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Life-threatening puerperal infection with group a streptococcus

A 17-year-old woman (gravida 2, para 1+0) with previous uncomplicated pregnancy and vaginal delivery had an uneventful antenatal period and delivered vaginally a healthy boy (3.16kg) after 7 hours of spontaneous labour. Her general condition including temperature during labour was normal. 24 hours after delivery she complained of severe lower abdominal pain. Her temperature was normal, general condition was satisfactory and clinical examination was unremarkable; a diclofenac suppository was prescribed. She became symptom-free and was discharged home at 30 hours postpartum. On the second postpartum day the microbiologist informed the obstetric and neonatal team of growth of group A streptococcus in the eye swab of the baby, which had been taken because of sticky eyes. Her general practitioner was contacted to prescribe antibiotics for both mother and baby. The woman was readmitted to the maternity unit on the third postpartum day (70 hours after delivery). She was drowsy, pale and jaundiced. Blood pressure was 70/50mmHg, pulse 130/min, temperature 37 °C. Investigations revealed impaired renal and liver functions and disseminated intravascular coagulation (DIC). Haemoglobin was 8.4 g/dL, platelets 37 x 109/L, urea 20 mmol/L, creatinine 415 1umol/L, bilirubin 138 ,umol/L and kaolin cephalin clotting time 61 s. Blood gases showed acidosis. Septic shock with multiple organ failure was diagnosed, treatment was started with benzylpenicillin, flucloxacillin, gentamicin, metronidazole and intravenous fluids, and she was transferred to the high dependency unit. She was transfused with packed red blood cells, fresh frozen plasma and platelets. There she continued to deteriorate, with severe DIC and features of adult respiratory distress syndrome necessitating ventilation. She was transferred to the intensive care unit where further fresh frozen plasma, platelets and packed red blood cells were transfused. The high vaginal swab and blood culture showed growth of group A beta-haemolytic streptococci. On the sixth postpartum day her condition was still worsening and ultrasound scan showed loculated fluid in the pelvis; therefore a laparotomy was thought necessary. At operation there was about one litre of straw-coloured free fluid in the abdominal cavity, and a 4 x 3 cm necrotic patch was seen on the posterior wall of the uterus. Total abdominal hysterectomy was performed uneventfully and postoperative care was continued in the intensive care unit with gradual improvement of her condition over twelve days. Histologically the uterus showed features of acute necrotizing inflammation with thrombophlebitis in myometrial venules. On the sixteenth postpartum day the patient expressed bizarre thoughts and a psychiatrist diagnosed puerperal affective psychosis. As her physical condition had improved sufficiently, she was transferred to the psychiatric ward and three weeks later she was discharged home in satisfactory condition.