Necrotizing Fasciitis in an Obstetric Patient

Background: Premature rupture of membranes (PROM) in a preterm infant is a serious concern. Additional complications, such as chorioamnionitis and a primary herpes outbreak, mean the delivery team must be vigilant in the care of such a patient. Case: A 32-year-old woman was transferred to our facility with a singleton pregnancy at 35 weeks gestation. The woman presented with unidentified PROM and had brown watery discharge for the past 3 weeks. Additionally, she had a primary herpes outbreak, was positive for group B streptococci, and reported flu-like symptoms for the past 3 weeks. The woman was febrile and her abdomen was tender to touch. Once stabilized with appropriate antibiotic and antiviral treatments, the woman underwent a primary cesarean. During the surgery, the uterus was found to be full of pus. The neonatal intensive care unit (NICU) team was present at the delivery. The newborn had a low Apgar score, oxygen saturation in the 30 s, no respiratory effort, and required prolonged respiratory support. The woman's postpartum course was progressing well until bowel sounds and urinary output decreased. Reddened areas around her incision were shown to her physicians and were attributed to tape burn. With no improvement, the woman was transferred back to the labor and delivery unit where she could receive a higher level of care. The nurse noticed the reddened area around the surgical site and convinced the physicians that this was not due to ordinary tape burn. A surgical consult was ordered and the woman was taken to the operating room (OR) to have her wound reopened. In the OR, her wound was cleaned and debrided but necrotizing fasciitis had set in. The woman was moved between the intensive care unit (ICU) and the OR for serial debridements. Eventually it was determined that her uterus could not be saved, and the woman had a hysterectomy. Soon after the surgery, she began to improve. The clinical nurse specialist was involved with keeping family and staff from the ICU, NICU, and OB departments up to date on the clinical condition of the dyad and provided resources to all areas as needed. The infant remained depressed for several days but did not contract herpes and was discharged appearing normal at 25 days of life. Conclusion: As this complex patient deteriorated, she was cared for by many specialists, including clinicians from obstetrics, infectious disease, neonatology, nephrology, general surgery, and critical care. Though this case was very medically intensive, nurses had a key role in identifying subtle changes in the patient, communicating and advocating for increased medical surveillance and treatment. © 2014 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses