Puerperal retroperitoneal abscess caused by Clostridium difficile: case report and review of the literature.

BACKGROUND: Retroperitoneal infection can be lethal. Optimal management is still elusive to describe because of the small number of case reports. We presented here a case of retroperitoneal abscess caused by Clostridium difficile arising in the puerperal period. METHODS: Case report and review of recent English-language literature. RESULTS: The patient presented with surgical incision dehiscence. A gas-forming fluid collection was discovered in the pelvic retroperitoneal fascia by computed tomography, but the patient did not show marked symptoms of sepsis. Emergency laparotomy drainage and debridement were performed. Clostridium difficile was isolated, and she was treated with a three-week course of vancomycin. The patient recovered without major morbidity. Recent case reports describe variation in the course of the disease and management options for puerperal retroperitoneal infection. CONCLUSION: Puerperal retroperitoneal abscess caused by C. difficile can present with minimal symptoms. Prompt recognition, early surgical intervention, and optimal use of antibiotics can reduce morbidity and prevent death.

Histerectomía obstétrica por sepsis en el puerperio / Obstetric hysterectomy due to sepsis in the puerperium

Los sangrados de origen obstétrico y las infecciones pélvicas severas constituyen las primeras causas para la realización de una histerectomía en el estado grávido puerperal. La decisión de realizar una histerectomía con un diagnóstico oportuno va a influir en la evolución y pronóstico de estas pacientes. El objetivo principal del presente estudio es analizar la histerectomía obstétrica por procesos infecciosos pélvicos severos, mediante un análisis retrospectivo de 5 años en pacientes del Hospital General de México y del Centro de Esterilidad y Ginecología Integral. Se incluyeron 17 casos de histerectomía obstétrica, el grupo de edad promedio fue entre los 20 y 30 años, la principal indicación fue la deciduomiometritis en el 35,2%, el tiempo promedio de la cirugía fue de 124,4min, las complicaciones principales fueron lesiones al tracto urinario y aquellas secundarias al proceso séptico (CID), la mortalidad fue del 35% (AU)

Bleeding of obstetric origin and severe pelvic infections are the main causes of hysterectomy in the puerperium. Timely diagnosis and hysterectomy influence the outcome of these patients. The main objective of the present study was to analyze obstetric hysterectomy for severe pelvic infectious processes. We retrospectively analyzed obstetric hysterectomies for severe pelvic infectious processes and sepsis in the puerperium performed over a 5-year period in the General Hospital of Mexico. Seventeen cases of obstetric hysterectomy were analyzed. Most patients were aged between 20 and 30 years. The main indication was endometritis in 35.2%, and the mean operating time was 124.4min. The main complications were urinary tract lesions and those secondary to the septic process (disseminated intravascular coagulation). Mortality was 35% (AU)

Postpartum rupture of the posteromedial papillary muscle.

We report a case of postpartum severe mitral regurgitation caused by papillary muscle rupture in a female with normal coronary arteries. The etiology of papillary muscle rupture was endocarditis from puerperal fever. Clinical stabilization was achieved with extracorporeal membrane oxygenation (ECMO) followed by mitral valve replacement two days later.

Methicillin-resistant Staphylococcus aureus infections may not impede the success of ultrasound-guided drainage of puerperal breast abscesses.

BACKGROUND: Ultrasound-guided percutaneous drainage has been suggested in recent years to be the treatment of choice for breast abscesses. Although MRSA has recently been observed to be a significant causative pathogen in mastitis, reports dealing with ultrasound-guided drainage of breast abscess did not address the bacteriology of these infections. STUDY DESIGN: Between January 1 and December 31, 2007, 129 women were diagnosed with puerperal mastitis at Taipei City Hospital. Data were collected by retrospective chart review. Charts were surveyed for mastitis recurrence for at least 1 year after the initial infection treatment, through December 31, 2008. RESULTS: The most commonly identified organism was Staphylococcus aureus, present in 69 of 78 of bacterial isolates (88%). There were 52 of 78 (66%) bacterial isolates that were MRSA. Forty-seven of 52 (90%) women infected by MRSA underwent initial ultrasound-guided percutaneous abscess drainage. Among them, 11 (23%) women underwent subsequent conversion to surgical incision and drainage. Comparing women infected with MRSA and women infected with other pathogens, there was no statistical difference in the duration of treatment, number of outpatient follow-up visits, duration of antibiotics use, or abscess recurrence rates. CONCLUSIONS: MRSA is the most common bacteria in puerperal breast abscess in our population. When these patients are treated initially by percutaneous abscess drainage followed by repeated ultrasound-guided drainage or surgical incision and drainage, the presence of MRSA may not adversely affect treatment outcomes.

Peripartum group A streptococcal sepsis: a case report.

BACKGROUND: Infections of the upper respiratory tract and skin are commonly attributed to group A Streptococcus (GAS). The organism can be found in the female genital tract and can cause peripartum sepsis in rare cases. CASE: A case of GAS peripartum sepsis did not respond to conservative measures despite early initiation of intravenous antibiotics. Radical surgical intervention improved the condition. CONCLUSION: A GAS uterine infection should be suspected at an early stage in cases of puerperal pyrexis that do not respond to broad-spectrum antibiotics.

Postpartum pyomyoma.

Leiomyomata are common benign tumors of the uterus and female pelvis. Myomas have been reported in 25% of Caucasian American women and 50% of African-American women. The true incidence is unknown, but descriptions of 50% have been found at postmortem examinations. Considering the high incidence of uterine myomata in women of reproductive age, they are reported as complications in only 2% of pregnancies. Pyomyoma (suppurative leiomyoma) a rare complication results from infarction and infection of a leiomyoma. Without a strong clinical suspicion and surgical intervention, fatalities may occur. Since 1945, only 15 cases have been described in the literature, mostly in pregnant or postmenopausal women after ascending infection. This report documents a pyomyoma that presented as a postpartum enlargement of a previously known leiomyoma. This case is unique because the patient did not undergo a hysterectomy at the time of exploratory laparotomy. Six months after the procedure, normal cyclic bleeding was noted.

