Case Report

A 28-year-old pregnant woman at 25 weeks gestation was transferred to the authors’ institution with abdominal pain caused by high-grade small bowel obstruction refractory to conservative treatment.The patient had an uncomplicated vaginal delivery 2 years earlier and an open appendectomy 6 months earlier. A decision was made to perform laparotomy due to the extent of obstipation and severity of abdominal tenderness.The patient was given ampicillin/sulbactam preoperatively.

An adhesive band was identified and divided through an upper midline incision.An incarcerated loop of small bowel was infarcted.Twenty-two centimeters of small bowel were resected, and a stapled anastomosis was performed. The uterus was proportionally large in this petite woman’s abdomen, and there was scant omentum available to lay over the intestines and uterus during midline closure with running #1 polydioxanone suture.

The patient developed pre-term contractions, for which terbutaline and a magnesium sulfate drip were administered until postoperative day 3. Contractions resolved, and she was maintained on parenteral nutrition until bowel function returned. By postoperative day 8, she was feeling well, eating, and maintaining normal bowel function and vital signs.The wound was intact and nonerythematous, and she was subsequently discharged home.

On postoperative day 12, the patient was treated at her local hospital for a superficial wound infection.The wound was opened slightly, packed, and oral cephalexin treatment was started. She developed worsening abdominal pain and was transferred to the authors’ institution on postoperative day 14. A computed tomographic scan revealed fluid collections between the uterusand the anterior abdominal wall (Figure 1). Formal wound exploration in the operating room revealed fascial dehiscence and deep intra-abdominal abscess.There was no evisceration of the bowel, but the gravid uterus was present at the wound base.The wound was left open after debridement of the necrotic tissue.The patient was maintained on intravenous ampicillin/sulbactam for coverage of mixed flora and was later transitioned to oral amoxicillin/clavulanate.Wet-to-dry gauze dressings were used to debride the fibrinopurulent exudates.Two days later, treatment with a negative pressure therapy system ([NPWT] V.A.C.^® Therapy^™, KCI Inc., San Antonio, Tex) began with the V.A.C. WhiteFoam^™ (KCI Inc., San Antonio, Tex) placed directly on the gravid uterus. The GranuFoam^™ (KCI Inc., San Antonio,Tex) was used over this, and continuous suction was maintained at -125 mmHg. The NPWT system was used for 23 days. Dressings were changed every 2 to 3 days. The wound healed completely in approximately 1 month and both mother and fetus were healthy.

The patient had an uncomplicated vaginal delivery at 39 weeks gestation.When she was seen 5 months postpartum; no hernia was palpated. At 13 months postpartum, the patient developed a small bowel obstruction from adhesions, which was treated at her local hospital by laparotomy and segmental small bowel resection. She developed another wound infection, which, like the first infection, was treated with the NPWT system.At 19 months postpartum, both mother and child were doing well.