Obstetrics & Gynecology>>>>>The Puerperium, Lactation, and Immediate Care of the Newborn
Question 35#

A 39-year-old G3P3 comes to see you on day 5 after a repeat cesarean delivery. During the surgery she received two units of packed red blood cells for a hemorrhage related to uterine atony. Her past medical history is significant for type 2 diabetes mellitus and chronic hypertension. She weighs 110 kg. She is concerned because her incision has become very red and tender, and pus started draining from a small opening in the incision this morning. She has been experiencing general malaise and reports a fever of 38.8°C (102°F). Her vital signs are: temperature 37.8°C (100.1°F), pulse 69 beats per minute, respiratory rate 18 breaths per minute, and blood pressure is 143/92 mm Hg. Physical examination shows erythema around the incision, and a 1-cm defect at the left corner of the skin incision, which is draining a small amount of purulent liquid. There is tenderness along the wound edges.

Which of the following is her greatest risk factor for her complication?

A) Anemia
B) Corticosteroid therapy
C) Diabetes
D) Hypertension
E) Obesity

Correct Answer is E

Comment:

The incidence of incisional wound infection following cesarean delivery is approximately 6%. Risk factors that predispose to wound infections include obesity, diabetes, corticosteroid therapy, anemia, poor hemostasis, and immunosuppression. Obesity confers the highest risk. The use of preoperative prophylactic antibiotics decreases the incidence of wound infection to about 2%. Usually, incisional abscesses will cause a fever around POD 4, and erythema, induration, and drainage from the incision are also frequently noted. Opening of the incision and surgical drainage are key to curing the infection. Broad-spectrum antimicrobial agents are also administered. In all cases of wound infection, the incision must be probed to rule out a wound dehiscence (separation of the wound involving the fascial layer). As long as the fascial layer is intact, the open wound is kept clean and allowed to heal by secondary intention.