Karin A. Fox
Cesarean delivery is the most commonly performed surgery worldwide, and although it is ubiquitous and routinely performed, it is a major, open abdominal surgery with inherent risks involved.
Complications may be anticipated owing to relatively common occurrence in the postoperative period or owing to a patient’s unique medical history, or unanticipated, and may range in severity from mild to life-threatening.
The U.S. Centers for Disease Control has formally defined “severe maternal morbidity” as unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a woman’s health. There are currently 25 conditions that are used to indicate severe maternal morbidity (Table 5.4.1).
Current efforts focus on reducing severe maternal morbidity, any preventable complication to improve patient safety, and reducing maternal mortality.
Table 5.4.1 List of Conditions Indicating Severe Maternal Morbidity
Acute Myocardial Infarction
Air and Thrombotic Embolism
Heart failure/arrest during surgery or procedure
Blood products transfusion
Acute renal failure
Puerperal cerebrovascular disorders
Adult respiratory distress syndrome
Pulmonary edema/acute heart failure
Amniotic fluid embolism
Severe anesthesia complications
Cardiac arrest/ventricular fibrillation
Sickle cell disease with crisis
Conversion of cardiac rhythm
Disseminated intravascular coagulation
This chapter is not an all-inclusive review of all postnatal morbidity, but rather will address the most common complications following cesarean delivery, particularly those that require surgical intervention. The following chapters provide important additional details regarding the management of complications that may arise following cesarean delivery:
Chapter 1.7, “Management of Critical Surgical Pregnant Patients”
Chapter 4.10, “Gastrointestinal Injuries During Delivery”
Chapter 4.11, “Urologic Injuries During Delivery”
Chapter 5.1, “Management of Postpartum Hemorrhage”
Chapter 6.3, “Disseminated Intravascular Coagulation in Pregnancy”
Chapter 6.4, “Massive Transfusion”
Physical Examination and Differential Diagnoses
Physical examination should include a head-to-toe assessment to ensure that important signs and symptoms are not missed that may narrow the differential diagnosis.
Focused examination will be targeted based upon the nature of complaints, especially in an unstable patient.
Examples of the findings and associated differential diagnosis using system-based approach are listed below:
General: Fever, malaise, mental status changes
Consider: Sepsis, infection, anemia, diabetic ketoacidosis (if diabetic)
Vital sign changes may alert to shock, including the shock index (SI).
Head, eyes, ears, nose, throat (HEENT)
Headache, visual changes
Preeclampsia (severe headache and visual changes herald preeclampsia with severe features): Visual changes may include scotomata (seeing flashing spots in vision), “squiggly lines,” loss of vision in part of the field of view (as though a “curtain” moving across one or both eyes).
Migraine (including atypical migraine): This is a diagnosis of exclusion, as many symptoms overlap those of preeclampsia and stroke.
Spinal headache (worse when upright, improves when supine)
Infection (sinusitis, meningitis)
Posterior reversible encephalopathy (PRES): Posterior edema seen on magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA)/magnetic resonance venography (MRV), with compression of optic nerve and reversible visual disturbance that occurs with severe hypertension. May present as blindness. Therapy includes reduction in systemic blood pressure, with initial goal of 20% reduction (goal mean arterial pressure [MAP] of <125 mm Hg) and then gradual continued reduction.
Stroke (hemorrhagic, ischemic): Monitor for signs of facial droop, slurred speech, unilateral weakness.
Retinal detachment (rare): Symptoms described for preeclampsia similar. Must be diagnosed with a retinal examination after dilatation of the pupils. Retinal detachment may occur with trauma, presence of preexisting retinopathy (as with hypertension or diabetes), exudates behind retina, or traction from the vitreous.
Atelectasis (temporary suboptimal inflation of dependent lung regions): Common in the first 1 to 2 days postoperatively, improves with upright positioning, ambulation, and deep breathing.
Pneumonia (community or hospital-acquired, aspiration): Often associated with febrile morbidity, may or may not be associated with oxygen desaturation or cough. Aspiration pneumonia or pneumonitis should be high on the differential in any patient who vomits during surgery (not uncommon after regional analgesia owing to hypotension), who is highly sedated without a secured airway, or who requires general endotracheal analgesia, especially emergently, when the stomach may not be empty.
Pulmonary edema (cardiogenic or noncardiogenic): Upon identification of pulmonary edema, echocardiogram is recommended to distinguish between the two.
Pulmonary embolism: Signs and symptoms may be subtle and mimic other pathologic entities; therefore, a high index of suspicion and prompt evaluation is warranted. These include mild shortness of breath, cough, chest pressure/pain, tachycardia, calf tenderness, swelling, or leg pain. Deep venous thrombosis (DVT) of the lower extremities or small, subtle pulmonary embolism may herald a larger, submassive, or massive embolism that may follow and be life-threatening.
Transfusion-related lung injury
For most cardiac complications, it is important to optimize and maintain physiologic parameters. Consultation and team-based management with critical care and cardiology colleagues are recommended. Monitor electrolytes and aim to maintain potassium near 4.0 mmol/L and magnesium at or near 2.0 mg/dL whenever possible. Consider providing supplemental oxygen as needed to maintain SaO2 ≥94%.
Diagnosis often relies upon physical examination (edema, cardiac heart sounds, and rhythm), electrocardiogram (EKG), echocardiogram (transthoracic and/or transesophageal), rhythm monitor (telemetry, 24-hour event monitor), and blood tests.
