Post-caesarean
sepsis
Post-caesarean sepsis ultrasound case study
USG
- Post-caesarean hematomas may become secondarily infected, resulting in septic collections.
- Internal echoes, septations, and echogenic debris suggest infected fluid rather than a simple seroma.
- Peripheral hypervascularity on color Doppler supports active inflammation or infection.
- Assessment for wound dehiscence, fascial disruption, and intraperitoneal extension is essential.
- Differential diagnoses include seroma, non-infected hematoma, pelvic abscess, urinoma, and lymphocele.
- Ultrasound is valuable for diagnosis and image-guided aspiration or drainage when indicated.
Definition — Post-caesarean Haematoma: A localized collection of blood that forms at or near the cesarean incision (subcutaneous, between uterine layers, or in the pelvis) due to bleeding from surgical vessels or inadequate haemostasis. It may present as a palpable tender mass, expanding uterine size, persistent anaemia, or delayed haemodynamic instability and can act as a nidus for infection if not resorbed or evacuated.
Definition — Septic Collection (Post-caesarean Abscess/Collection): An infected fluid collection (abscess or infected seroma/haematoma) occurring in the wound bed, subcutaneous tissue, uterine incision plane, or pelvic spaces after cesarean delivery. It is characterized clinically by fever, wound erythema/tenderness, raised inflammatory markers, and may require antibiotic therapy and ultrasound-guided or surgical drainage.
Definition — Wound Disruption (Dehiscence/Evisceration): Partial or complete separation of the layers of the surgical incision after cesarean section — ranging from superficial wound dehiscence (skin/subcutaneous) to deep dehiscence involving fascia and uterine closure, and in severe cases evisceration. Presents with wound gaping, serosanguinous discharge, pain or visible bowel/uterine edges, and requires prompt surgical assessment and management.
::content Reference[R. K. Mouj].
Ultrasound report lines — Post-caesarean sepsis / wound collections:
Uterus appears bulky in size (103x39x69mm) and shows Complex, multiloculated hypoechoic collection with internal mobile echoes and no peripheral hyperaemia on colour Doppler at the wound/uterine incision plane /parametrium measuring, 44.2 x 24.3 mm comunicating with endometrial cavity The endometrial cavit containig slightely hypo to hetrogeneus colection. — findings favour an infected collection/abscess.
Conclusions: Findings favour infected collection/abscess.(Post-caesarean sepsis).
Recommendation: image-guided aspiration for culture and CT Pelvis
Case Study — Post-caesarean Sepsis:
Mrs. S., 28 years old, G2P2, underwent an emergency lower segment caesarean section (LSCS) 28 days ago for prolonged obstructed labour. The immediate postoperative period was uneventful, and she was discharged on day 4. On day 7, she developed fever, lower abdominal pain, and foul-smelling wound discharge. Symptoms worsened over 2 days with chills, malaise, and suprapubic tenderness. She was re-admitted on day 9.
Clinical Examination:
Patient febrile (38.9°C), tachycardic (pulse 112/min). Pfannenstiel incision erythematous with induration and purulent discharge. Uterus bulky and tender. No generalized peritonitis.
Laboratory Findings:
CBC: leukocytosis (WBC 15,200/ยตL, neutrophilia). Hb 9.8 g/dL. CRP markedly raised. Blood cultures pending.
Ultrasound Examination:
Transabdominal ultrasound performed with a curvilinear probe (3.5–5 MHz).
- Uterus appears bulky in size (103 × 39 × 69 mm).
- At the uterine incision plane/parametrium: a complex, multiloculated hypoechoic collection measuring 44.2 × 24.3 mm with internal mobile echoes.
- The collection communicates with the endometrial cavity, which also contains a small heterogeneous fluid collection.
- No significant peripheral hyperaemia on colour Doppler.
- Minimal free intraperitoneal fluid detected.
- Right kidney: Moderate hydronephrosis with proximal hydroureter noted.
- The right ureter is seen dilated up to the level of the ureterovesical junction (UVJ), where it is compressed/extrinsically obstructed by the adjacent parametrial infected collection/abscess.
