Peritonitis is rarely encountered ater vaginal delivery, and many such cases are due to virulent strains of group A 3-hemolytic streptococci or similar organisms. Importantly in postpartum women, abdominal rigidity may not be prominent with puerperal peritonitis because of physiological abdominal wall laxity from pregnancy. Pain may be severe, but frequently, the irst symptoms of peritonitis are those of adynamic ileus. Marked bowel distention may develop, which is unusual ater uncomplicated cesarean delivery. If the infection begins in an intact uterus and extends into the peritoneum, antimicrobial treatment alone usually sufices. Conversely, peritonitis caused by uterine incisional necrosis as discussed subsequently, or from bowel perforation, must be treated promptly with surgical intervention .
For some women in whom metritis develops following cesarean delivery, parametrial cellulitis is intensive and forms an area of induration-a phlemon-within the leaves of the broad ligament (Fig. 37-3). hese infections are considered when fever persists longer than 72 hours despite intravenous antimicrobial therapy (Brown, 1999; DePalma, 1982).
Phlegmons are usually unilateral, and they frequently are limited to the parametrium at the base of the broad ligament.
FIGURE 37-3 Left-sided parametrial phlegmon: cellulitis causes induration in the parametrium adjacent to the hysterotomy incision. (Reproduced with permission from Worley KC: Postoperative complications. In Yeomans ER, Hofman BL, Gilstrap LC III, et al (eds): Cunningham and Gilstrap's Operative Obstetrics, 3rd ed. New York, McGraw Hill Education, 201o7.)
FIGURE 37-4 Pelvic computed tomography scan showing necrosis of the uterine incision with gas in the myometrium (arrows). There is also a large right-sided parametrial abscess (a).
If the inflammatory reaction is more intense, cellulitis extends along natural lines of cleavage. he most common form of extension is laterally along the broad ligament, with a tendency to extend to the pelvic sidewall. Occasionally, posterior extension may involve the rectovaginal septum, producing a firm mass posterior to the cervix. In most women with a phlegmon, clinical improvement follows continued treatment with a broad-spectrum antimicrobial regimen. Typically, fever resolves in 5 to 7 days, but in some cases, it persists longer. Absorption of the induration may require several days to weeks.
In some women, severe cellulitis of the uterine incision may ultimately lead to necrosis and separation (T reszezamsky, 201r1). Extrusion of purulent material as shown in Figure 37-4 causes intraabdominal abscess formation and peritonitis as described above. Surgery is reserved for women in whom uterine incisional necrosis is suspected because of ileus and peritonitis. For most, hysterectomy and surgical debridement are needed and are predictably diicult because the cervix and lower uterine segment are involved with an intense inflammatory process that extends to the pelvic sidewall. he adnexa are seldom involved, and one or both ovaries can usually be conserved. Blood loss is often appreciable, and transfusion is usually necessary.