The differential includes, but is not limited to:
Cardiomyopathy (hypertensive, viral, or peripartum): Peripartum cardiomyopathy is a diagnosis of exclusion. Cardiomyopathy may be classified as hypertrophic (concentric thickening and dysfunction of the myometrium), dilated (thinning and “ballooning” of the chambers), restrictive (owing to stiffening of the muscle walls causing diminished relaxation and filling), and arrhythmogenic. A beta-natriuretic peptide (BNP) level above 100 pg/mL and an NT-proBNP level > 450 pg/mL suggest congestive heart failure in nonpregnant patients, and although values of BNP approximately double in pregnancy, they usually remain within the normal range; therefore, elevations in these analytes warrant further evaluation, especially in a symptomatic patient.
Arrhythmia: EKG, 24-hour event monitor, and telemetry recommended. Treatment should be directed to the specific arrhythmia.
Myocardial infarction: Check serial Troponin I, CK-MB, and 12-lead EKG. May give aspirin (if no contraindications) and oxygen liberally. Give fentanyl or morphine to provide pain relief and pulmonary venous dilatation. Myocardial infarction requires an immediate evaluation by a cardiologist, possible cardiac catheterization.
Coronary artery or aortic dissection: May present very similarly to myocardial infarction, as severe chest pain, shock, and arrhythmia. Aortic dissection should be high on the differential in patients with known aortopathy, aortic root dilatation, and inherited disorders of collagen formation, such as Ehlers-Danlos or Loeys-Dietz. Initial management is like that of myocardial infarction, also requires immediate evaluation by a cardiologist, possible surgical intervention.
Transfusion-related circulatory overload (TACO): Pulmonary edema which follows transfusion owing to volume overload or circulatory excess. Risk increases with high volume and a high number of products transfused, rapid transfusion, and in patients with preexisting cardiac and renal dysfunction.
Embolism (thrombotic, rarely amniotic fluid): Pulmonary embolism may present with acute cor pulmonale or acute, right-sided dilatation and heart failure, chest pain, and dyspnea.
Shock (hypovolemic, septic, cardiogenic, and anaphylactic): Hypotension, often accompanied by tachycardia, dizziness, and syncope. May be postural. The SI is the heart rate divided by systolic blood pressure. This calculation rapidly identifies patients with shock but does not distinguish the underlying etiology. A value of 0.5 to 0.7 is considered normal. Higher values suggest hypovolemia or hypoperfusion. Values ≥1.0 are associated with significantly higher morbidity and mortality.
Ileus/small bowel obstruction: See the section below for detailed information about diagnosis and management of small bowel obstruction.
Bowel injury (acute or delayed): Bowel injury should be identified and repaired immediately if seen at surgery. If bowel contents are seen at surgery, immediately call in for surgical repair. Delayed bowel injury may follow severe bowel obstruction, toxic megacolon (marked dilatation of the colon ≥10 cm in diameter on x-ray), or thermal injury to the bowel. Abdominal pain, distension, nausea/vomiting associated with fever, and marked elevation of white blood cell count should alert the clinician to a possible bowel injury. Free air in the abdomen on imaging may reflect normal changes following the laparotomy required for cesarean. A new appearance of free air on repeat imaging, however, is more concerning. A bowel series with contrast that shows spillage of contrast is diagnostic and prompts immediate surgical intervention.
Hemoperitoneum: Abdominal pain, distension, and early or advances stages of shock may be present. See the section below for more detailed information.
Retroperitoneal hematoma: Abdominal or flank pain, fundal diversion to one side, and early or advanced stages of hemorrhagic shock may be present.
Urinary tract infection: May occur in up to 1% of patients who have an indwelling catheter, which is routinely placed to drain the bladder for cesarean delivery. Urinalysis and culture are recommended.
Bladder or ureteral injury: May be identified immediately at the time of surgery, as a delayed injury (such as a thermal injury). Delayed injury may present with acute pain, ileus, increase in serum creatinine, and the appearance of intra-abdominal fluid on imaging (ultrasound or computed tomography [CT] with contrast). See also Chapter 4.11, “Urologic Injuries During Delivery,” for further details.
Vesicovaginal fistula, ureterovaginal fistula: Most commonly presents following a prolonged labor. May also develop postsurgically following cesarean hysterectomy, especially if the vaginal cuff is devitalized or if there is insufficient space between the vaginal cuff and bladder. Symptoms include leakage of urine from the vagina or urine dermatitis of the perineum. Please see Chapter 6.2, “Vaginal Fistula Repair,” for more information.
DVT: Unilateral limb edema, pain, common. Up to one-third of DVTs during pregnancy may originate in the pelvis. Venous Doppler is the first-line imaging modality. Anticoagulation should be started before imaging whenever there is a strong suspicion for DVT.
Superficial thrombophlebitis: This presents as painful, tender, and sometimes erythematous cording of superficial veins. Treatment usually consists of warm compresses, nonsteroidal anti-inflammatory medication for pain control. Antibiotic use may be considered if there are signs of infection. Patients at increased risk for DVT formation may be started on prophylactic Lovenox or heparin.
Localized infection at venipuncture site: Erythema, purulent exudates, warmth, and pain characterize a local infectious process. If sepsis is suspected, blood cultures should be sent. Removal of any remaining lines and antibiotics targeted for common skin pathogens are the usual first-line treatment.
This chapter will briefly review the following surgical complications:
Hemoperitoneum: Accumulation of blood and/or clot within the intra-abdominal cavity. May occur following any surgical procedure. Damage to an omental vessel may cause slow, steady bleeding without an obvious bleeding source. Rarely, spontaneous hemoperitoneum may occur because of rupture of an endometrial rest or vascular aneurysm.
Retroperitoneal hematoma: Accumulation of blood in the retroperitoneal space (Figure 5.4.1). This can occur following cesarean delivery, with lateral extension of the hysterotomy, if a small hematoma forms within the broad ligament and then slowly expands. Inadvertent rupture of lateral vessels may also occur rarely during vaginal delivery or retraction of a vascular pedicle at the time of cesarean hysterectomy.
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