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| Journal of the New Zealand Medical Association,
15-December-2006, Vol 119 No 1247
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Necrotizing fasciitis after the post partum diastasis
of the symphysis pubis
Anastasios Athanassopoulos, Terry Creagh, William
McMillan
Necrotizing soft tissue infections are uncommon, highly
lethal infections that are usually associated with trauma and surgery. The
paucity of early clinical features leads to diagnostic delay and poor outcome.
Post partum rupture of the pubic symphysis is a rare but debilitating
complication that is associated with significant pain and delayed mobility.
We present a New Zealand case of Group B streptococcus
necrotizing soft tissue infection occurring after diastasis of the pubic
symphysis during a spontaneous vaginal delivery.
Case reportA 38-year-old gravida 2, para 2 woman underwent spontaneous
vaginal delivery of a brow presentation that was complicated by a diastasis of
the symphysis pubis. This was treated conservatively with a pelvic binder and
she required 2 weeks hospitalisation for analgesia.
She was readmitted 1 week later with lower abdominal pain,
swelling of the labia and erythema across the lower suprapubic area. A
provisional diagnosis of cellulitis was made and intravenous antibiotics
commenced. Twelve hours later, areas of blistering and skin necrosis were now
evident (Figure 1) and a plastic surgical consult was requested.
Figure 1. Preoperative view
 The patient was shocked, mentally obtunded, and complaining
of intense abdominal pain. A diagnosis of necrotizing fasciitis was apparent and
immediate resuscitative measures instituted. Laboratory studies demonstrated
multiorgan dysfunction including acute renal failure, hepatic derangement, and
coagulopathy.
At the time of surgery, extensive necrosis and suppuration
involving the lower abdominal wall to the anterior labial commissure was
evident. Dishwater exudate tracked from the site of the symphyseal diastasis
with multiple separate foci of suppuration within the extraperitoneal fat,
rectus abdominis, and subcutaneous tissues. There was significant destruction of
both recti with exposure of transversalis fascia beneath the arcuate line and
the posterior layer of the rectus sheath above (Figure 2).
Fig 2 Post debridement defect
 Twelve days later an abdominal reconstruction component
separation was performed along with an abdominoplasty procedure and a delayed
extended tensor fascia lata pedicled flap. On day 19, the tensor fascia lata
flap was transposed and the abdominal defect closed. The patient made an
uneventful recovery.
DiscussionPost partum pubic symphyseal diastasis is an uncommon
complication associated with severe suprapubic and iliosacral pain as well as a
waddling gait.1 Various aetiological factors
have been suggested including multiparity, instrumental vaginal delivery,
cephalopelvic disproportion, and rapid labour.
Necrotizing fasciitis (NF), commonly termed by laypersons as
“flesh-eating disease” or “flesh-eating bacteria”, is a
rare, rapidly progressive and often fatal infection that requires early and
aggressive surgical debridement. Surgery and trauma are common aetiologies and
any anatomic area may be affected. Predisposing factors include diabetes
mellitus, malnutrition, renal failure, and immunosuppression. NF has not
previously been reported after diastasis of the pubic symphysis.
Although several distinct clinical-bacteriological entities
may be described, the initial management is the same. Type I is a synergistic
polymicrobial infection composed of gram negatives and anaerobes. Type II is
caused by Group A and B streptococci and is associated with streptococcal toxin
shock like syndrome in 50%. There is evidence to support the use of
immunoglobulins in this condition.2 As a
commensal of the female urogenital tract Group B streptococcus has a higher
incidence in neonatal and obstetric related NF.
Patients present with the triad of fever, swelling, and
pain.3 The intensity of the pain is out of
proportion to the clinical findings and the tenderness extends significantly
beyond the margins of the visible erythema. The skin develops a violaceous hue
as its blood supply is compromised. Haemorrhagic bullae, skin necrosis,
fluctuance, and sensory deficits then appear. Gas is not a reliable sign
(occurring in between 20–40% of cases)4
but when present it is a specific sign.
Successful treatment of NF requires early diagnosis, radical
debridement, antibiotics, nutritional support, and intensive treatment unit
care. The commonest errors are delay in diagnosis and inadequate debridement. An
incision and drainage-type approach has absolutely no role in management.
A second look in theatre the following day is mandatory, or
sooner if the patient deteriorates. We have found topical negative pressure
dressings a useful temporising measure.
In the obstetric and gynaecological literature, the reported
mortality rate varies between 13%–48% although this includes post partum
and gynaecological patients. Gallup et al attribute their low mortality of 13%
to increased awareness as well as diagnosis of 86% of patients within 48
hours.3 Stephenson et al report a mortality of
11 out of 15 when the diagnosis was delayed greater than 48
hours.4
Teaching pointsA high level of vigilance and raised awareness through
clinician education are fundamental to diagnosis. Urgent radical debridement,
followed by a second look in theatre within 24 hours, is recommended. Moreover,
a multidisciplinary approach is essential for debridement, reconstruction, and
rehabilitation.
Author information: Anastasios
Athanassopoulos, Terry Creagh, William McMillan; Plastic Surgical
Registrars; Department of Reconstructive, Plastic and Burns Surgery, Waikato
Hospital, Hamilton
Correspondence: TA Creagh, 140 Straven
Road, Fendalton, Christchurch. Email: Terrence.Creagh@cdhb.govt.nz
References:
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