(780) Streptococcal Toxic Shock Syndrome From Puerperal Endometritis

Introduction: Pregnancy is an immunomodulated state with a significantly increased risk for invasive Group A Streptococcus (GAS) (Streptococcus pyogenes) that can lead to septic shock and multiorgan failure when compared to a non-pregnant population. GAS can be a lethal bacterial pathogen with a risk for septic shock/Streptococcal Toxic Shock Syndrome (TSS) and multiorgan failure. Invasive GAS infection has a fatality of 15-20% in non-pregnant people and increases to 40-60% leading to septic shock.1 60% of all maternal infections occur within the intrapartum and postnatal period, with 60% accounting for severely complicated infections2 with a fatality of 2% in pregnant women.1 This is a rare case of spontaneous vaginal birth complicated by Streptococcal TSS that ultimately led to hysterectomy.

Description: 30-year-old woman at 40+ weeks had a precipitous vaginal delivery at home and then went to the emergency room for post-delivery evaluation. After initial evaluation, she returned to the hospital in septic shock. Workup showed Streptococcus pyogenes bacteremia, pulmonary embolism and and gas within the myometrium. Antibiotics and intravenous immunoglobin therapy were given without improvement. Eventually, she was sent to a tertiary center for definitive source control, including a hysterectomy.

Discussion: GAS is a facultative gram-positive bacteria that lives in human skin and mucous membranes. It can ascend from the gastrointestinal tract and endometrium. Any state of pregnancy, including the puerperal period and 6-week postpartum period, is considered a highly immunomodulated state, increasing tolerogenic immune cells, including cytokine-producing uNK, ILC2, and Fetal-specific CD8/CD4 T cells.3 Invasive GAS can lead to TSS and multiorgan failure within 48-96 hours. Two most common are endometrium (endomyometritis) and necrotizing soft tissue infection. Just as in any septic shock state, cultures and empiric broad-spectrum antibiotics, including vancomycin, clindamycin, and a beta-lactam, should be initiated without delay. In some cases, intravenous immune globulin is added to manage TSS. Early recognition, including treatment before any confirmatory cultures and source control, is vital to favorable outcomes in the pregnant population.