Fulminanter Schmerz bei progredientem Erythem

A 42-year-old woman with breast cancer was admitted to our hospital during her chemotherapy nadir with elevated body temperature and a painful perianal erythema. Within a few hours her pain worsened and the erythema continued to spread over the gluteal region. A CT scan was performed, indicating necrotizing fasciitis. Despite immediate surgical debridement of the infected tissue and antibiotic therapy, she died a few hours later from septic shock. Necrotizing fasciitis is rare and early aggressive treatment is most important for the outcome of these patients.     

Necrotizing fasciitis arising from episiotomy

Necrotizing fasciitis is a fatal, rapidly progressive, often initially unrecognized condition. Mortality rates range from 30% to 76%. Prognosis depends on the delay of diagnosis, antimicrobial treatment and surgical excision of all necrotic tissue. A case of postpartum perineal necrotizing fasciitis arising from episiotomy is presented. Prompt recognition and aggressive therapy resulted in a favorable outcome despite significant morbidity.     

Necrotizing fasciitis in gynecologic and obstetric patients: a surgical emergency

OBJECTIVE: We reviewed the cases of 23 patients who were admitted to the hospital with a primary diagnosis of histopathologically confirmed necrotizing fasciitis in the lower abdomen or pelvis. Rapid demise of a healthy postpartum women piqued our interest in trying to identify the early signs and symptoms that may lead to earlier diagnosis and treatment of this often fatal disease. STUDY DESIGN: A retrospective analysis of charts of all patients who were admitted to the gynecology and obstetrics services of our hospital systems with a diagnosis of necrotizing fasciitis for the past 14 years was performed. Age, comorbid factors, precipitating events, weight, symptoms and signs, microbiologic factors, radiographs, surgical therapy, and morbidity were correlated. RESULTS: Definitive operation was accomplished within 48 hours of the diagnosis of necrotizing fasciitis in all but 3 patients. Of the 17 patients who were not puerperal, 88% of the women were obese; 65% of the women were hypertensive, and 47% of the women were diabetic. Of the total 23 patients, 70% of the women complained of severe pain, and 35% of the women had radiographic diagnostics for necrotizing fasciitis ("gas"). Four patients had diverting colostomies, and 39% of the patients had flaps or synthetic grafts. Three patients died (mortality rate, 13%). One patient who was puerperal died of a severe rapid septicemia; the 2 late deaths were the result of systemic candidiasis. CONCLUSION: Necrotizing fasciitis is a rapidly progressive, often lethal, infectious disease process that requires early aggressive debridement. Any patient with inordinate pain and unilateral edema in the pelvis, especially in the puerperium, should be suspected of having this disease. Radiographic studies are often diagnostic of this condition. The triad of pelvic pain, edema, and any sign of septicemia carries an extremely grave prognosis and mandates immediate surgical intervention.     

Necrotizing fasciitis: a review of management guidelines in a large obstetrics and gynecology teaching hospital

Necrotizing fasciitis is a severe, life-threatening soft tissue infection that results in rapid and progressive destruction of the superficial fascia and subcutaneous tissue. Because of its varied clinical presentation and bacteriological make-up, it has been labelled with many other names such as acute streptococcal gangrene, gangrenous erysipelas, necrotizing erysipelas, hospital gangrene, and acute dermal gangrene. Although described by Hippocrates and Galen, it has received increasing attention in obstetrical and gynecological literature only within the last 20 years. This review includes two recent cases successfully managed at Parkland Memorial Hospital, Dallas, Texas. The first patient was a 50 year old, morbidly obese, diabetic woman who presented with a small, painful lesion on the vulva. After failing triple antibiotic therapy with ampicillin, clindamycin, and gentamicin, the diagnosis of necrotizing fasciitis of the vulva was made, and she was taken to the operating room for extensive excision. She was discharged home on hospital day 29. The second patient was a 65 year old, obese, diabetic woman with risk factors for atherosclerosis who had a wound separation after an abdominal hysterectomy. Two days later a loss of resistance to probing was noted in the subcutaneous tissue. Necrotizing fasciitis was suspected, and she was taken to the operating room for resection. The patient was discharged home on hospital day 27. The mortality rate after diagnosis of necrotizing fasciitis has been reported to be 30% to 60%. We review the literature and outline the guidelines used in a large Ob/Gyn teaching hospital to minimize the adverse outcome. Lectures on soft-tissue infections are included on a regular basis. The high-risk factors of age over 50, diabetes, and atherosclerosis are emphasized. The need for early diagnosis and surgical treatment within 48 hours is stressed, and any suspicious lesions or wound complications are reported to experienced senior house officers and staff. We use two recent cases to highlight the diagnostic clues and management strategies for this often fatal polymicrobial infection.     

