First, massive uterine myonecrosis can be caused by group A be excluded-usually by CT scanning-then in our experiences, 3-hemolytic streptococcal or clostridial infections (Soper, 2011; as well as in others, hysterectomy may not be necessary (Soper, Sugiyama, 2010; Yamada, 2010). hose with early-onset disease 2011). Still, these infections are highly lethal (Yamada, 2010). present with findings listed in Table 47-6. The mortality rate in As a second exception, necrotizing fasciitis of the episiotomy these women with gangrene s shown in Figure 47-7 is high, and site or of the abdominal surgical incision is a surgical emergency. prompt hysterectomy may be lifesaving (Mabie, 1997; Nathan, As described by Gallup and coworkers (2002), these infections 1993). Group A 3-hemolytic streptococci and clostridial coloare aggressively managed as discussed in Chapter 37 (p. 671). nization or infection also cause toxic-shock syndrome without Sinha and colleagues (2015) described a woman with Fournier obvious gangrene (Mason, 2012). These are due to either strepgangrene who required radical debridement and colostomy. tococcal toxic-shock-syndrome-like toxin or clostridial exotoxin As a inal exception, persistent or aggressive postpartum that evolved from 5 aureus (Chap. 37, p. 675). In many of these uterine infection with necrosis, uterine incision dehiscence, and severe peritonitis may lead to sepsis (Chap. 37, p. 672). In this regard, women following cesarean delivery who are suspected of having peritonitis should be carefully evaluated for uterine incisional necrosis or bowel perforation. These infections tend to be less aggressive than necrotizing group A streptococcal infections and develop later postpartum. CT imaging of the abdomen and pelvis can frequently disclose these. If either is suspected, then prompt surgical exploration is indicated. With incisional necrosis, hysterectomy is usually necessary (Fig. 37-5, p. 673). Finally, peritonitis and sepsis much less commonly may result from a ruptured parametrial, intraabdominal, or ovarian abscess (Chap. 37, p. 671).
As shown in Figure 47-6, a woman with severe sepsis syndrome is supported with continuing crystalloid infusion, blood
FIGURE 47-7 A fatal case of group A 3-hemolytic Streptococcus pyogenes puerperal infection following an uncomplicated vaginal delivery at term. The infection caused uterine gangrene and overwhelming sepsis syndrome. Arrows point to overtly "balloonedout" black gangrenous areas of the postpartum uterus at the time of laparotomy for hysterectomy.
transusions, and ventilation. In some cases, other measures may be necessary. Vasoactive drugs are not given unless aggressive luid treatment fails to correct hypotension and perfusion abnor malities. First-line vasopressors are norepinephrine, epinephrine, dopamine, dobutamine, or phenylephrine (Vincent, 2013).
he use of corticosteroids remains controversial. Some stud ies, but not all, show a salutary efect of corticosteroid admin istration. It is thought that critical ilness-related corticosteroid sion. hus, corticosteroids may be considered for use in vaso pressor-dependent patients (Angus, 2013; Munford, 2015).