Laura Jacques, MD; Bridget Kelly, MD; John Soehl, MD; Matthew Wagar, MD; Janine Rhoades, MD; Elise S. Cowley, BS; Peter G. Pryde, MD; Abigail Cutler, MD; David Eschenbach, MD
WMJ. 2024;123(3); published online in advance June 3, 2024.
ABSTRACT
Introduction: Uterine clostridial myonecrosis is a rare infection associated with a high mortality rate. This report presents 2 cases of maternal mortality resulting from peripartum clostridial myonecrosis of the uterus.
Case Presentation: Case 1 is a 30-year-old woman (nullipara) who presented in labor at term with an intra-amniotic infection and fetal demise. She rapidly developed septic shock, and cesarean hysterectomy was performed for a suspected necrotizing uterine infection later identified to be Clostridium septicum. Case 2 is an adolescent who presented in septic shock following first trimester medication abortion and died during emergent exploratory laparotomy; cultures grew Clostridium sordellii. Both patients expired within 18 hours of hospital admission.
Discussion: Given the rapidly progressive course of clostridial infections, maintaining a high index of suspicion is imperative for ensuring timely diagnosis and effective treatment. Prompt recognition of clinical features associated with clostridial myonecrosis – abdominal pain, tachycardia, leukocytosis and hyponatremia – is essential in preventing mortality. The utilization of point-of-care ultrasound may expedite the diagnosis of uterine myonecrosis. When uterine myonecrosis is suspected, immediate initiation of penicillin-based antibiotics, alongside clindamycin, and aggressive surgical intervention including hysterectomy are essential for ensuring survival. Although the decision to perform a hysterectomy can be challenging, especially in cases involving child-bearing-aged patients, it is a vital step to avert a fatal outcome.
Conclusions: By presenting these cases, we aim to raise awareness of this uncommon, but highly lethal infection to expedite diagnosis and treatment to improve patient outcomes.