Necrotizing fasciitis following postpartum tubal ligation

Necrotizing fasciitis is a rare, but devastating subcutaneous bacterial infection which occurs following breaks in skin integrity, either natural, post traumatic or post surgical. Although it has been described following many surgical procedures, necrotizing fasciitis has not been previously described following postpartum tubal ligation. Necrotizing fasciitis was diagnosed four days after an uncomplicated postpartum tubal ligation via an infraumbilical incision. Rapid surgical debridement with broad spectrum antibiotic coverage provided successful therapy. Postpartum tubal ligation is one of the most common surgical procedures in obstetrics and gynecology, thus reports of complications resulting from this procedure are quite relevant to clinical practice. We present here the first reported case of necrotizing fasciitis following postpartum tubal ligation through an infraumbilical incision.     

Postpartum retroperitoneal fasciitis: a case report and review of literature

We present a case of a postpartum female with iliopsoas fasciitis in the puerperium. Two days after a spontaneous vaginal delivery at 38 weeks without any complications, the patient complained of pain in the left thigh and hip, associated with a temperature of 38 degrees C. Consequently, she could not walk 4 days after delivery and her body temperature had increased to 39 degrees C. Extreme left flank pain and tenderness in the left pelvic wall were prominent, whereas the tenderness in the pelvis was moderate. Magnetic resonance imaging led us to diagnose iliopsoas fasciitis. This was complicated by sepsis but improved after a protracted antibiotic treatment without any surgical intervention. A literature review revealed that serious complications, including sepsis or permanent functional disturbance, could arise although retroperitoneal fasciitis and/or abscesses are very rare after vaginal delivery. Iliopsoas fasciitis could be considered when patients complain of extreme pain in the pelvic wall, sacroiliac joint region, or thigh-symptoms that are uncommon in uncomplicated endometritis.     

Incidence, severity, and determinants of perineal pain after vaginal delivery: a prospective cohort study

OBJECTIVES: The purpose of this study was to determine the frequency of perineal pain in the 6 weeks after vaginal delivery and to assess the association between perineal trauma and perineal pain.Study design This was a prospective cohort study of parturients at 1 day, 7 days,' and 6 weeks' post partum in an academic tertiary obstetric unit in Toronto, Canada. Four hundred forty-four women were followed up, including women with an intact perineum (n=84), first-/second-degree tears (n=220), episiotomies (n=97), or third-/fourth-degree tears (n=46). Primary outcome was the incidence of perineal pain on day of interview; secondary outcomes were pain score measurements and interference with daily activities. RESULTS: Perineal trauma was more common among primiparous women, those with operative vaginal deliveries, and those with epidural analgesia during the second stage of labor. The incidence of perineal pain among the groups during the first week was intact perineum 75% (day 1) and 38% (day 7); first-/second-degree tears 95% and 60%; episiotomies 97% and 71%; and third-/fourth-degree tears 100% and 91%. By 6 weeks, the frequency of perineal pain was not statistically different between trauma groups. CONCLUSION: Acute postpartum perineal pain is common among all women. However, perineal pain was more frequent and severe for women with increased perineal trauma.     

Recurrent necrotizing fasciitis of the vulva. A case report.

Necrotizing fasciitis most often occurs in the context of prior trauma or surgery. Predisposing medical conditions include diabetes mellitus, arteriosclerosis, obesity, hypertension and prior irradiation. De novo occurrence in the vulva, in the absence of prior injury, surgery or irradiation, has been reported rarely. Necrotizing fasciitis of the vulva in the diabetic patient may have an insidious onset but requires an early diagnosis and aggressive surgical episode of fasciitis occurred in an obese, diabetic woman. Aggressive, wide excision of all infected vulvar, mons and thigh tissue, followed by aggressive medical and surgical postoperative care, resulted in minimal morbidity. Prompt recognition and aggressive care are required to treat this condition.     

