Hindawi Publishing Corporation Infectious Diseases in Obstetrics and Gynecology Volume 2006, Article ID 51931, Pages 1–4 DOI 10.1155/IDOG/2006/51931 Obstetrics Case Report Severe Life Threatening Maxillofacial Infection in Pregnancy Presented as Ludwig’s Angina Shelly Abramowicz,1 Jacques S. Abramowicz,2 and M. Franklin Dolwick1 1 Department of Oral and Maxillofacial Surgery, University of Florida School of Dentistry, Gainesville, FL 32610, USA 2 Department of Obstetrics and Gynecology, Rush University, Chicago, IL 60612, USA Received 5 January 2006; Revised 27 April 2006; Accepted 27 April 2006 Background. Ludwig’s angina is a rapidly spreading cellulitis that may produce upper airway obstruction often leading to death. There is very little published information regarding this condition in the pregnant patient. Case. A 24-year old black female was admitted at 26 weeks gestation with tooth pain, submandibular swelling, severe trismus, and dysphagea, consistent with Ludwig’s angina. Her treatment included emergent tracheostomy, incision and drainage of associated spaces, teeth extraction, and antibiotic therapy. Conclusions. During a life threatening infectious situation such as the one described, risks of maternal and fetal morbidity include both septicemia and asphyxia. Furthermore, the healthcare provider must consider the risks that the condition and the possible treatments may cause the mother and her unborn child. Copyright © 2006 Shelly Abramowicz et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. INTRODUCTION Ludwig’s angina, named after the German physician who de- scribed the condition for the ﬁrst time in 1948, is a rapidly spreading cellulitis that may produce upper airway obstruc- tion often leading to death. The most common cause of Lud- wig’s angina is an odontogenic infection, from one or more grossly decayed, infected teeth, and is usually as a result of na- tive oral streptococci or a mixed aerobic-anaerobic oral ﬂora [1]. Additional possible etiological factors include sialadeni- tis, compound mandibular fractures, or puncture wounds of the ﬂoor of the mouth [1]. While this is a life threatening infection, an extensive literature search did not yield much published information regarding this condition in the preg- nant patient. CASE REPORT A 24-year old black female, G4P3, at 29 weeks gestation, was presented to a local hospital complaining of facial swelling (Figure 1(a)). The patient’s only signiﬁcant medical history included history of anemia and sickle cell trait. She described that her pregnancy had been proceeding without diﬃculty, except for a three-day history of lower left quadrant tooth pain, and a one-day history of fever and chills. On pre- sentation, her vital signs were the following: temperature 38.5◦C, blood pressure 115/44, pulse 118/min, respiratory rate 18/min, oxygen saturation on room air 96%, and white cell count of 16800/µL. Her clinical presentation included large soft tissue swelling under her mandible, extending bi- laterally to the angles of the mandible and inferiorly approx- imately down to her hyoid bone. Because of her severe im- pending airway deterioration, she was ﬂown by helicopter to a tertiary medical center for deﬁnitive care. In the Emergency Room of the University of Florida Shands Hospital, the diag- nosis of Ludwig’s angina was made. It was diﬃcult to per- form an adequate oral exam secondary to pain, swelling, and severe trismus (Figure 1(b)) which allowed her to open her mouth to only 15 mm (average range 40–45 mm). The pa- tient was having diﬃculty maintaining her own salivary se- cretions because of dysphagea but denied dyspnea. Since in similar situations patients can desaturate very quickly, even though her oxygen saturation was recorded to be 96% on room air, she was given supplemental oxygen and a pulse oxymeter was placed on her right index ﬁnger because of possible impending quick respiratory diﬃculties. Of note, al- though not used, an emergent cricothyrotomy kit was avail- able at the patient’s bedside at all times. The Department of Oral and Maxillofacial Surgery (OMFS) formally consulted the Departments of Obstetrics and Gynecology (Ob/Gyn) and Anesthesiology. Understanding that in administering medications and/or undergoing any surgical treatment in pregnancy, one must consider the risks and the beneﬁts both to the mother and the unborn, it was determined that the