Uterine Dehiscence and Abdominal Wall Necrotizing Fasciitis Following Cesarean Section: A Case Report

BACKGROUND Necrotizing soft tissue infections, known as NSTIs, are well known for being acute, aggressive, and rapidly progressive and can cause systemic sepsis, toxic shock syndrome, and multi-organ failure. Clinical presentation varies from tense edematous skin to blisters and necrosis. The correlation between necrotizing fasciitis and cesarean section has been reported to be 1.8 per 1000 women, but its pathogenesis is not fully understood. CASE REPORT We present a case of a 28-year-old woman who underwent emergency cesarean section and presented 1 week later with septic shock and profuse foul-smelling wound discharge. IV antibiotic therapy began with meropenem, vancomycin, and clindamycin for suspected necrotizing fasciitis. Upon exploration, we found complete uterine dehiscence, necrotizing fasciitis of the anterior lower abdominal wall, and cutaneous fistulation. Emergency hysterectomy, extensive wound debridement, and vacuum-assisted closure (VAC) were performed. Tissue culture revealed methicillin-resistant Staphylococcus aureus (MRSA) and Enterococcus faecalis. Multiple VAC dressing changes and debridement of the abdominal wall were performed. The histopathology results confirmed a diagnosis of acute suppurative endometritis with bilateral acute salpingitis. The patient was discharged 22 days after exploratory laparotomy. CONCLUSIONS Endomyometritis can lead to severe complications, including uterine dehiscence, with infection rapidly spreading along fascial planes and into subcutaneous tissue, ultimately resulting in necrotizing fasciitis, which is a rare but potentially fatal condition. Management in this case required extensive surgical debridement and emergency postpartum hysterectomy, in addition to broad-spectrum antimicrobial therapy. This case of an uncommon yet life-threatening complication strongly reinforces the critical importance of early diagnosis and prompt management of postpartum endometritis to reduce maternal morbidity and mortality.