Postpartum Peripheral Symmetrical Gangrene: A Case Report
A 25-year old P1L1 woman presented to the emergency two day post partum with bluish discoloration of hands and feet. Pregnancy had been unsupervised but she had received tetanus immunization. Delivery had been conducted at home by an unskilled midwife and she had been administered a single intramuscular injection of ergot postpartum. There was no prior history of intermittent claudication, cold or heat intolerance, tobacco smoking, collagen vascular disease or similar family history. Vitals were stable, all peripheral pulses were palpable. Extremities were cold, swollen with purple discoloration of both hands extending to wrist joints. Similar changes were seen in feet extending to mid calf. Both hands and feet had blue-black nail beds. On per abdominal examination a well contracted uterus corresponding to 20 weeks gravid size was felt. On local examination, a complete perineal tear with black gangrenous margins and excoriation was present; similar patchy changes were seen over lower abdomen and the mons pubis. Internal examination was normal. A differential diagnosis of early gangrene was made.\nOn investigation her Hb was 9 g/dl, total leukocyte count (TLC) 18,000/mm, platelet count 250.000/mm; liver function tests: (LFT) serum bilirubin (t) 8 mg/dl, ALT/AST 28/25 and kidney function tests: (KFT) serum creatinine 0.6 mg/dl and blood urea 11 mg/dl. On sepsis work-up, her blood and urine cultures were sterile and culture taken from perineal wound had no pathogenic growth. The patient's ELISA for HIV was negative and VDRL was non-reactive. On coagulation screen her PT was 12 s and PTTK 32 s. On transvaginal ultrasonography uterine cavity was empty. Patient was further investigated for all possible causes of peripheral gangrene which included antiphospholipid antibody testing (ACL Ig G and Ig M and LAC which all were negative), lipid profile (Serum chol sterol 140 mgs/dl, Serum TG 110 mg/dl, HDL-chol 40 mg/dl), antinuclear anti-body and rheumatoid factors were negative too. Color Doppler of lower limb vessels was done which indicated normal flow.\nSurgical consultation was sought and perineal wound debrided. Therapy in the form of broad spectrum antibiotics, low molecular weight dextran and a hemorheologic agent, pentoxyphylline, was started. By day five, improvement was noted with subsidence of swelling and sharp demarcation of margins (). Patient lost most nails of both hands and feet by day 28, gangrenous scabs were shed from tips of fingers while the toes still had scabs (). Patient was discharged on pentoxyphylline, with advice on the care of hands and feet. By six weeks there was regrowth of nails but scabs on feet remained. By eight weeks hands, feet and mons pubis appeared normal.