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Unexpected Baby vs. Unexpected Bacteria: A Case of Post-Cesarean Necrotizing Fasciitis

Bell, J., Djomani, M., Harris, A., Oraee, S., Singh K., M.

OBGYN Interest Group, American University of the Caribbean School of Medicine, Cupecoy, St. Maarten

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Clinical Presentation

Initial presentation: 43-year-old female presents with abdominal pain and worsening malodorous purulent drainage of a cesarean section incision performed two weeks prior of an unknown full-term pregnancy. Patient developed polymicrobial necrotizing fasciitis as a result of improper post-operative wound care.

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Medical History:

  • 2 C-sections (1st: Breech presentation; 2nd: preeclampsia)
  • BMI 40+
  • Pneumonia
  • Cataract transplant Bowman’s layer and vision loss
  • Multiple uterine fibroids
  • Obesity
  • Cholecystectomy
  • Anemia
  • Eczema

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Family History:

  • Cancer (Mother, maternal Grandfather, maternal Aunt)

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Figure 1. Post-cesarean patient at presentation with wound complication

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Evaluation

Physical Examination :

  • Patient arrived with systolic hypertension, tachycardic, and tachypneic.
  • Described as generally well-appearing and non-toxic.
  • Abdominal palpation revealed a soft c-section wound with opened areas with malodorous drainage. The area was remarked as indurated with significant surrounding erythema. Tenderness was appreciated from patient’s right flank to perineum. No crepitus.
  • No LE edema and 2+ peripheral pulses.

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Patient Vitals :

  • Blood Pressure-- 136/76

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  • Heart Rate-- 111 BPM

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  • Respiratory Rate-- 24/min

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  • SpO2-- 97%

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Evaluation Continued...

Laboratory Values :

  • Patient’s blood work indicates leukocytosis. Lactic acid, serum lipase, and CMP were within normal ranges.

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  • Gram stain revealed thin gram variable bacilli with vacuoles or central spores.

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  • Blood Cultures reveal anaerobic gram negative bacilli.

Radiological Imaging :

  • Abdominal CT revealed enlarged uterus consistent with postpartum state with gas loci in myometrium, endometrium, and lower abdominal wall. Bilateral inguinal LA noted.

Figure 2. Computed tomography scan showing free intra-abdominal air and uterine myonecrosis

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Pathophysiology

What is necrotizing fasciitis and how does it develop?

  • Necrotizing fasciitis is a rare fulminant infection causing extensive soft tissue and fascia necrosis with/without involvement of underlying muscle
  • The etiology of this condition is not fully understood but most patients develop necrotizing fasciitis following a variety of surgical procedures- a Cesarean in our case- or minor trauma or in some cases there may be no evidence of trauma
  • Most patients who develop this condition have pre-existing conditions such as diabetes, obesity, immunosuppression, etc which makes them more susceptible to infection
  • Group A Streptococcus is the most common microbe causing necrotizing fasciitis; however, polymicrobial infections can occur as well, which we see in our patient

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Resolution Management

  • Necrotizing Fasciitis: resolved after surgery and post-op WVAC placement
    • IV Zosyn, Vancomycin, Clindamycin
  • Post-partum Tinea Rash: improved after course of treatment
    • Diflucan 150mg, Keflex 500mg
  • Secondary stress due to prolonged recovery

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Figure 3. (A) Necrosis in post-cesarean patient; (B) Wound vacuum therapy placement over incision site; (C) Wound is healed after 6 days of WVAC

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Discussion

  • Obese women are more at risk of wound infections after a cesarean section when compared to non-obese women (BMI < 25)
  • Post-operative patients make up 20% of Necrotizing Fasciitis cases
    • Post-cesarean cases account for .18%
  • Early stages are difficult to diagnose; Non-specific tenderness, swelling and pain are commonly experienced after a cesarean section

Figure 4. Percentage of cesarean patients with wound complications in various BMI categories

