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CLINICAL CASE
КЛИНИЧЕСКИЙ СЛУЧАЙ
© Group of authors, 2021
UDC 618.5-089.888.61:616-002
DOI - https://doi.org/10.14300/mnnc.2021.16050
ISSN - 2073-8137
FOURNIER GANGRENE IN PUERPERAS AFTER CESAREAN SECTION
Ryzhkov V. V. \ Gasparyan S. A. \ Derevyanko T. I. \ Kopylov A. V. 1, Papikova K. A. 1, Pydra A. R. 1, Pivovarova N. I. 2, Gordeeva L. P. 2
1 Stavropol State Medical University, Russian Federation
2 City clinical hospital of the emergency medical services, Stavropol, Russian Federation
ГАНГРЕНА ФУРНЬЕ У РОДИЛЬНИЦЫ ПОСЛЕ ОПЕРАЦИИ КЕСАРЕВА СЕЧЕНИЯ
В. В. Рыжков 1, С. А. Гаспарян 1, Т. И. Деревянко 1, А. В. Копылов 1, К. А. Папикова 1, А. Р. Пыдра 1, Н. И. Пивоварова 2, Л. П. Гордеева 2
1 Ставропольский государственный медицинский университет, Российская Федерация
2 Городская клиническая больница скорой медицинской помощи, Ставрополь, Российская Федерация
Fournier gangrene is a form of necrotizing fasciitis that mainly affects men suffering from immunodeficiency after surgeries of the genitals and perineum. Literature data on the occurrence of this complication in women are rare, and there are no data in obstetric practice. Herein, we present a clinical case of severe sepsis with an unfavorable outcome owing to anterior abdominal wall phlegmon (Fournier phlegmon) in a puerperal woman after cesarean section.
Keywords: cesarean section, Fournier gangrene, sepsis
В современных условиях гангрена Фурнье (эпифасциальный некроз) трактуется как специфическая форма некро-тизирующего фасциита, поражающая преимущественно мужчин, страдающих иммунодефицитом, после операций на половых органах и промежности. Данные литературы о возможности наличия этого осложнения у женщин единичные, а в акушерской практике отсутствуют. Описан клинический случай тяжелого сепсиса с неблагоприятным исходом вследствие флегмоны передней брюшной стенки (флегмона Фурнье) у родильницы после операции кесарева сечения.
Ключевые слова: операция кесарево сечение, гангрена Фурнье, сепсис
For citation: Ryzhkov V. V., Gasparyan S. A., Derevyanko T. I., Kopylov A. V., Papikova K. A., Pydra A. R., Pivovarova N. I., Gordeeva L. P. FOURNIER GANGRENE IN PUERPERAS AFTER CESAREAN SECTION. Medical News of North Caucasus. 2021;16(2):212-215. DOI - https://doi.org/10.14300/mnnc.2021.16050
Для цитирования: Рыжков В. В., Гаспарян С. А., Деревянко Т. И., Копылов А. В., Папикова К. А., Пыдра А. Р., Пивоварова Н. И., Гордеева Л. П. ГАНГРЕНА ФУРНЬЕ У РОДИЛЬНИЦЫ ПОСЛЕ ОПЕРАЦИИ КЕСАРЕВА СЕЧЕНИЯ. Медицинский вестник Северного Кавказа. 2021;16(2):212-215. DOI - https://doi.org/10.14300/mnnc.2021.16050
Fournier gangrene (epifascial necrosis) is a specific form of necrotizing fasciitis that affects patients of both sexes and of any age. However, it is mainly observed in men suffering from immunodeficiency [1, 2], especially in those with injuries of the genitals and perineum. Cases of the development of Fournier gangrene after piercing and injection of drugs into the veins of the penis and cavernous bodies have been described [3, 4]. Streptococcus, Staphylococcus, Escherichia coli, and microbial associations involving anaerobic bacteria play a significant role as infectious agents [5-7]. The disease is characterized by the vastness and high rate of lesion spread; total necrosis can develop up to the anterior abdominal wall and even further into the axillary areas as well as the inner surface of the thighs. This is owing to the mixed nature of the infection, involving the release of enzymes and toxins by microbes; this causes high pathogenic-
ity and thrombosis in the vessels, resulting in tissue necrosis. Owing to tissue hypoxia, anaerobes that produce hyaluronidase, lecithinase, and collagenase begin to actively multiply. These favorable conditions aid the microorganisms in rapidly overcoming interstitial and fascial barriers [8, 9]. The mortality rate is extremely high and can exceed 40 % [10]. Nevertheless, successful treatment of these patients has been previously reported [11-14].
