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Wound infection after cesarean delivery is a serious complication that can increase postpartum morbidity, length
of hospital stay, and cost. Wound infection has been
reported in 216% of all women who have cesareans.13
Potential risk factors that are unique to cesarean delivery
include preexisting intra-amniotic infection, perioperative
antibiotic use, presence or duration of ruptured membranes, number of vaginal examinations, and elective or
From the Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, South Carolina.
emergency reason for the surgery.4 The thickness of subcutaneous tissue also was a significant risk factor for
wound infection after abdominal hysterectomy, but has
not been evaluated in women delivered by cesarean.5
We designed a prospective study to estimate the
effect of thickness of subcutaneous tissue and other
variables reported as risk factors for wound infection in
women who delivered by cesarean.
0029-7844/00/$20.00
PII S0029-7844(99)00642-0
923
Uninfected
(n 129)
Infected
(n 11)
26.9 6.4
29.1 7.2
NS
68 (53%)
61 (47%)
6 (54%)
5 (46%)
NS
NS
41 (32%)
61 (48%)
3 (27%)
4 (36%)
NS
NS
120
0 24,480
2.6 2.3
8 (6%)
165
0 2880
2.9 2.3
1 (9%)
NS
NS
NS
Results
Wound infection was diagnosed in 11 of 140 women
(7.8%) after cesarean. The demographic and intrapartum
924 Vermillion et al
Variable
Thickness of subcutaneous
tissue (cm)
Height (cm)
Weight (kg)
Body mass index (kg/m2)
Operative time (min)
Skin incision
Pfannenstiel
Vertical
Uterine incision
Low transverse
Classic uterine
Type of cesarean
Elective
Unscheduled
Uninfected
(n 129)
Infected
(n 11)
2.3 1.2
4.1 1.8
.04
161.3 7.9
82.8 18.6
44.5 2.1
59.5 16.6
159.8 11.5
99.4 33.3
49.7 6.3
71.1 18.4
NS
.002
.001
NS
119 (22%)
10 (8%)
8 (72%)
3 (28%)
NS
NS
102 (79%)
27 (21%)
7 (63%)
4 (36%)
NS
NS
20 (16%)
109 (85%)
1 (9%)
10 (91%)
NS
NS
NS not significant.
Data are presented as mean standard deviation or n (%).
Discussion
Obesity has long been regarded as a risk factor for
abdominal wound infection.6 10 However, obesity has
been equated with an overall increase in weight and not
specifically with the patients habitus. When obesity
was calculated anthropometrically using skin-fold
thickness, no significant association with wound infection could be found.11 Our data suggest that increased
weight or BMI does not specifically increase patients
risks of wound infection, but that the thickness of
subcutaneous tissue at the site of the incision does.
Thus, a larger and heavier woman with the same
subcutaneous tissue thickness of a smaller and lighter
woman would have the same risk of wound infection.
Our findings are similar to those reported by Soper et
al5 from a sample of women who had abdominal
hysterectomies, in which subcutaneous tissue thickness
was the most significant risk factor for wound infection.
It is widely accepted that ischemic wounds heal
poorly because of limited perfusion and delivery of
fibroblasts and leukocytes. Previous investigators
found that wounds with large unapproximated areas or
dead space remained relatively hypoxic.12 Large unapproximated surfaces also might accumulate serosanginous fluid, which can act as an ideal culture
medium for contaminating pathogens. Greater subcutaneous tissue thicknesses increase the likelihood of
such an environment and might explain the association
with wound infection seen in our study.
Other identifiable risk factors for wound infection
after cesarean delivery have included increased vaginal
examinations, prolonged rupture of membranes, and
emergency surgeries.13,14 However, we were unable to
confirm such associations in our population. The predominant pathogens isolated from a few of the wound
infections in our population were E coli and Enterococcus
species, which are consistent with the findings of previous investigators.15,16
Identifying subcutaneous tissue thickness as a significant risk factor for postoperative wound infection after
cesarean is not useful as a diagnostic test. In our study,
the positive predictive value of subcutaneous tissue
thickness of at least 3 cm was only 19% (nine of 47), with
a negative predictive value of 98% (91 of 93). Most
women with subcutaneous tissue measurements of at
least 3 cm will not have wound infections more than
80% of the time.
Several mechanical prevention strategies for wound
infection have been studied, including closed-suction
drainage and closure of the subcutaneous tissue, with
varying degrees of success.3,17 Soisson et al18 conducted
a randomized trial of subcutaneous retention sutures
versus skin closure alone in women with subcutaneous
tissue thickness of at least 5 cm after gynecologic
laparotomy. In that study, the investigators found a
significant reduction in the frequency of superficial
wound separation in women with retention sutures.18
Perioperative antibiotic prophylaxis during cesarean
has been widely accepted, but increasing resistance
among bacterial pathogens soon might limit obstetri-
cians options for wound-infection prophylaxis. Perhaps with the evolution of many antibiotic-resistant
pathogens, the focus of wound-infection prevention
might change to mechanical strategies in which subcutaneous tissue thickness will be important. On the basis
of the findings in the present study, we are currently
conducting a randomized trial of closed-suction drainage versus observation after cesarean for the prevention
of wound infection in women with a subcutaneous
tissue depth of at least 4 cm.
References
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Vermillion et al
925
Stephen T. Vermillion, MD
Department of Obstetrics and Gynecology
Medical University of South Carolina
96 Jonathan Lucas Street, Suite 634
PO Box 250619
Charleston, SC 29425
E-mail: vermills@musc.edu
926 Vermillion et al