University of Wisconsin–Madison Medical College of Wisconsin

Peripartum Uterine Clostridial Myonecrosis: A Report of Two Fatal Cases

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.

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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.

Author Affiliations: Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health (UWSMPH), Madison, Wisconsin (Jacques, Kelly, Wagar, Rhoades, Cutler); Department of Maternal Fetal Medicine, Women and Infants Hospital, Providence Rhode Island (Soehl); Department of Bacteriology, University of Wisconsin-Madison, Madison, Wisconsin (Cowley); Microbiology Doctoral Training Program, UW-Madison, Madison, Wisconsin (Cowley); Madison Anesthesiology Consultants, Madison, Wisconsin (Pryde); Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington (Eschenbach).
Corresponding Author: Laura Jacques, MD, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, McConnell Hall, 4th Floor, 1010 Mound St, Madison, WI 53715, email; ORCID ID 0000-0003-2343-8358
Funding/Support: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Elise Cowley is a Medical Science Training Program student and was supported by a National Library of Medicine training grant to the Computation and Informatics in Biology and Medicine Training Program (NLM 5T15LM007359) at UW-Madison and in part by MSTP grant T32GM140935.
Financial Disclosures: None declared.
Acknowledgements: The authors thank Amanda Wildenberg and Cassidy Slinger for administrative support and Michael Fritsch, MD, Department of Pathology, UW-Madison, for the photos provided as figures.
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