Necrotizing Fasciitis In An Obstetric Patient

Background: Premature rupture of membranes in a preterm infant is of concern to all in obstetrics.  Additional complications such as chorioamnionitis and a primary herpes outbreak means the delivery team must be vigilant in thier care.  As this complex patient deteriorated, she was cared for by many specialities, including Obstetrics, Infectious Disease, Neonatology, Nephrology, General Surgery, and Critical Care.

Case: This patient was a 32 year old who transferred into our facility with a singleton pregnancy at 35 weeks.   The patient presented with unidentified premature rupture of membranes, having brown watery discharge for 3 weeks.  Additionally she had a primary herpes outbreak, was Group B Strep Positive and reported flu-like symptoms for the past 3 weeks.  She was febrile and her abdomen was tender to touch.   Once stabilzed with appropriate antibiotic and antiviral treatments started, the patient underwent a primary c-section.  During the surgery, the uterus was found to be full of pus.  The NICU team was present at the delivery.  The baby had  low Apgars, oxygen saturation in the 30's, no respiratory effort and required prolonged respiratory support.  

The patient's postpartum course was progressing well until she had decreased bowel sounds and urinary output.  Reddened areas around her incision were shown to her physicians and were attributed  to tape burn.  With no improvement, the patient was transferred back to Labor and Delivery where she could receive a higher level of care.  The nurse noticed the reddended area around the surgical site and convinced the physicians that this was not ordinary tape burn.   A surgical consult was ordered and patient was taken to the Operating Room to have her wound reopened.   In the OR, her wound was cleaned and debrided but necrotizing fasciitis  had set in.  The patient moved between ICU and OR for serial debridements.    Eventually it was determined that her uterus could not be saved,  the patient had a hysterectomy and soon after that the patient began to improve.   

The CNS was involved with keeping family and staff from the ICU, NICU and OB department 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 luckily  did not contract herpes.   The baby was discharged from the  NICU at 25 days of life, and appeared normal.  

Conclusion: Although this case was very medically intensive, nursing had a key role in identifying subtle changes in the patient, communicating and advocating for increased medical surveillance and treatment. 

Keywords: Teamwork, Patient Advocacy, interdepartmental communication