We have presented three cases of post-caesarean section peritonitis in patients from the same health sector over a 24-month period. The two adjacent maternity units involved have 2600 and 2400 deliveries per year with caesarean section rates of 42% and 33%, respectively. Both rates have increased 2.5% every 5 years over the last 20 years that we have records for and both surpass the national average rate of approximately 30%, leading us to believe that an increasing CS rate, with a consequent increase in caesarean complications, is responsible for this cluster. Certainly, the incidence in our area of late has heightened awareness of this entity among our local obstetric, surgical and histopathological community and with increasing awareness in the general community, we may see a paradoxical rise in reported cases that may have previously been undiagnosed or assumed to be due to other disease processes. Mopping the paracolic gutters of excess debris and blood before closure to reduce postoperative pain has been traditional teaching and is certainly routine practice within our teaching hospital and those surgeons involved in all our cases. That said, the increasing caesarean section rate we are seeing, mirroring that of the nation, may contribute to more surgical laxity in this area and an increased incidence of VCP.
The health population in our area comprises a moderate to high socio-economic group and ages of our patients ranged from 32 to 43 years of age where there may be an as yet undiagnosed element of immunological hypersensitivity. If this is the case, then the volume of VC needed to incite a reaction is probably small and mopping of the paracolic gutters may not be helpful. However, two of our patients were primipara suggesting that hypersensitivity reaction is less likely given there has been inadequate time for sensitisation to occur, even from an antenatal priming event. In keeping with hypersensitivity reactions, there are too few cases reported to see whether multipara have a more exaggerated response and this is a potential focus for future research.
The principal symptoms of VCP are generalised severe abdominal pain, pyrexia, peritonism and elevated white cell count with inconclusive or normal imaging. Other causes of peritonism are more likely including intraperitoneal sepsis, endometritis and iatrogenic ureteric/bowel injury. We agree that there should be no hesitation in undertaking further emergency laparoscopic or open surgical investigation should the clinical presentation be such that it warrants exclusion of these other more common pathologies. However, the observation of white cheese-like plaques and/or VC within the peritoneal cavity upon entering should raise the suspicion of VCP. Appropriate serosal biopsies are needed to confirm the diagnosis in the absence of other identifiable aetiologies. Our review of the literature found that most reported cases had significant additional procedures of laparotomy that, with hindsight, may have compromised recovery. The subsequent normal histological findings in the excised organs highlight the need for improved awareness among surgeons to reduce the morbidity from additional surgery.
Various conservative treatments have been tried although many authors omitted to outline their postoperative management [2
]. Some advocated postoperative antibiotic therapy [1
]. Adjuvant steroid therapy was used in two cases with resistant symptoms where infection had been excluded [9
]. Facilitation of recovery was achieved in both of these cases and the authors postulated that steroids had significantly enhanced the clinical course by suppression of the inflammatory response. However, all of our cases developed significant morbidities following the initial diagnosis of VCP that did require further operative procedures. Complications such as bowel obstruction are life-threatening showing that this condition is not entirely benign. Our review of the literature suggests that VCP is generally a self-limiting condition and resolves with conservative management alone. However, our experience suggests that this is not always the case and monitoring the postoperative course of those diagnosed with VCP is important as delayed morbidities may arise.