Perforated appendicitis during near-term pregnancy causing necrotizing fasciitis of the lower extremity: a rare complication of a common disease

A 33-year-old woman presented with pain in the right side of the abdomen at 35 weeks of gestation. She was treated for cystitis. A few days later, her abdominal pain had disappeared; however, she had developed pain in the right thigh and fever. She delivered a healthy child, but postpartum her leg symptoms deteriorated. She was found to have a necrotizing fasciitis, which necessitated disarticulation of the hip. The source of the infection was a perforated appendix.     

Fascitis necrosante tras histerectomía

Necrotizing soft tissue infections represent a highly lethal group of infections. Necrotizing fasciitis is a rare, rapidly progressive infection with extensive necrosis of subcutaneous tissue and fascia, usually accompanied by severe systemic toxicity. The cornerstone of treatment is early diagnosis and treatment. Unfortunately, a delay in accurate diagnosis or definitive treatment may prove fatal.     

Perineal Trauma and Postpartum Perineal Morbidity in Asian and Non-Asian Primiparous Women Giving Birth in Australia

Objectives: To describe the postpartum perineal morbidity of primiparous women who had a vaginal birth and compare outcomes between Asian and non-Asian women in the first 2 days following the birth and at 6 and 12 weeks postpartum.
Design: Data from a randomized clinical trial of a perineal management technique (perineal warm packs) were used to address the study objective.
Setting: Two maternity hospitals in Sydney, Australia.
Participants: Primiparous women who had a vaginal birth in the trial were included ( n =697). One third of the women were identified as "Asian."
Results: Compared with non-Asian women, Asian women were significantly more likely to have an episiotomy; require perineal suturing; sustain a third- or fourth-degree perineal tear; and report their perineal pain as being moderate to severe on day 1 following the birth. Asian women were less likely to give birth in an upright position or to resume sexual intercourse by 6 or 12 weeks following the birth.
Conclusion: More research is needed into methods that could reduce the high rates of perineal trauma experienced by Asian women, and midwives need to be able to offer appropriate support for Asian women.     

Postpartum Perineal Pain in a Low Episiotomy Setting: Association with Severity of Genital Trauma,Labor Care,and Birth Variables

Background: Perineal pain is common after childbirth. We studied the effect of genital tract trauma, labor care, and birth variables on the incidence of pain in a population of healthy women exposed to low rates of episiotomy and operative vaginal delivery. Methods: A prospective study of genital trauma at birth and assessment of postpartum perineal pain and analgesic use was conducted in 565 midwifery patients. Perineal pain was assessed using the present pain intensity (PPI) and visual analog scale (VAS) components of the validated short‐form McGill pain scale. Multivariate logistic regression examined which patient characteristics or labor care measures were significant determinants of perineal pain and use of analgesic medicines. Results: At hospital discharge, women with major trauma reported higher VAS pain scores (2.16 ± 1.61 vs 1.48 ± 1.40; p < 0.001) and were more likely to use analgesic medicines (76.3 vs 23.7%, p = 0.002) than women with minor or no trauma. By 3 months, average VAS scores were low in each group and not significantly different. Perineal pain at the time of discharge was associated in univariate analysis with higher education level, ethnicity (non‐Hispanic white), nulliparity, and longer length of active maternal pushing efforts. In a multivariate model, only trauma group and length of active pushing predicted the pain at hospital discharge. In women with minor or no trauma, only length of the active part of second stage labor had a positive relationship with pain. In women with major trauma, the length of active second stage labor had no independent effect on the level of pain at discharge beyond its effect on the incidence of major trauma. Conclusions: Women with spontaneous perineal trauma reported very low rates of postpartum perineal pain. Women with major trauma reported increased perineal pain compared with women who had no or minor trauma; however, by 3 months postpartum this difference was no longer present. In women with minor or no perineal trauma, a longer period of active pushing was associated with increased perineal pain.     

Premenarchal recurrent periclitoral abscess: a case report

BACKGROUND: Periclitoral abscesses in premenarchal girls is a serious condition and can have negative implications for future reproductive health. Recurrent periclitoral abscess in premenarchal girls is rare. CASE: An 11-year-old, premenarchal girl presented complaining of dysuria, vulvar swelling, pain and erythema of the clitoral hood and a similar episode 12 months previously. Intravenous antibiotics and local measures resulted in spontaneous drainage of the abscess. On day 3 the area was healing, and the patient was discharged on oral antibiotics and sitz baths. At her 6-month follow-up, she had a normal clitoral hood without tenderness or erythema. CONCLUSION: Broad-spectrum antibiotics and local measures may prevent surgical treatment and potential associated reproductive morbidity.     

