Severe hyperthermia following oral misoprostol in the immediate postpartum period

cesarean delivery at term, she developed endometritis and septic thrombophlebitis, requiring prolonged treatment. She presented in 1996 with twins at 17 weeks’ gestation following donor egg IVF, complaining of vaginal bleeding and lowgrade fever for 1 week. There was no history of premature rupture of membranes. The uterus was soft and nontender. There was no abnormal vaginal discharge. Ultrasound examination revealed a dichorionic, diamniotic twin gestation with normal amniotic fluid volume and normal fetal activities. The upper twin had scalp and nuchal edema as well as echogenic bowel, prompting amniocentesis. The amniotic fluid obtained was cloudy, and Gram stains revealed 4+ budding yeast. No bacteria or polymorphoneuclear cells were observed. A clinical diagnosis of fungal chorioamnionitis was made. Blood cultures were obtained, and intravenous amphotericin and broad-spectrum antibiotics were started. Labor was induced, and she delivered two stillborn fetuses vaginally. Maternal blood cultures, placenta, and tissue from both fetuses grew fungal organisms identified as C /usita71inr. She received a 3-week course of intravenous amphotericin. Both fetuses had normal karyotypes. Her other laboratory investigations were notable for a normal white blood cell count, despite her spiking temperature. Human immunodeficiency virus screening was negative.

tinal, respiratory, and urinary tracts and on the skin of such patients.’ C lusitaniae commonly is resistant to amphotericin, and septicemia carries a high mortality. No case of C lusitaniae chorioamnionitis was found in MEDLINE and PaperChase searches; however, neonatal infection has been noted in premature infants3r4 It is unclear whether these infections were acquired in utero or during the neonatal period. Immunodepression precedes and persists for years after bone marrow transplantation, and the present case suggests that pregnancy in such patients may be a risk of infection. A registry of these patients may help allow risk and outcome assessment.

References 1. Rio B, Letur-Konirsch Ziegler D, Pelissier donated myeloid 2. Wingard pathogens 3. Sanchez

H, Ajchenbaum-Cymbalista C, et al. Full-term pregnancy

the newborn:

Case report Dis J 1992;11:878-80.

Systemic fungal infection is rare in patients with intact immune capacity. Fungal infections complicating pregnancy involve Candidaalbicansmost commonly. Predisposing risk factors include retained intrauterine contraceptive devices and antibiotic use after premature rupture of membranes. C lusitaniaeis a relatively common pathogen causing fungemia in bone marrow transplant recipients and has been found in the gastrointes-

SEVERE HYPERTHERMIA ORAL

MISOPROSTOL

IMMEDIATE

FOLLOWING IN THE

POSTPARTUM

PERIOD

Yap Seng Chong, MMed, MRACOG, Selina Chua, MMed, MRCOG, FAMS, and Sabaratnam Arulkumaran, DCH, LRCP, MRCS, FRCS (Ed), FRCOG, FAMS, MD, PhD

Misoprostol administered

(Cytotec; Searle, Chicago, IL) is an orallyprostaglandin E, analogue prescribed

From the Dizlisim of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, National Unizjersity of Singapore, Singapore.

VOL.

90, NO.

4, PART

2, OCTOBER

1997

F, De from

oocytes in a 36year old woman allografted for chronic leukemia. Bone Marrow Transplant lYY4;13:487-8. JR. Importance of candida species other than C. &IC~IIS as in oncology patients. Clin Infect Dis 1995;20:115-25. I’J, Cooper BH. Coulli& I~ts/tnuia~v Sepsis and meningitis in

a neonate. Pediatr Infect Dis J 1987;6:758-9. 4. Yinnon AM, Woodin KA, Powell KR. Candida

Comment

F, Bauduer with embryos

and review

Iusltnru~~r

of the literature.

infection

Pediatr

in

Infect

Recrizvd April 3, 1997. Received in vezkrd forfn Ma!/ 13, 1997. Accqhd May 30, 1997. Copyright Gynecologists.