Pathophysiological Explanation:
The infected post-caesarean collection located in the right parametrium exerts mass effect on the distal ureter at the UVJ. This results in impaired urinary drainage from the right kidney, leading to back pressure changes (hydronephrosis and hydroureter). Such obstruction may worsen sepsis by impairing urinary clearance and increasing risk of secondary urosepsis if untreated.
Ultrasound Impression:
Complex multiloculated hypoechoic collection with internal echoes and endometrial extension, associated with secondary right hydronephrosis due to UVJ obstruction by mass effect of the collection — consistent with infected collection/abscess (post-caesarean sepsis).
Related Ultrasound report lines — Post-caesarean sepsis / wound collections:
1. No collection detected:
No sonographic evidence of wound, subcutaneous or pelvic fluid collection. Uterine incision appears intact with no focal defect. No free intraperitoneal fluid identified.
2. Subcutaneous haematoma (acute / subacute):
Heterogeneous, predominantly echogenic collection in the subcutaneous plane at the Pfannenstiel incision measuring {{length}}×{{width}}×{{depth}} mm, with no internal vascularity on colour Doppler — appearances most consistent with haematoma.
3. Organ/uterine-incision haematoma / muscular plane collection:
Well-defined complex collection deep to the fascia at the region of the uterine incision measuring {{size}} mm, variable internal echoes and layering; no internal Doppler flow. Correlate with haemoglobin trends and clinical status.
4. Infected collection / abscess:
Complex, multiloculated hypoechoic collection with internal mobile echoes and peripheral hyperaemia on colour Doppler at the wound/uterine incision plane, measuring {{size}} mm — findings favour an infected collection/abscess. Recommend image-guided aspiration for culture and targeted drainage if clinically indicated.
5. Gas-forming infection (suggestive):
Collection containing multiple echogenic foci with dirty posterior reverberation/dirty shadowing and ring-down artefact compatible with intralesional gas — highly suspicious for gas-forming infection. Urgent clinical correlation and surgical/infectious disease review advised.
6. Deep pelvic / parametrial abscess:
Complex fluid collection in the anterior pelvic/pouch of Douglas region measuring {{size}} mm with internal echoes and peripheral vascularity, tracking towards the uterine incision — features consistent with deep pelvic abscess; cross-sectional imaging (CT/MRI) and image-guided drainage may be required.
7. Tracking collection / sinus to skin:
Fluid collection in continuity with a superficial wound tract extending from the uterine incision to the subcutaneous layer/skin, suggestive of sinus/superficial to deep communicating infection.
8. Wound dehiscence with subfascial collection / evisceration risk:
Fascial discontinuity at the prior incision with underlying subfascial fluid collection and visible bowel loops abutting the defect on dynamic Valsalva — concerning for deep wound dehiscence; urgent surgical review recommended.
9. Postoperative seroma / simple collection:
Anechoic, avascular fluid collection in the subcutaneous plane consistent with seroma measuring {{size}} mm; consider conservative management or aspiration if symptomatic or infected.
10. Suggestion for image-guided management:
Ultrasound-guided diagnostic aspiration and/or catheter drainage is feasible and recommended to obtain fluid for Gram stain/culture and to help source control; correlate with CBC, CRP and blood cultures prior to antibiotic therapy where possible.
11. Final summary sentence (template):
Summary: {{one-line finding}}. Recommend clinical correlation (fever, WBC, CRP), review by obstetrics/surgery and consideration of image-guided aspiration/drainage and microbiology sampling.
Notes — technique / limitations:
Exam performed with graded compression and colour Doppler. Small collections or deep retroperitoneal/loculated pockets may be better defined on contrast CT/MRI — correlation recommended if clinical suspicion persists despite negative ultrasound.
Post-caesarean Haematoma — Causes:
- Poor haemostasis at the time of surgery (bleeding from uterine artery branches, subcutaneous vessels or superficial fascia).
- Inadvertent vessel injury during entry or closure, multiple uterine incisions or difficult dissection.
- Coagulopathy (pre-existing or acquired), antiplatelet/anticoagulant drugs.
- Hypertension or sudden rise in blood pressure post-op.
- Obesity, prolonged labour or emergency CS with friable tissues.
- Placenta accreta spectrum (bleeding from placental bed) or retained placental tissue.
