The case reported herein describes use of a negative pressure wound therapy (NPWT) system in the treatment of surgical wound infection and dehiscence with exposed, gravid uterus after emergent small bowel resection in a woman 25 weeks pregnant.

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.

Figure 1.

       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.

Discussion
       Bowel obstruction in pregnancy is a rare event that occurs from 1 in 1500 to 1 in 66,431 pregnancies. Adhesions from prior operations and pelvic inflammatory conditions are the most common causes of bowel obstruction during pregnancy. Adhesions account for 58% of intestinal obstructions in pregnancy.¹ Other causes of obstruction are volvulus and intussusception (occurring in 24% and 5%, respectively).¹ Diagnosis may be difficult because nausea and vomiting may be attributed to the pregnancy, because the gravid uterus masks abdominal distension, and because there is a greater hesitancy to use radiographic imaging in pregnant patients. Maternal mortality can range from 5% to 26%, and fetal mortality from 26% to 50%.² Aggressive surgical intervention is warranted because of such relatively high mortality rates.³
       The patient in the present case presented with a complex problem including infarcted bowel necessitating resection. Her postoperative course was complicated by pre-term contractions treated with magnesium.This may have exacerbated her ileus.The increased abdominal distension from the ileus would have resulted in more tension applied to her fascial closure, placing her at greater risk for facial dehiscence. In the presented case, primary fascial closure was believed to be a precarious option given the gravid uterus. Prosthetic mesh was also deemed inappropriate given the presence of an active infection and gravid uterus. While true abdominal domain could not be achieved, repeated moist gauze dressings would have left the exposed uterus susceptible to the open environment.The use of the NPWT offered drainage of the wound and provided coverage to the exposed gravid uterus.
       Wound dehiscence and loss of abdominal domain in pregnancy is a rare event. A review of PubMed using “gravid” and “dehiscence” yielded only 3 results.Two of these dealt with uterine rupture and the third is a casereport. Searching “abdominal domain” and “pregnancy” did not yield any results. Expanding the search to use the keywords “pregnancy, dehiscence, and delivery” yielded 91 results of which the majority address dehiscence of a cesarean wound. Dehiscence in a gravid patient was not addressed.
       The management of abdominal domain loss in a gravid patient is not clearly outlined in the literature.A review article concerning the management of wound complications from cesarean delivery listed secondary closure, secondary intention with dressings, and secondary intention using NPWT as treatment options.
       The implications of fascial disruption during pregnancy affect whether the patient will tolerate the trial of labor or if cesarean delivery is necessary. This is not defined clearly in the literature. In this case, the patient was able to have a successful vaginal delivery.
       Negative pressure wound therapy has gained popularity in recent years for a variety of wounds—among them, sternal wounds, decubitus ulcers, non-healing extremity wounds, and open abdominal wounds. The NPWT system offers increased patient comfort and convenience, as well as less nursing time spent with dressing changes.⁴ The NPWT system has been used in a variety of patient populations including orthopedic, pediatric, and gynecologic-oncology patients. It has also been used to treat post-cesarean section superficial wound disruption.⁵ A recent randomized controlled trial concluded that while patient comfort was an important advantage, NPWT therapy did not result in significantly faster granulation, wound surface reduction, or better bacterial clearance. However, in the first week of treatment, granulation tissue formation and wound closure seemed better in the NPWT group when compared with that of the conventional treatment group.⁴

Conclusion
       The authors present a novel approach to a complex wound in a pregnant patient.To the authors’ knowledge, use of negative pressure therapy placed directly on a gravid uterus has not been reported previously in the literature. The outcome was excellent for both the patient and her baby.