Necrotizing fasciitis in obstetric practice

Septic complications in obstetrics remain a relevant problem due to the high morbidity and frequency of critical obstetric conditions. A rare form of purulent and inflammatory diseases of soft tissues is necrotizing fasciitis (NF), which is characterized by progressive necrosis of superficial fascial masses with rapid involvement of the skin and subcutaneous fatty tissue. It is accompanied by the development of severe endotoxemia, sepsis and multiple organ failure. Pregnant women and puerperas are at risk for developing NF, as its main risk factors include the damage to mucous membranes and skin of any origin (spontaneous or postoperative), immunosuppression (associated with pregnancy, disease or treatment), metabolic disorders, diabetes, obesity. The disease presents with a variety of clinical manifestations, and the absence of specific signs makes timely diagnosis by clinicians of various specialties challenging. This lack of diagnosis can result in the development of severe complications and lethal outcomes. The prognosis depends on the early administration of broad-spectrum antibiotics and rapid surgical removal of necrotizing tissue with the treatment of multiple organ disorders.

Two clinical observations of the development of NF and sepsis after spontaneous vaginal delivery (first case) and cesarean section (second case) are presented. When the first signs of the infectious process appeared, broad-spectrum antibiotics were administered to both patients, and surgical irrigation was performed in case of soft tissue necrosis. The first clinical case was characterized by a more severe course and less favorable outcome for a 31-year-old woman (hysterectomy, panhypopituitarism), which could probably be due to the presence of significant risk factors (history of sepsis, grade 1 obesity, autoimmune thyroiditis). In the second case, the clinical course of NF after cesarean section was more favorable, which largely resulted from the initial somatic health of the 37-year-old patient.

Conclusion: For early diagnosis of NF, it is necessary to pay special attention to mothers who complain of increasing pain in the genital area (even without obvious birth trauma) and postoperative area after cesarean section with the signs of local fever, erythema, ecchymosis and edema as well as the changes in the laboratory tests. Timely and complex therapy, including antibacterial drugs, immunoglobulins, surgical irrigation, efferent methods of treatment, and hyperbaric oxygenation, can improve the outcome of the disease and prevent maternal mortality.