Reports of Fournier gangrene in women are rare [15], and there are no data in obstetric practice. Pregnancy itself, particularly its pathological course, contributes to the development of immunodeficiency [16, 17]. Surgical interventions on the perineum (i.e., episiotomies, vaginal tissues, and perineum restoration after traumatic childbirth); surgical delivery, including cesarean section; and damage to nearby organs, specifically the urethra, bladder, and rectum, all contribute to the parturient occurrence of this disease.
MEDICAL NEWS OF NORTH CAUCASUS 2021. Vol. 16. Iss. 2
МЕДИЦИНСКИЙ ВЕСТНИК СЕВЕРНОГО КАВКАЗА
2021. Т. 16. № 2
Clinical case. A 25-year-old primigravid from Stavropol had been observed by obstetrician-gynecologists since 5-6 weeks of gestation. She had a height of 170 cm, body weight of 46 kg, and body mass index of 17. Her examination revealed endocervicitis, E. coli growth in the cultures of samples from the cervical canal, and the presence of leptotrichia and diphteroids on vaginal smears. Antibacterial treatment was prescribed. At the 17th week of gestation, E. coli growth (104) was detected in the urine. There was severe lymphocytopenia with threat of pregnancy termination; thus, she was repeatedly hospitalized and was administered multicomponent therapy, including progesterone derivatives. After consultation with a therapist, the patient was diagnosed with heart connective tissue dysplasia syndrome with mitral valve prolapse of moderate hemodynamic significance. The pregnancy was complicated by moderate preeclampsia, leading to hospitalization in the pathological pregnancy department of a multispeciality hospital at the 37th week of gestation; preeclampsia treatment was initiated and preparations for childbirth were begun. Owing to premature discharge of amniotic fluid, she was transferred to the maternity unit. Regular birth activity developed, which later became uncoordinated. The waterless period was 9 h and 38 min. A live, full-term female child was delivered via emergency cesa-rean section (Stark method). The baby weighed 3260 g, was 51 cm long, and had an Apgar score of 8-9 points. The mother experienced blood loss of 800.0 ml (1.6 % of body weight and 20 % of blood volume). Preventive measures were taken for purulent-septic complications during the operation and blood transfusion.
The placenta was 16x16x1.0 cm in size, 256 cm3 in volume, and 580 g in weight. The placental-fetal mass index was 0.18 (normal: 0.14-0.15). The placenta was fleshy, dark maroon with a gray surface. Histopathological examination revealed serous choriodeciduitis.
The postoperative period was complicated by acute purulent endometritis, salpingoophoritis, peritoneal sepsis, and septic shock. On the 2nd day after the cesarean section, hysterectomy with tubes, sanitation, and drainage of the abdominal cavity were performed. In the abdominal cavity, there was a 200-ml foul-smelling cloudy effusion containing fibrin. Upon incision, the uterine muscle was noted to have the color of boiled meat; the serous cover was gray, and the tubes were hyperemic and edematous. The uterus had a putrid smell. Intensive antibacterial therapy, infusion therapy, and inotropic support were performed. The vital signs stabilized and the symptoms of peritonitis subsided. Subsequently, the putrefactive phlegmon of the anterior abdominal wall rapidly spread both up and down from the transverse incision line of the anterior abdominal wall, causing total necrosis and further spread to the pubis and thighs (Fig. 1).
Because of the progression of the putrefactive-necrotic process, repeated step-by-step necrectomies with a wide capture of healthy tissues were performed, with daily sanitization of the wound surface using antiseptic solutions as well as intensive therapy for multiple organ failure combined with extracorporeal detoxification methods in a ventilator. Unfortunately, on the 14th day post-delivery, with increasing symptoms of multiple organ failure, the mother died. Bacteriological examination of the anterior abdominal wall wound discharge revealed a continuous growth of hemolytic E. coli; clostridium was not detected. The child was diagnosed with intrauterine pneumonia, which was effectively treated in the neonatal intensive care unit.
On the basis of the obtained clinical and pathohistolo-gical data of the placenta study, the ascending path of fetus infection should be considered.
Fig. 1. Total necrosis of the anterior abdominal wall
After a pathologic-anatomical autopsy followed by microscopic examination of histological preparations of all vital organs, similar changes were noted: necrosis, dystrophy, microcirculation disorders in the form of capillary dilation, full blood, leukocyte stasis in blood, thrombosis, and hemorrhages. Signs of respiratory distress syndrome were also noted in the lungs.
Purulent necrotic endometritis and metrothrombo-phlebitis were observed in the uterus. Parametritis was also observed. Acute purulent salpingitis was observed. Vascular thrombosis, vasculitis, and leukocyte infiltrates were noted in the ovaries.
There was no free fluid in the abdominal cavity. The serous intestinal membranes and the abdominal layers were smooth and shiny. The pelvis was clear.