Post-caesarean Haematoma — Symptoms / Clinical features:
- Local: increasing wound tenderness, swelling or a palpable, often tender mass near the incision.
- Uterine enlargement or persistent lochia/bleeding; expanding abdominal girth if retroperitoneal/pelvic.
- Systemic: falling haemoglobin, tachycardia, hypotension or signs of hypovolaemia if bleeding is significant.
- Low-grade fever may occur; a chronic haematoma can later become infected.
Post-caesarean Haematoma — Diagnostic strategy:
- Clinical assessment: inspection and palpation of wound, vital signs, serial haemoglobin/hematocrit.
- Baseline labs: CBC, coagulation profile, type & crossmatch if significant bleeding suspected.
- Ultrasound (transabdominal ± transvaginal) is first-line to identify and estimate size/location — acute haematoma may be relatively echogenic and become more complex/hypoechoic over time; no internal Doppler flow within organised clot.
- CT abdomen/pelvis with contrast if ultrasound equivocal or to assess deep/retroperitoneal bleeding, expanding collection, or haemodynamic instability (useful for surgical planning).
- If concern for infection of the haematoma, obtain blood cultures and consider image-guided aspiration for culture and sensitivity before/after starting antibiotics.
- Urgent surgical review if expanding haematoma, hemodynamic instability, or suspicion of ongoing arterial bleeding.
Septic Collection (Post-caesarean Abscess / Infected Haematoma) — Causes:
- Secondary infection of a seroma or haematoma at the wound or uterine incision site.
- Contamination at surgery, prolonged rupture of membranes, chorioamnionitis or retained products of conception.
- Poor wound hygiene, diabetes, obesity, immunosuppression, prolonged operative time.
- Superficial wound infection that tracks deeper into fascial or pelvic planes.
Septic Collection — Symptoms / Clinical features:
- Fever, chills and malaise; often persistent or recurrent fever despite usual postpartum care.
- Local signs: wound erythema, induration, warmth, increased pain, purulent discharge or sinus formation.
- Pelvic/heavy lower abdominal pain, tenderness, guarding if deep pelvic abscess.
- Raised inflammatory markers (CRP, ESR) and leukocytosis on blood tests.
- If severe, systemic sepsis with tachycardia, hypotension and organ dysfunction.
Septic Collection — Diagnostic strategy:
- Clinical inspection of the wound and focused history (timing of fever, wound changes, antibiotic exposure).
- Laboratory tests: CBC, CRP/ESR, blood cultures (if febrile/septic), wound swab for microscopy/culture if discharge present.
- Ultrasound (first-line) to detect fluid collections in the subcutaneous tissue, uterine incision plane or pelvis — infected collections often appear complex with internal echoes; peripheral hyperemia may be seen on Doppler.
- CT pelvis/abdomen with contrast for deeper, multiloculated or complex collections, to guide drainage and exclude other intra-abdominal sources.
- Image-guided (US/CT) aspiration or drainage both diagnostic (culture) and therapeutic — obtain specimens before starting antibiotics if safe to do so.
- Consult surgery/obstetrics for combined management (antibiotics ± drainage ± debridement); escalate urgently if signs of sepsis.
Wound Disruption (Dehiscence / Evisceration) — Causes:
- Surgical factors: inadequate fascial closure, inappropriate suture material/technique.
- Infection of the wound causing breakdown of tissue integrity.
- Patient factors: obesity, diabetes, malnutrition, steroid use, smoking, raised intra-abdominal pressure (cough, vomiting, constipation).
- Early excessive strain on the wound or poor postoperative care/compliance.
Wound Disruption — Symptoms / Clinical features:
- Visible separation of the incision edges, serosanguinous or purulent discharge from the wound.
- Pain out of proportion, visible subcutaneous tissue or (in severe cases) bowel/omentum protruding through the wound (evisceration).
- Fever if infected; local erythema and induration.
- In deeper dehiscence, abdominal wall laxity, bulge on coughing or rising, and risk of secondary hernia formation.
Wound Disruption — Diagnostic strategy:
- Immediate visual and bedside assessment of the wound — document extent, depth and presence of exposed viscera.