Necrotizing fasciitis arising from a suprapubic catheter site. A case report

Necrotizing fasciitis is an unusual complication of gynecologic surgery. A woman developed necrotizing fasciitis at the site of suprapubic urinary catheter placement. The diagnostic criteria for necrotizing fasciitis were fulfilled by the patient, whose predisposition for the disease was undiagnosed diabetes mellitus. This rare complication of suprapubic catheter drainage must be considered in high-risk patients presenting with an inflammation at this site of cutaneous trauma.     

Necrotizing fasciitis of the perineum secondary to a surgical treatment of Bartholin's gland abscess

Necrotizing fasciitis of the perineum is a rare but of fast evolution, and potentially fatal infectious disease process. It is characterized by progressive inflammation and extensive necrosis of subcutaneous tissue involving the fascia and other adjacent tissues. This infection may be idiopathic or secondary to local trauma or pelvic surgery. Its mortality rate is 20%. We report a case of necrotzing fasciitis of the perineum in a 34-year-old woman following incision and drainage of Bartholin's gland abscess. Streptococcus A, Proteus mirabilis, Escherichia coli, and Candida albicans were isolated. Intravenous broad spectrum antibiotic therapy was promptly instituted. Concurrent surgical debridement of all necrotic areas was required. Post debridement therapy required a long period of dressing changes until cicatrisation. Necrotizing fasciitis of the perineum is a surgical emergency. Early diagnosis and prompt aggressive debridement are the keys to successful management.     

Massive Uterustonisierung unklarer Ursache

This case report describes a patient who was admitted for treatment to a hospital in Zambia exhibiting the clinical picture of early placental abruption. She presented with severe abdominal pain and constant contraction of the uterus that was sensitive on palpation. The ultrasound examination was relatively unremarkable except for thinning of the portio. Fetal cardiography revealed borderline pathological findings. The diagnosis was reached by taking a meticulous patient history: instead of drug prophylaxis against malaria, the patient had taken misoprostol which she had already received during pregnancy but was intended for use after birth to prevent postpartum hemorrhage. The patient responded well to tocolysis with nifedipine and could be discharged a few days later.     

Unusual perineal pain in postpartum period: contribution of perineal ultrasound

We report two cases of persistent [correction of persistant] perineal pain in postpartum period due to transfixation of the anus with a suture and the contribution of perineal ultrasound in the diagnosis of unusual perineal pain.     

Trombosis séptica puerperal de la vena ovárica

We report a case of postpartum ovarian vein thrombosis and review the literature on the topic. The patient developed fever and abdominal pain after delivery. Empiric antibiotic treatment was prescribed and computed tomography showed right ovarian vein thrombosis.Ovarian vein thrombosis is an exceptional cause of postpartum fever. Differential diagnosis must be made with more frequent complications (appendicitis, pyelonephritis, and tubo-ovarian abscesses). The pathogenesis is multifactorial and treatment is based on a combination of antibiotics and anticoagulation. The diagnostic procedure of choice is computed tomography scan.     

Amniotic membranes as a temporary wound dressing in necrotizing fasciitis

A diabetic patient was seen at Magee-Womens Hospital with a vulvar abscess extending to the abdomen. Necrotizing fasciitis was diagnosed at operation, and the involved tissue was widely excised. The authors describe the successful use of amniotic membranes as a temporary wound dressing. The benefits of this method over conventional gauze dressings are easy availability, better adherence to the wound, less pain, and negligible cost to the patient.     

Necrotizing fasciitis of vulvar origin in diabetic patients

Necrotizing fasciitis is a rare, rapidly progressive, and often fatal infection of the superficial fascia and subcutaneous tissues. The integrity of the deep muscle fascia is usually not breeched, thus limiting the depth of involvement. Centrifugal spread within the planes of the superficial fascia and subcutaneous tissues is characteristic. Patients with diabetes mellitus constitute the group most vulnerable to necrotizing fasciitis, and a vulvar or perineal origin is associated with particularly high mortality. The authors report four such patients. Other apparent predisposing factors are advancing age, peripheral vascular disease, chronic debilitating illness, malnutrition, and possibly other states predisposing patients to immunodeficiency. None of these factors is an absolute prerequisite to the development of necrotizing fasciitis.