There were findings of leukocyte infiltration, vasculitis, hemorrhages, necrosis of muscle fibers, and microabscesses in the tissues of the anterior abdominal wall (dermis, subcutaneous fat, and muscles) (Fig. 2).
Fig. 2. Anterior abdominal wall. Necrosis of muscle fibers (1). Microabscesses (2). Magnification 40. Hematoxylin-eosin staining
A bacteriological study of blood from the heart revealed an increase in the levels of Enterobacteriaceae with a predominance of E. coli.
The patient's main cause of death was severe sepsis and multiple organ failure. Infection foci were found in the anterior abdominal wall (total necrosis, resulting in Fournier gangrene) and uterus (purulent necrotic endometritis). Removal of the uterus led to the elimination of peritonitis. Repeated step-by-step necrectomies were ineffective owing to the extremely rapid progression of the necrosis of the anterior abdominal wall (purulent necrotic fasciitis, myositis, and skin and subcutaneous fat gangrene).
Prevention, early detection, and treatment of Fournier gangrene are all critical in disease outcomes.
Initially, the clinical picture resembled cellulitis. There was swelling of the skin, hyperemia, local soreness,
CLINICAL CAsE
КЛИНИЧЕСКИЙ СЛУЧАЙ
increased body temperature, signs of intoxication, weakness, and muscle and joint pain. The edema rapidly increased, crepitation developed, and the skin hyperemia was replaced by the appearance of purplish-black foci, indicating pronounced tissue ischemia. The wound had a putrid smell. Necrosis and tissue rejection occurred. To confirm the diagnosis, culture studies of the blood, urine, and wound discharge were performed. Arterial blood gas was evaluated. Radiological evaluation of the abdominal cavity was also performed. Clinical tests of blood, urine, coagulation, biochemical tests, and serum electrolytes were conducted [18-20].
In maternity hospitals, preventive measures for Fournier gangrene aim to reduce maternal birth trauma and surgical obstetric interventions in obstetrics, with a
Disclosures: The authors declare no conflict of interest.
References
1. Urology: National guidance. Ed. N. A. Lopatkin. Moscow: GEOTAR-Media Publ. 2009;582-583.
2. Ephimenko M. A., Privolnev V. V. Fournier's gangrene. Clinical Microbiology and Antimicrobial Chemotherapy. 2008;10(1):34-42.
3. Ekelius L., Bjorkman H., Kalin M., Fohlman J. Fournier's gangrene after genital piersing. Scand. J. Infect. Dis. 2004;36:610-612.
https://doi.org/10.1080/00365540410017086
4. Mouraviev V. B., Pautier S. E., Hauman W. P. Fournier's gangrene following penile self-injection with cocaine. Scand. J. Urol. Nephrol. 2002;36:31:7-8. https://doi.org/10.1080/003655902320248326
5. Yegorkin M. A. Fournie's disease and anaerobic paraproctitis - different clinical forms of same pathological process? News of Coloproctology. - Novosti koloprokto-logii. 2012;22(4):66-72.
6. Amr A., Sajad S. Fournier's gangrene - Case report and a brief review. Journal of Pakistan Association of Dermatologists. 2015;25:44-51.
7. Tahmaz L., Erdemir F., Kibar V., Cosar Ah., Yalcyn O. Fournier's gangrene: report of thirty-three cases and a review of the literature. Int. Urol. 2006;13(7):960-967. https://doi.org/10.1111/j.1442-2042.2006.01448.x
8. Thwaini A., Khan A., Malik A. Cherian J., Barua J. [et al.] Fournier's gangrene and it's emergency management. Postgraduate Medical Journal. 2006;82:516-519. https://doi.org/10.1136/pgmj.2005.042069
9. Grinev M. V., Soroka I. V., Grinev K. M. Fournier's Gangrene - a model of necrotizing fasciitis (Clinical and pathogenetic aspects). Urologiya. 2007;6:69-75.
10. Unal B., Kocer B., Ozel E., Boskurt B., Yildirim O. [et al.] Fournier Gangrene Approaches to Diagnosis and Treatment. Saudi Med. 2006;27:1038-1043.
11. Chinikov M. A., Tkachenko Yu. N., Bagdasaryan A. G., Do-brovolskii S. R. Successful treatment of patient with fournier's phlegmon. Pirogov Russian Journal of Surgery. -Khirurgiya. Zhurnal im. N.I. Pirogova. 2007;11:53-54.
