Fatal maternal streptococcus A infection after cesarean section

A case is reported of an infection with Streptococcus pyogenes, occurring 24 hours after an elective Caesarean section in a 30 year old woman. She worsened during the first 48 h, with shock (Pasys less than 70 mmHg, pH 7.28) as well as abdominal tenderness and guarding. Laparotomy revealed peritonitis, and subtotal hysterectomy was carried out. Gram positive cocci were found in the peritoneal exudate, with bacterial cultures yielding Streptococcus pyogenes. Histopathological examination of the specimen revealed necrosing endomyometritis with septic thrombophlebitis. During the immediate post-operative period, there were several prolonged episodes of circulatory arrest treated with dobutamine, adrenaline, and noradrenaline. Multiple organ failure occurred during the next five days, despite antibiotic therapy (vancomycin, tienamycin, amikacin) and intensive care. It included jaundice, thrombocytopaenia (10 G.l(-1] adult respiratory distress syndrome (ARDS). A further laparotomy was carried out because of abdominal and thigh cellulitis, with completion of the hysterectomy and bilateral salpingo-oophorectomy. Streptococcus pyogenes was still present in the peritoneal cavity. There followed an improvement, with a return to normal of the platelet count, haemodynamic stability such that vasoactive drugs were no longer needed, and a decrease in the degree of jaundice. However, the ARDS worsened, and the patient died 15 days after the Caesarean section. There have been recent reports of similar cases, suggesting an increase in the virulence of group A streptococci linked to a re-emergence of exotoxin A.