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Infectious Diseases in Obstetrics and Gynecology 5:341-344 (1997) (C) 1998 Wiley-Liss, Inc. Maternal Death From Postpartum Necrotizing Fasciitis Arising in an Episiotomy: A Case Report Catherine M. Lynch,* Donna M. Pinelli,1 C. Wayne Cruse,2 William N. Spellacy,1 John T. Sinnott,3 and Ron G. Shashy1 Department of Obstetrics and Gynecology, University ofSouth Florida, Tampa, FL eDepartmet ofSurgery, Division ofAesthetic and Reconstructive Surgery, University ofSouth Florida, Tampa, FL -Department ofMedicine, Divisio oflfectious Diseases, Uiversity ofSouth Florida, Tampa, FL ABSTRACT Background: Necrotizing fasciitis is a rare condition. We report a fatal case arising from an episi- otomy in a previously healthy woman. Case: A healthy 23-year-old prima gravida white female underwent vaginal delivery with repair of a proctoepisiotomy. Eighty-four hours postpartum, she developed increasing perineal swelling with severe pain. She presented on the 4th postpartum day with edema, erythema localized to the perineum, and vital signs significant only for tachycardia of 120/min. With a leukocytosis of 45,000/ pl (87%) neutrophils, she was admitted to the hospital with an initial diagnosis of perineal cellulitis and empirically started on broad-spectrum intravenous antibiotic therapy. The patient's condition continued to deteriorate and she was then transferred to our facility on postpartum day 9 where a team performed two radical debridements of all necrotic tissue. Despite this and a broadened antibiotic coverage, the patient eventually experienced cardiopulmonary arrest and died on post- partum day 12. Conclusion: Necrotizing fasciitis must be considered in the differential diagnosis of the postpar- tum patient presenting with severe vulvar pain and erythema. Our patient exemplifies the obscure presentation with seemingly minimal skin changes. Any delay in diagnosis and treatment, which must include expeditious aggressive surgical debridement, will likely result in severe morbidity or mortality. Infect. Dis. Obstet. Gynecol. 5:341-344, 1997. (C) 1998 Wiley-Liss, Inc.

thema. Our patient exemplifies the obscure presentation with seemingly minimal skin changes. Any delay in diagnosis and treatment, which must include expeditious aggressive surgical debridement, will likely result in severe morbidity or mortality. Infect. Dis. Obstet. Gynecol. 5:341-344, 1997. (C) 1998 Wiley-Liss, Inc. KEY WORDS infection; surgical debridement; postpartum nccrotizing fasciitis; proctoepisiotom7 n the past 20 years there have been 8 case reports in the world literature regarding necrotizing fasci- itis in the postpartum period.1,7,s We report a fatal case of necrotizing fasciitis arising in an episiotomy site in a previously healthy woman. CASE REPORT A healthy-23-year-old prima gravida white female with an uncomplicated prenatal course underwent a vacuum-assisted vaginal delivery with repair of a fourth degree episiotomy (proctoepisotomy). No antibiotics were administered for this tear. She was discharged with a healthy male infant 36 h later with no postpartum complications. Over the next 48 h the patient developed increasing perineal swelling. Severe pain and malaise ensued, making her unable to care for her infant. Due to her worsening condition, she presented to a local hospital on the 4th postpartum day. The involved area was edematous and erythematous and appeared to localize to the perineum. Vital signs were blood pressure 118/72 mmHg, respira- *Correspondence to: Dr. Catherine Lynch, Department of Obstetrics and Gynecology, University of South Florida, 4 Columbia Drive, Suite 529, Tampa, FL 33606. Received 23 June 1997 Case Report Accepted 3 November 1997 POSTPARTUM NECROTIZING FASCIITIS LYNCH ET AL. tions 20/min, pulse 120/min, and temperature 97.5F. Significant laboratory studies included a white blood cell count of 45,000/pl (87% neutro- phils), hemoglobin 15.6 g/dl, platelets 194,000/lal, COz of 22 mmol/1, glucose 126 mg/dl, creatinine 1.1 mg/dl, and albumin 2.2 g/dl. She was admitted with an initial diagnosis of pcrineal ccllulitis at the epi- siotomy site. Broad-spectrum antibiotics (ampicillin, genta- micin, clindamycin) were empirically initiated in addition to local wound care (sitz baths and beta- dine). No debridement was undertaken. Despite this, the patient complained of increasing pelvic and left leg pain and inability to ambulate. As her pain was felt to be out of proportion to her physical findings, a physical therapy consult was obtained to aid in ambulation.