12. Yanar H., Taviloglu K., Ertekin C., Guloglu R., Zorba U. [et al.] Fournier's gangrene: risk factors and strategies for management. World J. Surg. 2006;30:1750-1754. https://doi.org/10.1007/s00268-005-0777-3
13. Bordakov P. V., Bordakov V. N., Gain Yu. M., Shakh-rai S. V., Gain M. Yu. Fournier's gangrene: clinic, diagnos-
focus on compliance with personal hygiene. Perioperative prevention of purulent-septic diseases is mandatory, particularly in high-risk groups, including pregnant women with chronic infection foci, diabetes mellitus, and other extragenital diseases [21-23]. Before delivery, it is extremely important to sanitize the infection foci in the mother's body, particularly those in the urogenital system and gastrointestinal tract, normalize the microflora of the vagina and intestines, and restore the acidic environment in the vagina.
Conclusions. The treatment of Fournier's gangrene should be based on urgent surgical excision of necrotic tissues with the drainage of abscesses and phlegmon alongside powerful antibacterial and detoxification therapy, including methods of extracorporeal detoxification.
tics, treatment. Wounds and wound infections. The prof. B. M. Kostyuchenokjournal/2017;4(1):14-23. https://doi.org/10.17650/2408-9613-2017-4-1-14-23
14. Dzhamalov F. G., Nabieva E. V., Abdullayev M. M., Za-khidov Z. T., Baranov A. V. [et al.] Diagnosis and treatment of hangren Furnie (practical experience). Laser Medicine. 2018;22(2):39-42.
https://doi.org/10.37895/2071-8004-2018-22-2
15. Novoshinov G. V., Sheremeteva A. A., Starchenkova L. P. Fournier Gangrene in a 1 Month old child. Russian Journal of Pediatric Surgery.2016;20(1):51-52. https://doi.org/10.18821/1560-9510-2016-20-21-51-52
16. Nickolsky V. I., Sergatsky K. I., Klimashevich A. V., Ogorodnik E. V. Rare causes of acute purulent-inflammatory lesions of pararectal tissue and Fournier's gangrene. Pirogov Russian Journal of Sergery. - Khirurgiya. 2020;(2):68-73.
https://doi.org/10.17116/hirurgia202002168
17. Privolnev V. V., Zabrosaev V. S., Danilenkov N. V. Fournier's gangrene (Review). Vestnik of Smolensk State Medical Academy. - Vestnik Smolenskoj gosudarstvennoj medicinskoj akademii. 2014;13(3):47-55.
18. Prohorov A. V. Fournier's gangrene: modern approaches to treatment (literature review). Experimental and Clinical Urology. 2016;(2):106-117.
https://doi.org/10.29188/2222-8543
19. Prokhorov A. V. Experience of Furnier's gangrene clinical diagnostics. Kazan Medical Journal. 2016;97(1):159-162. https://doi.org/10.17750/KMJ2016-159
20. Priyma O. B. Treatment of patients with gangrene Fournier. Grekov's Bulletin of Surgery. 2017;176(1):76-79. https://doi.org/10.24884/0042-4625-2017-176-1-76-79
21. Prokhorov A. V. The modern view of Fournier gangrene. Pacific Medical Journal. 2017;1:5-9. https://doi.org/10.17238/PmJ1609-1175.2017.1.5-9
22. Prokhorov A. V. Fournier's Gangrene: the Criteria for Diagnosis, Prognostic Factors, Complications and Mortality. Journal of Experimental and Clinical Surgery. 2017;10:2:154-164.
https://doi.org/10.18499/2070-478X-2017-10-2-154-164
23. Prokhorov A. V. Fournier's gangrene. Clinical and laboratory picture (literature review). Experimntal and clinical urology. 2016;1:78-89. https://doi.org/10.29188/2222-8543
About authors:
Ryzhkov Valery Vladimirovich, MD, DMSc, Professor, Head of the Department of obstetrics and gynecology
of the further vocational education; tel.: +78652554331, +79187722165; e-mail: [email protected]; https://orcid.org/0000-0002-0694-9984
Gasparyan Susanna Artashesovna, MD, DMSc. Professor, Professor of the Department of urology, pediatric urology-andrology, obstetrics and gynecology of the further vocational education;
tel.: +79624019121; e-mail: [email protected]; https://orcid.org/0000-0001-8284-8117
Derevyanko Tatyana Igorevna, MD, DMSc, Head of the Department of urology, pediatric urology-andrology, obstetrics and gynecology, of the further vocational education; tel.: +78652554331, 904832; e-mail: [email protected]; https://orcid.org/0000-0003-1659-319Х
Kopylov Anatoly Vasilyevich, CMSc, Associate Professor, Head of the Stavropol Regional Forensis Medical Bureau, Head of Forensic Medicine and Law Department with a course of further vocational education, Honored Doctor of the Russian Federation; tel.: +78652260132, +78652428771; e-mail: [email protected]; https://orcid.org/0000-0003-3793-1370
