Successful multi-disciplinary management of a 24 year old pregnant woman with necrotising fasciitis of the forearm

Introduction

Necrotising fasciitis a relatively uncommon but rapidly progressive soft tissue infection. The incidence is 0.24-0.4 per 100,000.¹ This condition requires urgent aggressive surgical debridement and broad-spectrum antibiotics. Mortality from this condition has been quoted to be from 6-76%.² Sepsis can cause pre-term labour, fetal infection, and preterm delivery. The prevention of these complications is through early recognition and targeted therapy. This should include aggressive rehydration and broad-spectrum antibiotics, with an emphasis on stabilisation of the mother as a priority, as in doing so the foetal status will likewise improve.³

Case description

A 24-year-old woman who was 24 weeks pregnant presented to the emergency department with septic shock. She had injured the tip of her right elbow four days previously, causing a 0.5cm laceration which was now discharging pus. Her initial blood pressure was 84/43mmgHg, heart rate 110 beat per minute, serum C-reactive protein (CRP) was 392mg/L, and white cell count (WCC) 32x10⁹/L. She was initially given fluid resuscitation, and broad spectrum IV antibiotics. Through prompt coordinated prioritisation of the multi-disciplinary team, this lady was taken to theatre for prompt debridement. We found dirty dishwater fluid, and pus above the fascial layer up to the wrist. She improved dramatically after this.

Results and Conclusions

We have presented a case of necrotising fasciitis in a 24 year old pregnant woman whom had extremely early broad spectrum antibiotics and radical surgical debridement. We feel this lady was prioritised by several teams and her efficient, early, coordinated management led to an excellent outcome for both mother and child. Necrotising fasciitis is an uncommon condition with a high morbidity and mortality. Our patient had no risk factors for necrotising fasciitis aside from pregnancy. This may imply as McHenry⁴ suggests, that pregnancy itself may cause an immunosuppressive state enough for it to be considered a risk factor for the disease.

Take home message

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  Necrotising fasciitis/necrotising soft tissue infection is a clinical diagnosis.

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  Management in pregnancy is the same.

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  Management includes broad spectrum antibiotics and very early aggressive surgical debridement.

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  Senior surgical input should be sought early.

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  This is very rare in pregnancy and there are no reported upper limb cases of necrotising fasciitis.