tion to local wound care (sitz baths and beta- dine). No debridement was undertaken. Despite this, the patient complained of increasing pelvic and left leg pain and inability to ambulate. As her pain was felt to be out of proportion to her physical findings, a physical therapy consult was obtained to aid in ambulation. Over the next 2 hospital days, the crythema and induration progressed, extending from the perineum to the inner thigh and to the buttock region. On postpartum day 6, wound and vaginal cultures returned, identifying growth of Streptococcus boris and Enterococcus. Based on sensi- tivity results, antibiotic treatment was altered to replace ampicillin with ticarcillin/clavulanic acid. On the 8th postpartum day, the patient dis- played increasing anesthesia over the perineum, with extensive swelling and induration. The pa- tient was still unable to ambulate despite physical therapy consultation. She remained afebrile but her white blood cell count had risen to 50,000/pl (74% neutrophils). Other significant laboratory findings were as follows: lactate dehydrogenase 206 U/1 (94-172 U/l), creatinine kinase 537 mg/dl (38- 173 mg/dl), SGOT 54 U/1 (12-48 U/l), and calcium 6.8 mg/dl (8.7-10.7 mg/dl). At this time, the patient was referred to our facility for further care. At the time of admission (postpartum day 9), a diagnosis of necrotizing fasciitis was made. This large area was discolored (purple to red), non- tender, and indurated (Fig. 1). There was marked vulvar edema with bullae, crepitus, and paresthe- sia. It involved the perineum and extended bilat- erally superiorly to just below the axilla and infe- riorly to just above the knees. Vital signs were blood pressure 123/75 mmHg, respirations 14/min, pulse 110/rain, and temperature 99.7F. Significant laboratory findings were a white blood cell count of 55,000/pl (91% neutrophils), hemoglobin 13.4 g/dl, platelets 229,000/pl, COz of 22 mmol/1, glucose 133 mg/dl, and creatinine 0.7 mg/dl. Intravenous peni- cillin G, gentamicin, and clindamycin were admin- istered at maximal dosages. Five hours after trans- fer, a combined plastic surgery and gynecology team performed a radical debridement of all ne- crotic tissue of the abdomen, perineum, and thighs (Fig. 2). An intraoperative infectious disease consult was obtained and aggressive intensive care was contin- ued postoperatively (postpartum day 10).

Five hours after trans- fer, a combined plastic surgery and gynecology team performed a radical debridement of all ne- crotic tissue of the abdomen, perineum, and thighs (Fig. 2). An intraoperative infectious disease consult was obtained and aggressive intensive care was contin- ued postoperatively (postpartum day 10). The an- tibiotic coverage was broadened with piperacillin/ tazobactam, vancomycin, and gentamicin at the recommendation of the infectious disease consul- tant. Despite this, the patient deteriorated. Her blood urine and wound cultures drawn after hospital transfer continued to be negative. She was intu- bated and required fluid support and blood prod- ucts. Thirty-six units of packed red cells and 9 units of fresh frozen plasma were administered over the next 24 h. A second debridement was per- formed on the lth postpartum day with removal of minimal tissue. The patient continued to experi- ence massive fluid losses from the open debride- ment sites. On the 12th postpartum day, the pa- tient's situation worsened and she eventually ex- perienced cardiopulmonary arrest. Resuscitation attempts failed and the patient died 48 h after hos- pital transfer. Postmortem examination revealed necrotizing fasciitis and necrotizing myositis. Status post ex- tensive debridement of the perineum, lower ab- dominal wall, and left inner upper thigh, the sur- gical wounds were grossly free of necrosis and in- fection. There was diffuse alveolar damage present with pulmonary microthrombi consistent with sep- sis with acute respiratory distress syndrome (ARDS), and an incidental finding of a serous cyst- adenoma of the left ovary. DISCUSSION Necrotizing fasciitis was first reported as "hospital gangrene" in 1871 by confederate army surgeon Joseph Jones, M.D.z It was subsequently further described by Meleney in 1924 and is therefore also known as Meleney's gangrene.3 Meleney was the first to describe the necessity for early surgical in- tervention in the treatment of this disease.4 Nec- rotizing fasciitis is often associated with patients who are immunocompromised, diabetic, or have other predisposing conditions including trauma, 342 INFECTIOUS DISEASES IN OBSTETRICS AND GYNECOLOGY POSTPARTUM NECROTIZING FASCIITIS LYNCH ET AL. Fig. I. Marked vulvar edema with early tissue necrosis on medial aspect of the left thigh. Some bronze discoloration is noted involving the left perineum. Fig. 2. Debrided wound.