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Public Health Significance

  • Rare, life threatening infection that can occur during pregnancy
    • Mortality rates: up to 76%
    • Risk factors: obesity, pregnancy (C-section), diabetes, anemia
  • Lack of proper post-operative (C-section) wound care within obese women population
    • Due to possible weight stigma in healthcare system
      • Causes limited patient-doctor relationship
  • Re-evaluation of wound care procedures for obese individuals

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Acknowledgements

We would like to thank Dr. Annalise Boisvert, MD, FACOG, NCMP alumna of American University of the Caribbean for referring us this case. We also thank Dr. David Adelstein, DO Assistant Professor of Clinical Medicine at the American University of the Caribbean as advisor to the Obstetrics and Gynecology Interest Group. We would like to acknowledge the efforts of Sarah Powell acting in role of Research Coordinator for her efforts in being the intermediate between Dr. Annalise Boisvert and this team to obtain the medical records reviewed for this case.

Special thanks to the Student Government Association at the American University of the Caribbean School of Medicine for putting on this remote showcase.

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Works Cited

  • Chhetry, M., Banerjee, B., Subedi, S., & Koirala, A. (2016). Necrotizing fasciitis of anterior abdominal wall following cesarean section in a low-risk patient. Journal of surgical case reports, 2016(7), rjw122. https://doi.org/10.1093/jscr/rjw122
  • Conner, S. N., Verticchio, J. C., Tuuli, M. G., Odibo, A. O., Macones, G. A., & Cahill, A. G. (2014). Maternal obesity and risk of postcesarean wound complications. American journal of perinatology, 31(4), 299–304. https://doi.org/10.1055/s-0033-1348402
  • David Kashan, Nagarajan Muthu, Benjamin Chaucer, Fidencio Davalos, Michael Bernstein, and Akella Chendrasekhar.Journal of Gynecologic Surgery.Jun 2016.182-184.http://doi.org/10.1089/gyn.2015.0115 Figure 2.
  • Hasham, S., Matteucci, P., Stanley, P. R., & Hart, N. B. (2005). Necrotising fasciitis. Bmj, 330(7495), 830-833. doi:10.1136/bmj.330.7495.830
  • Jacobson, J. D., & Zieve, D. (2018). Going home after a C-section. Retrieved November 13, 2020, from https://www.mountsinai.org/health-library/discharge-instructions/going-home-after-a-c-section
  • Macones, G. A., Caughey, A. B., Wood, S. L., Wrench, I. J., Huang, J., Norman, M., . . . Wilson, R. D. (2019). Guidelines for postoperative care in cesarean delivery: Enhanced Recovery After Surgery (ERAS) Society recommendations (part 3). American Journal of Obstetrics and Gynecology, 221(3). doi:10.1016/j.ajog.2019.04.012
  • Mold, F., & Forbes, A. (2011). Patients' and professionals' experiences and perspectives of obesity in health-care settings: A synthesis of current research. Health Expectations, 16(2), 119-142. doi:10.1111/j.1369-7625.2011.00699.x
  • Nikolaou, M., Zampakis, P., Vervita, V., Almaloglou, K., Adonakis, G., Marangos, M., & Decavalas, G. (2014). Necrotizing Fasciitis Complicating Pregnancy: A Case Report and Literature Review. Case Reports in Obstetrics and Gynecology, 2014, 1-4. doi:10.1155/2014/505410 Figure 1.
  • Stevens, D. L., & Baddour, L. M. (2020). Necrotizing soft tissue infections. UpToDate. Retrieved November 12, 2020, from https://www-uptodate-com.aucmed.idm.oclc.org/contents/necrotizing-soft-tissue-infections?search=Necrotizing%20soft%20tissue%20infections&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H3655791.
  • Zhang, M., Sun, P., Liu, M., Jiang, Z., Fu, Z., Min, D., Guo, G., & Liao, X. (2020). A case report of a woman after childbirth with a dehisced abdominal wound as well as fat liquefaction and large skin necrosis. Annals Of Palliative Medicine, 9(2), 493-496. doi:10.21037/apm.2020.03.15

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Thank you.