POSTPAR TUM NECR0TIZING FAS(,’11TIS found that a delay in diagnosis of >48 h resulted in 73% mortality. In our case, there was a 5-day delay before surgery was performed at the tertiary care center. Once surgical debridement is performed on these patients, the postoperative management is often complicated by hypoalbuminemia with asso- ciated low oncotic pressure and increased capillary permeability. These patients should be managed by surgeons and critical care teams experienced in the care of the critically ill patient. 1,11 Necrotizing fasciitis is a rare complication in vaginal delivery. It must be considered in the dif- ferential diagnosis of the postpartum patient pre- senting with severe vulvar pain and erythema. Our patient exemplifies the obscure presentation of the disease with seemingly minimal skin changes. This differential is paramount especially when the pa- tient presents with pain out of proportion to the clinical findings. Once necrotizing fasciitis is enter- tained as a potential diagnosis, immediate and ag- gressive diagnostic therapy must be undertaken. The first line therapy is aggressive surgical de- bridement with concomitant broad-spectrum intra- venous antibiotic therapy. As illustrated by our case, any delay in diagnosis and delivering treat- ment will likely result in severe morbidity or mor- tality. 9 LYNCH E T AL. REFERENCES 1. Sutton GP, Smirz LR, Clark DH, Bennett JE: Group B streptococcal necrotizing fasciitis arising from an episi- otomy. Obstet Gynecol 66:733-736, 1985. 2. Schneider GT: A postpartum emergency--Necrotizing fasciitis. Contemp OB/GYN 109-114, February 1988. 3. Meleny FL: A Treatise on Surgical Disease. Oxford: Oxford University Press, p 12, 1948. 4. Nolan TE, King LA, Smith EP, Gallup DC: Necrotizing surgical infection and necrotizing fasciitis in obstetric and gynecologic patients. South Med J 86:1363-1367, 1993. 5. Hoffman MS, Turnquest D: Necrotizing fasciitis of the vulva during chemotherapy. Obstet Gynecol 74:483- 484, 1989. 6. Addison WA, Livengood CH, Hill GB, Sutton GP, For- tier KJ: Necrotizing fasciitis of vulvar origin in diabetic patients. Obstet Gynecol 63:473-478, 1984. 7. Ammari NN, Hasweh YG, Hassan AA, Karyoute S: Post- partum necrotizing fasciitis. Case report. Br J Obstet Gynaecol 93:82-83, 1986. 8. Piper JM, West P: Necrotizing fasciitis following post- partum tubal ligation. A case report and review of the literature. Arch Gynecol Obstet 256:35-38, 1995. 9. Stephensen H, Dotters DJ, Katz V, Droegemueller W: Necrotizing fasciitis of the vulva. Am j Obstet Gynecol 166:1324-1327, 1992. 10. Stamenkovic I, Lew PD: Early recognition of poten- tially fatal necrotizing fasciitis. The use of frozen- section biopsy. N Engl j Med 310:1689-1693, 1984. 11. Salvino C, Harford FJ, Dobrin PB: Necrotizing infec- tions of the perineum. South Med J 86:908-911, 1993. 344 INFECTIOUS DISEASES IN OBSTETRICS AND GYNECOLOGY