predisposing conditions including trauma, 342 INFECTIOUS DISEASES IN OBSTETRICS AND GYNECOLOGY POSTPARTUM NECROTIZING FASCIITIS LYNCH ET AL. Fig. I. Marked vulvar edema with early tissue necrosis on medial aspect of the left thigh. Some bronze discoloration is noted involving the left perineum. Fig. 2. Debrided wound. The operator's fingers are within the rectum demonstrating the original proctoepisiotomy. extensive surgery, radiation therapy, or chemo- therapy.,6 Obstetrical trauma was the only risk factor for necrotizing fasciitis in our patient. Necrotizing fasciitis is typically described as deep pain out of proportion to clinical findings associated with su- perficial paresthesia over the involved area. Patho- physiologically, this entity is believed to first irri- tate and then destroy nerve fibers. Early clinical signs include local edema, induration, skin discol- oration, and hypoaesthesia. As with our patient, su- perficial skin changes may be minimal and thus obscure the diagnosis. Despite this innocuous ap- pearance, the disease constantly progresses to in- volve deeper tissue levels, specifically to the level of the fascia. Fascial involvement with nerve com- promise results in rapid progression of analgesia. In general, this syndrome is caused by a poly- microbial infection which may or may not include Clostridium. Organisms that have been associated with necrotizing fasciitis following a vaginal deliv- ery include Streptococcus, Escherichia coli, Klebsiella, Pseudomonas aeruginosa, Proteus, Bacteroides fragilis, Peptostreptococcus, Peptococcus, group A beta hemo- lytic Streptococcus, group B beta hemolytic Strepto- coccus, and Staphylococcus aureus. 1,7-9 Early aggressive surgical debridement is the mainstay of therapy for this disease. Stephenson et al.9 reviewed the records of 29 non-pregnant pa- tients with necrotizing fasciitis of the vulva and INFECTIOUS DISEASES IN OBSTETRICS AND GYNECOLOGY 343 POSTPARTUM NECR0TIZING FAS(,'11TIS LYNCH ETAL. found that a delay in diagnosis of >48 h resulted in 73% mortality. In our case, there was a 5-day delay before surgery was performed at the tertiary care center. Once surgical debridement is performed on these patients, the postoperative management is often complicated by hypoalbuminemia with asso- ciated low oncotic pressure and increased capillary permeability.

ted in 73% mortality. In our case, there was a 5-day delay before surgery was performed at the tertiary care center. Once surgical debridement is performed on these patients, the postoperative management is often complicated by hypoalbuminemia with asso- ciated low oncotic pressure and increased capillary permeability. These patients should be managed by surgeons and critical care teams experienced in the care of the critically ill patient.1,11 Necrotizing fasciitis is a rare complication in vaginal delivery. It must be considered in the dif- ferential diagnosis of the postpartum patient pre- senting with severe vulvar pain and erythema. Our patient exemplifies the obscure presentation of the disease with seemingly minimal skin changes. This differential is paramount especially when the pa- tient presents with pain out of proportion to the clinical findings. Once necrotizing fasciitis is enter- tained as a potential diagnosis, immediate and ag- gressive diagnostic therapy must be undertaken. The first line therapy is aggressive surgical de- bridement with concomitant broad-spectrum intra- venous antibiotic therapy. As illustrated by our case, any delay in diagnosis and delivering treat- ment will likely result in severe morbidity or mor- tality.9 REFERENCES 1. Sutton GP, Smirz LR, Clark DH, Bennett JE: Group B streptococcal necrotizing fasciitis arising from an episi- otomy. Obstet Gynecol 66:733-736, 1985. 2. Schneider GT: A postpartum emergency--Necrotizing fasciitis. Contemp OB/GYN 109-114, February 1988. 3. Meleny FL: A Treatise on Surgical Disease. Oxford: Oxford University Press, p 12, 1948. 4. Nolan TE, King LA, Smith EP, Gallup DC: Necrotizing surgical infection and necrotizing fasciitis in obstetric and gynecologic patients. South Med J 86:1363-1367, 1993. 5. Hoffman MS, Turnquest D: Necrotizing fasciitis of the vulva during chemotherapy. Obstet Gynecol 74:483- 484, 1989. 6. Addison WA, Livengood CH, Hill GB, Sutton GP, For- tier KJ: Necrotizing fasciitis of vulvar origin in diabetic patients. Obstet Gynecol 63:473-478, 1984. 7. Ammari NN, Hasweh YG, Hassan AA, Karyoute S: Post- partum necrotizing fasciitis. Case report. Br J Obstet Gynaecol 93:82-83, 1986. 8. Piper JM, West P: Necrotizing fasciitis following post- partum tubal ligation. A case report and review of the literature. Arch Gynecol Obstet 256:35-38, 1995. 9. Stephensen H, Dotters DJ, Katz V, Droegemueller W: Necrotizing fasciitis of the vulva. Am j Obstet Gynecol 166:1324-1327, 1992. 10.

naecol 93:82-83, 1986. 8. Piper JM, West P: Necrotizing fasciitis following post- partum tubal ligation. A case report and review of the literature. Arch Gynecol Obstet 256:35-38, 1995. 9. Stephensen H, Dotters DJ, Katz V, Droegemueller W: Necrotizing fasciitis of the vulva. Am j Obstet Gynecol 166:1324-1327, 1992. 10. Stamenkovic I, Lew PD: Early recognition of poten- tially fatal necrotizing fasciitis. The use of frozen- section biopsy. N Engl j Med 310:1689-1693, 1984. 11. Salvino C, Harford FJ, Dobrin PB: Necrotizing infec- tions of the perineum. South Med J 86:908-911, 1993. 344 INFECTIOUS DISEASES IN OBSTETRICS AND GYNECOLOGY