POSTPARTUM NECROTIZING FASCIITIS LYNCH E T AL. Fig. I. Marked vulvar edema with early tissue necrosis on medial aspect of the left thigh. Some bronze discoloration is noted involving the left perineum. Fig. 2. Debrided wound. The operator’s fingers are within the rectum demonstrating the original proctoepisiotomy. extensive surgery, radiation therapy, or chemo- therapy. ,6 Obstetrical trauma was the only risk factor for necrotizing fasciitis in our patient. Necrotizing fasciitis is typically described as deep pain out of proportion to clinical findings associated with su- perficial paresthesia over the involved area. Patho- physiologically, this entity is believed to first irri- tate and then destroy nerve fibers. Early clinical signs include local edema, induration, skin discol- oration, and hypoaesthesia. As with our patient, su- perficial skin changes may be minimal and thus obscure the diagnosis. Despite this innocuous ap- pearance, the disease constantly progresses to in- volve deeper tissue levels, specifically to the level of the fascia. Fascial involvement with nerve com- promise results in rapid progression of analgesia. In general, this syndrome is caused by a poly- microbial infection which may or may not include Clostridium. Organisms that have been associated with necrotizing fasciitis following a vaginal deliv- ery include Streptococcus, Escherichia coli, Klebsiella, Pseudomonas aeruginosa, Proteus, Bacteroides fragilis, Peptostreptococcus, Peptococcus, group A beta hemo- lytic Streptococcus, group B beta hemolytic Strepto- coccus, and Staphylococcus aureus. 1,7-9 Early aggressive surgical debridement is the mainstay of therapy for this disease. Stephenson et al. 9 reviewed the records of 29 non-pregnant pa- tients with necrotizing fasciitis of the vulva and INFECTIOUS DISEASES IN OBSTETRICS AND GYNECOLOGY 343