Management of Panniculus Gangrene After Cesarean Hysterectomy for Placenta Accreta: A Case Report

BACKGROUND Placenta accreta spectrum (PAS) disorders are more likely with repeated cesarean sections and can result in life-threatening postpartum hemorrhage (PPH). Consequences can include ischemia, septic shock, and rare complications such as necrosis of abdominal fatty tissue after a cesarean hysterectomy. There are several reported cases of panniculus fat necrosis following a Pfannenstiel incision after cesarean sections or hysterectomies. CASE REPORT A 40-year-old woman, pregnant with twins and with a history of 5 pregnancies and 4 previous cesarean sections, was diagnosed with placenta previa during her antenatal assessment. She had an elective cesarean section at 35 weeks, during which focal placenta accreta was discovered, requiring delivery in fragments. This complication resulted in postpartum hemorrhage and an emergency hysterectomy. On postoperative day 3, she developed septic shock from a disseminated E. coli infection and non-occlusive bowel ischemia, leading to severe abdominal fat necrosis and gangrene. Extensive debridement of the surgical wound was required, and negative-pressure wound therapy (NPWT) using Promogram Collagen Matrix dressing was implemented for closure. After 86 days of debridement and NPWT, satisfactory healing was achieved without skin grafting. CONCLUSIONS Postpartum hemorrhage from placenta accreta can be managed conservatively but carries serious risks. A multidisciplinary approach is crucial to address these challenges. Even patients without typical risk factors can have significant ischemia and sepsis, leading to complications like panniculus skin gangrene. Notably, negative-pressure wound therapy (NPWT) has proven effective, even in extensive wound defects.