Abdominal rectus muscle sheath abscess after spontaneous vaginal delivery. A case report.

Postpartum infections cause severe morbidity of the mother. Abdominal wound infection and abscess formation are common complications after cesarean delivery. We report a case with abscess formation inside the abdominal rectus muscle sheath after normal, spontaneous vaginal delivery. A 32-year-old woman, para 2, had a normal vaginal delivery at term. The second postpartum day she complained of lower abdominal pain and was unable to stand up or walk. The fourth day, cellulitis of the skin of the lower abdomen developed and was treated with broad-spectrum intravenous antibiotics. The seventh day the patient developed septic fever and an abdominal rectus muscle sheath abscess was diagnosed. The abscess was treated with incisions and evacuation and the patient was discharged the 12th postoperative day. The abscess in this case, as hematoma formation was not preceded, was referred to ascending contamination via the lymphatic vessels.

Group A streptococcal puerperal sepsis with retroperitoneal involvement developing in a late postpartum woman: case report.

Group A beta-hemolytic streptococci cause a wide range of infectious diseases such as pharyngitis, impetigo, rheumatic fever, and even septic shock. Group A streptococcal puerperal sepsis is uncommon today, but recent reports indicate a reemergence of virulent strains can cause toxic-mediated shock and multiple organ failure. We present a case report of a 29-year-old postpartum woman after cesarean section who presented group A streptococcal puerperal sepsis. Furthermore, we discuss the GAS strain in this patient and its relation with close contact among family members. The group A streptococci (GAS) were isolated from the patient's retroperitoneal fluid and from her husband's throat swab, respectively. Both isolates were shown to be identical: M type 1. It is well known that exotoxin A produced by M1 or M3 serotypes of the organisms plays a crucial role in streptococcal toxic shock syndrome (STSS). We conclude that in this patient, close contacts of persons with GAS appear to be at risk for colonization with identical strains of STSS-causing GAS such as M1 or M3 serotypes. Therefore, the appropriate antibiotic including antibiotic prophylaxis for close contact should be considered.

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.

Fistula-in-ano after episiotomy.

BACKGROUND: In the past 2 years, we treated three women with fourth-degree lacerations or episiotomy infections presenting with persistent pain and drainage not responding to standard treatment. CASES: These women were referred for evaluation 5 weeks, 3.5 months, and 2 years postpartum. After diagnosing fistula-in-ano, we treated them with fistulotomy and curettage, which resolved the problem. CONCLUSION: When a patient presents with pain or drainage at her episiotomy site, fistula-in-ano should be considered.

Infective endocarditis complicated by mycotic cerebral aneurysm: two case reports of women in the peripartum period.

Mycotic cerebral aneurysm is a relatively rare but very serious complication of infective endocarditis. Infective endocarditis is a rare but a potentially fatal complication of pregnancy. We report here two very rare cases of infective endocarditis associated with mycotic cerebral aneurysm in peripartum women. In one case, cardiac surgery was performed prior to cerebral surgery and after delivery. In the other case, emergency cerebral surgery was performed due to rupture on the day cardiac surgery had been scheduled, 45 days after delivery. The surgical management of a patient with infective endocarditis and mycotic cerebral aneurysm is reviewed. The surgical strategy for a pregnant patient is also reviewed.

Ross operation and mitral homograft for aortic and tricuspid valve endocarditis.

We report here a case of concomitant aortic and tricuspid valve endocarditis occurring in a 26-year-old woman 2 weeks after she had given birth by cesarean delivery. Preoperative transthoracic echocardiography revealed a previously undetected aorta-right atrium fistula, which at operation appeared to be congenital in origin. Surgical treatment consisted of aortic valve replacement with a pulmonary autograft, tricuspid valve replacement with a cryopreserved mitral homograft, and closure of the fistulous communication. The postoperative recovery was uneventful.

[Sepsis and SIRS (systemic inflammatory response syndrome) in the puerperium--pathogenesis and clinical management]. / Sepsis und SIRS (Systemic Inflammatory Response Syndrome) im Wochenbett--Pathogenese und klinisches Vorgehen.

PURPOSE: We report about 5 cases of "puerperal sepsis" to elucidate the clinical significance and resulting therapeutic management of Sepsis, SIRS (Systemic inflammatory response syndrome) and MODS (Multiple organ dysfunction syndrome), whose definitions were introduced at the Consensus Conference of the American College of Chest Physicians/Society of Critical Care Medicine in 1992. RESULTS: All patients had documented endomyometritis, 3 of them in combination with ovarian vein thrombosis. None of the patients responded adequately to conservative treatment with antibiotics and intravenously applied Heparin. After 12 to 72 hours, because of clinical deterioration, all women underwent laparotomy with hysterectomy combined with an ovarectomy in 3 cases. Although the inflammatory "septic" source was removed by the surgical intervention, the clinical condition of 3 of the patients further deteriorated; they were suffering from SIRS, and 2 developed MODS. Symptoms of MODS were DIC, hypotension, kidney failure and encephalopathy. CONCLUSIONS: Our results support the theory that infection or trauma may initiate an endogenous inflammatory response which could progress to MODS even after removal of the initial source. Our findings, however, do not support the view that septic endomyometritis and postpartum ovarian vein thrombosis should be treated nonsurgically, because the clinical course in our patients was less complicated the earlier the surgical intervention was initiated.