 6 More than 3 8

Symptoms Fever, abdominal pain Fever, abdominal pain, AUB Fever, abdominal pain, AUB

Size of abscess (cm) 2.4 × 3 × 1.9 9 × 6 × 5 12 × 10 × 10

Treatment Antibiotics followed b y l a p a r o s copic

and hysteroscopic reconstruction Antibiotics followed b y t o t a l

abdominal hysterectomy Antibiotics followed b y t o t a l

abdominal hysterectomy

AUB: abnormal uterine bleeding; Ref: ref erence n umber; C/S: C esarean s ection.

T. Taguchi et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 244-246

246

conservative medical treatments using antibiotics failed

in all three reported cases, prompt surgical treatment is

recommended for Cesarean scar abscess.

REFERENCES

[1] Florio, P., Filippeschi, M., Moncini, I., Marra, E., Fran-

chini, M. and Gubbini, G. (2012) Hysteroscopic treatment

of the cesarean-induced isthmocele in restoring infertility.

Current Opinion in Obstetrics & Gynecology, 24, 180-

186.

[2] Diaz-Garcia, C., Estellés, J.G., Escrivá, A.M., Mora, J.J.,

Torregrosa, R.R. and Sancho, J.M. (2009) Scar abscess

six years after cesarean section: Laparoscopic and hys-

teroscopic management. Journal of Minimally Invasive

Gyn ecology , 16, 785 - 7 88 . doi:10.1016/j.jmig.2009.07.020

[3] Ou, Y. C., Huang, K.H., Lin, H., Eng, H.L., Lu, H.M. and

Changchien, C.C. (2011) Sepsis secondary to cesarean

scar diverticulum resembling an infected leiomyoma.

Taiwan Journal of Obstetrics and Gynecology, 50, 100-

102. doi:10.1016/j.tjog.2011.01.004

[4] Fabres, C., Aviles, G., De La Jara, C., Escalona, J., Muñoz,

J.F., Mackenna, A., Fernández, C., Zegers-Hochschild, F.

and Fernández, E. (2003) The cesarean delivery scar

pouch: Clinical implications and diagnostic correlation

between transvaginal sonography and hysteroscopy. Jour-

nal of Ultrasound in Medicine, 22, 695-700.

[5] Gubbini, G., Centini, G., Nascetti, D., Marra, E., Moncini,

I., Bruni, L., Petraglia, F. and Florio, P. (2011) Surgical

hysteroscopic treatment of cesarean-induced isthmocele

in restoring fertility: Prospective study. Journal of Mini-

mally Invasive Gynecology, 18, 234-237.

doi:10.1016/j.jmig.2010.10.011

[6] Gubbini, G., Casadio, P. and Marra, E. (2008) Resecto-

scopic correction of the “isthmocele” in women with

postmenstrual abnormal uterine bleeding and secondary

infertility. Journal of Minimally Invasive Gynecology, 15,

172-175. doi:10.1016/j.jmig.2007.10.004

[7] Menada Valenzano, M., Lijoi, D., Mistrangelo, E., Co-

stantini, S. and Ragni, N. (2006) Vaginal ultrasonographic

and hysterosonographic evaluation of the low transverse

incision after caesarean section: Correlation with gynae-

cological symptoms. Gynecologic and Obstetric Investi-

gation, 61, 216-222. doi:10.1159/000091497

[8] Donnez, O., Jadoul, P., Squifflet, J. and Donnez, J. (2008)

Laparoscopic repair of wide and deep uterine scar dehis-

cence after cesarean section. Fertility and Sterility, 89,

974-980. doi:10.1016/j.fertnstert.2007.04.024