0

1997 by Published

The American by Elsevier

College of Obstetricians Science Inc.

and

for preventing nonsteroidal anti-inflammatory druginduced gastric ulcers. Because of its uterotonic action, it also has been used orally for inducing abortions and has been suggested for use in the third stage of labor. We observed a woman who developed severe hyperthermia after oral misoprostol800 pg given as prophylaxis for postpartum hemorrhage. Case A previously healthy 20-year-old woman, gravida two, para one, who delivered normally at 41 weeks’ gestation after an uneventful antenatal and intrapartum period was given oral misoprostol800 pg for prophylaxis against postpartum haemorrhage as part of a clinical trial. She received no other medication. Thirteen minutes after receiving misoprostol, the woman complained of chills and rigors. Her axillary temperature was 36.8C and her pulse and blood pressure were

0029.7844/97/$17,00 PII SOO29-7844(97)00275-S

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normal. She was warmed with blankets but continued to complain of chills despite a normal axillary temperature. Ninety minutes later, she became restless and disoriented and had a rectal temperature of 41.9C and a pulse of 180 beats per minute. Her blood pressure was normal. Cooling was started immediately by sponging her with ice water and evaporating the water with fans. Her core temperature, monitored continuously with a rectal probe, remained above 40C 1 hour after the start of treatment. A nasogastric tube was inserted and ice saline lavage was instituted. After 30 minutes of lavage, her core temperature was brought down to 38.9C. Cold sponging was continued until her core temperature reached 37.3C 3 hours and 40 minutes after the commencement of treatment. Thereafter, she was afebrilr and asymptomatic. Her serum creatinine phosphokinase level reached a peak of 4715 IU/L (normal range: 60-375) on the first postnatal day before returning to normal. There was no myoglobinuria. Other studies were essentially normal. The woman recovered without any deleterious effects and was discharged on the third postnatal day.

CUmlnent There has been a recent surge of interest in misoprostol because of its uterotonic effect and its potential applications in the field of obstetrics and gynecology. We are investigating the use of oral misoprostol in the active management of the third stage of labor. Our initial results with oral doses of 200-800 pg have been encouraging, with only a few women experiencing mild pyrexia (less than 38.5C) and shivering, until this incident. As single oral doses of $00 pg of misoprostol have been used for inducing abortions in many women with no significant adverse effects, the severity of this

NECROTIZING

FASCIITIS

DELAYED

SECONDARY

CLOSURE

AND

Scott Poehlmann,

AFTER

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References 1. El-Refaey H, Rajasekar D, Abdalla M, Calder L, Templeton A. Induction of abortion with mifepristone (RU 486) and oral or vaginal misoprostol. N Engl J Med 1995;332:983-7. 2. El-Refaey H, Templeton A. Early abortion induction by a combination of mifepristone and oral misoprostol: A comparison between two dose regimens of misoprostol and their effect on blood pressure. Br ] Obstet Gynaecol 1994;101.792-6. 3. Bond GR, Van Zee A. Overdosage of misoprostol in pregnancy. Am J Obstet Gynecol lYY4;171:561-2 4. Graber DJ, Meier KH. Acute misoprostol toxicity. Ann Emerg Med lYY1;20:549-51.

Copyright 0 1997 by The American College of ObstetrIclam Gynecologists. Published by Elsevier Science Inc.

element of treatment ment. ‘,2

is complete

surgical

and

debride-

WOUND

CESAREAN

DELIVERY

MD, rind Kalli Varaklis, MD

Necrotizing fasciitis is a rare, rapidly progressive, and potentially fatal infection. Mortality rates exceed 30%’ It has been reported after many surgical and obstetric procedures, ‘J including cesarean delivery.’ The critical

704

patient’s hyperthermia was unexpected.‘,’ Only two cases of misoprostol toxicity have been reported in the literature.3’4 Both involved doses (3 mg and 6 mg, respectively) greatly exceeding the recommended daily dosage (400-800 pg). These patients developed hyperthermia as a toxic effect of misoprostol. However, no reports of severe hyperthermia have ever been made with usual doses. This case illustrates that routinely prescribed maximal doses of misoprostol may cause severe hyperthermia in the immediate postpartum period. Clinicians are advised to watch for this rare but alarming complication.

Case A 27-year-old multipara presented in spontaneous labor at term after an uncomplicated pregnancy. After spontaneous rupture of membranes, repetitive late fetal heart rate decelerations appeared and the patient underwent cesarean delivery through a Pfannenstiel incision. A single prophylactic dose of ampicillin-sulbactam 1.5 g was given. The hysterotomy was closed with #O polyglactin 910 Wicryl; Ethicon, Somerville, NJ). The fascia was closed with the same material. The skin was closed with stainless steel staples (Ethicon). The postoperative course was uncomplicated until day 3, when serosanguineous drainage appeared at the incision. The skin staples were removed, and 15 mL of fibrinous debris was removed from the wound. The fascia was found to be intact. The wound was irrigated and packed with sterile dressings. Dressings