A 32-year-old woman, gravida 1 para 1, is evaluated on the postpartum floor due to fluid leakage from her incision. Two days ago, the patient underwent a cesarean delivery after failed induction of labor and intraamniotic infection. She had her incision bandage removed this morning with minimal clear fluid on the bandage. The patient then walked to the nursery, where she noticed that serosanguineous fluid had stained her hospital gown. Fluid has continued to drain from her abdominal incision. Temperature is 37.2 C (99 F). BMI is 35 kg/m². The uterus is palpable below the umbilicus and has no fundal tenderness. The Pfannenstiel incision has a 4-cm defect at the right corner that is draining scant serosanguineous fluid. There is no surrounding erythema or induration. The subcutaneous tissue has no areas of necrosis or crepitus, and the rectus fascia is intact. Which of the following is the best next step in management of this patient?

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Explanation: 11ec25c8_da94_6dc1_bc81_11f1ebc7eb83_MD0003_00 Abdominal surgery can result in a variety of postoperative wound complications (eg, infection, dehiscence). These complications are more common in obese patients (as seen in this case), those who are immunocompromised (eg, chronic corticosteroids, cancer), and those with increased intraabdominal straining (eg, excessive lifting, cough). Postoperative abdominal wounds can be categorized based on fascial involvement: Superficial wound dehiscence is a separation of the skin and subcutaneous tissue with an intact rectus fascia (as seen in this patient). It typically develops within the first postoperative week and occurs secondary to an abnormal subcutaneous fluid buildup (eg, seroma), resulting in a scant serosanguineous fluid drainage. Deep (fascial) wound dehiscence involves the rectus fascia (ie, nonintact) and results in exposure of the intraabdominal organs to the external environment. Patients with a superficial dehiscence and no signs of infection (eg, induration, erythema, purulent drainage) are conservatively managed with regular dressing changes. These regular changes help with delayed (secondary) closure by removing excessive fluid and closing physiologic dead space, which debrides nonviable tissue and eliminates potential bacterial reservoirs. In contrast, fascial dehiscence is a surgical emergency because of the risk of bowel evisceration and strangulation (Choice B). (Choices A and D) CT scan of the abdomen and pelvis may be used in patients with suspected necrotizing fasciitis or abscess. These patients typically have signs of infection (eg, edema, induration, purulent drainage); those with necrotizing fasciitis may also have associated crepitus. In both cases, treatment is with systemic antibiotics and wound debridement. (Choice E) Abdominal binders may be used temporarily in patients with fascial dehiscence (but no evisceration) in preparation for emergency surgery. They are not used for superficial dehiscence because they do not improve outcomes. Educational objective: Superficial wound dehiscence, separation of the epidermis and/or subcutaneous tissue with an intact fascia, is typically managed conservatively with regular dressing changes. In contrast, deep (fascial) dehiscence involves the fascia and is a surgical emergency. References: Role of subcutaneous closure in preventing wound complications after cesarean delivery with Pfannenstiel incision: a randomized clinical trial. (http://www.ncbi.nlm.nih.gov/pubmed/24738117) Postoperative wound dehiscence: predictors and associations. (http://www.ncbi.nlm.nih.gov/pubmed/25683272) Impact of evidence-based interventions on wound complications after cesarean delivery. (http://www.ncbi.nlm.nih.gov/pubmed/28601567)

A 32-Year-Old Woman, Gravida 1 Para 1, Is Evaluated on the Postpartum