Intended for healthcare professionals

Endgames Case Review

A woman with spreading erythema after caesarean section

BMJ 2020; 368 doi: (Published 27 February 2020) Cite this as: BMJ 2020;368:m445
  1. Oscar Johnson, vascular research fellow,
  2. Anna Louise Pouncey, plastic surgery CT1,
  3. Sonya Gardiner, plastic SPR,
  4. David Ross, plastic surgery consultant
  1. Guy’s and St Thomas’ Hospital, London, UK
  1. Correspondence to A Pouncey anna-louise.pouncey{at}

A 26 year old woman presented to the emergency department six days after having a caesarean section with an area of spreading erythema extending from her wound site over the infra-umbilical abdomen (fig 1). She had a body mass index of 30 and gestational diabetes, and during labour had experienced premature rupture of membranes. She reported that the area of erythema had doubled in size over the preceding 12 hours and an area of dark bruising had appeared over the last four hours. The wound had become increasingly painful, despite regular analgesia, with a pain score of 9/10, and she felt generally unwell. Her temperature was 39°C, heart rate 135 beats/min, and respiratory rate 27 breaths/min. Results of relevant blood tests are shown in table 1.

Fig 1
Fig 1

Photograph of abdomen at presentation

Table 1

Relevant bloods results

View this table:


  1. What is the most likely diagnosis?

  2. How would you manage this condition?

  3. What is the prognosis of this condition?


1. What is the most likely diagnosis?

Abdominal wall necrotising fasciitis.

Ecchymosis (a result of tissue necrosis and capillary breakdown), rapidly spreading cellulitis, and pain out of proportion are highly suggestive1 of necrotising fasciitis, which is a surgical emergency.

The spectrum of necrotising soft tissue infections ranges from mild pyoderma to necrotising fasciitis. Necrotising fasciitis is a fulminant, progressive bacterial infection which spreads along the fascial layers, causing subcutaneous tissue necrosis. It is characterised by its rapid progression and extreme inflammatory response; it can rapidly progress to shock and end organ damage.

Recent surgery is a risk factor. Other associated factors include anaemia, diabetes, obesity, malnourishment, hypertension, and immunosuppression.1

Necrotising fasciitis occurs in 1.8 per 1000 patients undergoing caesarean section,2 and usually appears within the first 5-17 days.3

2. How would you manage this condition?

Immediate broad spectrum intravenous antibiotics and intensive haemodynamic support,4 followed by surgical debridement with excision extending beyond the margins of necrotic tissue.

3. What is the prognosis of this condition?

Mortality in necrotising fasciitis ranges from 8% to 76%.5 Appropriate treatment has been associated with a decrease in mortality (10%-40%)6; however, mortality is higher if there is shock and end organ damage (50% to 70%).7

Learning points

Consider necrotising fasciitis when moderate to severe cellulitis is present at any location on the body, especially if the patient has had recent surgery or trauma, or has anaemia, diabetes, obesity, immunosuppression, malnutrition, hypertension, or peripheral vascular disease.

Rapidly progressive cellulitis and ecchymosis with pain out of proportion to clinical findings are late signs.

Patient outcome

The patient underwent emergency surgical resection of the necrotic tissue with 24 hours high dependency care postoperatively. After surgery she was able to continue breastfeeding her baby with temporary use of a breast pump. She was discharged 14 days later.



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