Necrotizing fasciitis as a rare form of postpartum sepsis. Case report

Abstract

Modern strategies of the World Health Organization and clinical guidelines of the world's leading professional communities of obstetricians and gynecologists, based on effective clinical practices, make it possible to attribute sepsis to potentially preventable causes of direct maternal mortality with the possibility of a near-miss situation outcome. Necrotizing fasciitis (NF) is a disseminated soft tissue infection that is a rare and life-threatening form of septic complications in obstetrics. The disease is little known to practical doctors, and its outcome largely depends on the timely diagnosis and early initiation of adequate treatment, including massive antibiotic therapy and urgent surgical removal of necrotic tissue with correction of multiple organ disorders. Pregnant women and women in labor are at risk for NF since its main risk factors are mucosal and skin injuries of any origin, immunosuppression, diabetes, and obesity. We present two cases of near miss due to the NF and sepsis after vaginal birth and cesarean section. At the manifestation of the disease, both patients started broad-spectrum antibiotic therapy. When soft tissue necrosis appeared, debridement was performed. A 31-year-old patient had a more severe course of the disease (septic shock, severe multiple organ failure) and a less favorable outcome (hysterectomy, panhypopituitarism, large ventral hernia), which is probably due to the presence of significant risk factors (history of sepsis, grade 1 obesity, autoimmune thyroiditis). In a 37-year-old somatically healthy patient with only one risk factor (age over 35 years), NF's clinical course and outcome after cesarean section were more favorable (the uterus was preserved, and the hormonal and metabolic status was not disturbed). Pregnant women and women in labor should be identified as a risk group for NF due to unavoidable damage of the mucous membranes and skin even during normal childbirth and routine obstetric procedures, a high rate of surgical delivery, physiological immunosuppression, and a high prevalence of obesity and diabetes. Rapidly initiated complex treatment, including massive antibiotic therapy, debridement, immunoglobulins, efferent therapies, and hyperbaric oxygenation, can improve the outcome of the disease and prevent maternal mortality.