- Wound swab for culture if discharge present; CBC and inflammatory markers to assess for systemic infection.
- Bedside ultrasound can identify fascial plane separation, subcutaneous collections or occult deep fluid; useful for planning management.
- CT abdomen/pelvis if deeper abdominal wall disruption is suspected or to assess intra-abdominal extension/evisceration not appreciated on exam.
- Urgent surgical/obstetric evaluation for wound exploration, debridement and re-closure when indicated — evisceration is a surgical emergency.
Red flags (require urgent action): expanding or tense haematoma, hemodynamic instability, signs of peritonitis, visible evisceration, rapidly worsening sepsis, or failure to improve on conservative therapy — all warrant immediate surgical review and likely operative intervention.
Risk factors — Post-caesarean Haematoma:
- Operative / surgical: inadequate haemostasis at closure, difficult dissection, multiple uterine incisions, long operative time, repeat CS, accidental vessel injury, use of anticoagulants/antiplatelets or intra-operative heparinization.
- Patient / medical: hypertension (including perioperative BP spikes), coagulopathy (inherited or acquired), thrombocytopenia, obesity (thicker subcutaneous tissue), anemia, advanced maternal age.
- Obstetric / peripartum: emergency CS (esp. after prolonged or obstructed labour), placenta accreta/placenta praevia or retained placental tissue, prolonged second stage, uterine atony or heavy blood loss.
- Post-op factors: vigorous coughing/straining, early physical strain, inadequate wound support or early anticoagulation therapy after delivery.
Risk factors — Septic collection / post-caesarean abscess (infected haematoma/seroma):
- Antecedent wound or retained collection: pre-existing haematoma or seroma that becomes secondarily infected.
- Intrapartum infection: chorioamnionitis, prolonged rupture of membranes, prolonged labour, multiple vaginal examinations.
- Maternal comorbidity: obesity, diabetes, immunosuppression, malnutrition, anemia, smoking.
- Procedure factors: emergency CS, prolonged operative time, poor aseptic technique, blood transfusion, prolonged catheterization.
- Health-system / social: limited antenatal care, delayed presentation, poor wound care at home.
Risk factors — Wound disruption (dehiscence / evisceration):
- Surgical technique: inadequate fascial closure, wrong suture choice/technique, excessive tissue trauma, long surgery or repeated attempts at closure.
- Infection: superficial or deep wound infection (which weakens tissue and predisposes to dehiscence).
- Patient factors: obesity (large subcutaneous thickness), malnutrition, anemia, diabetes, steroid use, chronic cough, chronic pulmonary disease, ascites, smoking.
- Perioperative / obstetric: emergency surgery, prolonged labour, repeated operations, blood transfusion, use of corticosteroids in labor.
- Post-op mechanical strain: early heavy lifting, vomiting, severe coughing, constipation/straining.
Quick preventive notes: careful haemostasis and fascial closure, perioperative antibiotic prophylaxis, optimal BP and glycaemic control, minimising operative time where safe, good wound care instructions, thrombosis/bleeding risk assessment before starting postoperative anticoagulation, and early recognition of wound collections reduce the risk of these complications. (See cited reviews for details and local protocol guidance.)
Declaration:
I, R. K. Mouj, hereby declare that the material presented in this document titled "Post-caesarean Sepsis: Post-caesarean Haematomas, Septic Collections and Wound Disruptions" has been prepared and compiled by me for educational purposes only. It is intended for learning, training and academic reference, and not for submission toward any formal degree or qualification. Sources and references used have been acknowledged where appropriate. Its my own original work. This thesis has not been submitted, either in whole or in part, for a degree at this or any other university. All sources and contributions from other authors have been clearly acknowledged and cited in the references. Where material from other authors has been used, permission has been obtained and is indicated in the text or figure captions.
Ethics / Patient Data Statement: Any patient images, clinical data or case material included in this thesis have been used in accordance with applicable ethical guidelines and with appropriate consent or institutional approval. Identifying patient information has been removed or anonymised.
Author: ____________________
Name: R. K. Mouj [Radio-imaging Technologist]
Supervisor / Guide:Department radiologist
Department: Radiology
Institution: ____________________
Date: 11-09-2025
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