Case Report

A 49 year old, gravida 3 para 2, perimenopausal female with a positive urine pregnancy test presented to the hospital with heavy vaginal bleeding. She was unaware that she was pregnant.

Obstetrical history consisted of 2 vaginal deliveries. Her medical history was significant for hypertension, diagnosed 1 month ago by her internist, for which she was taking metoprolol. Her remaining histories were unremarkable.

On the initial examination, the woman was afebrile and hemodynamically stable; however, she was experiencing active vaginal bleeding with the passage of grape-like tissue. Bimanual examination revealed a 20 week–sized uterus, and the cervix was 3 cm dilated. Her beta human chorionic gonadotropin was 77,577. An ultrasound demonstrated an enlarged uterus containing irregular cystic products within the endometrial cavity. A suction dilation and curettage was performed, which was uncomplicated. A repeat ultrasound confirmed an empty uterine cavity.

Postoperatively she began having recurrent fevers (Tmax 40.5°C). Blood and urine cultures were obtained, and she was started on intravenous piperacillin/tazobactam and metronidazole for presumed endometritis. A chest x-ray was also obtained and found to be normal. She had only mild fundal tenderness with minimal vaginal bleeding. She demonstrated no other signs or symptoms of infection. On postoperative day 1, a computed tomography of the abdomen and pelvis was performed because of persistent fevers despite broad-spectrum antibiotics. The scan revealed a fibroid uterus with a low attenuation area within the myometrium containing a focus of gas; free intraperitoneal fluid was also noted.

The patient was counseled on the findings and underwent a total abdominal hysterectomy, bilateral salpingectomy, and collection of pelvic washings later that evening. Intraoperative findings included copious purulent ascites; an enlarged fibroid uterus without gross evidence of uterine perforation; and normal-appearing bowel, fallopian tubes, and ovaries. She remained afebrile after the surgery. Two sets of blood cultures grew C perfringens . She was started on a carbapenem for monotherapy following infectious disease consultation.

Pathology from the dilation and curettage revealed a hydatidiform mole. Pathology from the hysterectomy showed acute endomyometritis with an intramural abscess and almost full-thickness involvement of the myometrium ( Figure ). There was also residual syncytial trophobastic proliferation involving the superficial myometrium. The patient completed a 14 day course of antibiotics and is currently doing well.

Acute endomyometritis with an intramural abscess

This is a pathology image from the hysterectomy specimen demonstrating infiltration of polymorphonuclear leukocytes within the myometrium, which is indicative of acute endomyometritis.

Adams. Clostridial sepsis after a molar pregnancy. Am J Obstet Gynecol 2014 .

Comment

C perfringens (formerly known as Clostridium welchii ) is a Gram-positive, anaerobic, spore-forming rod found in soil, the gastrointestinal tract, and in the normal genital tract flora of about 1-10% of healthy females with increased rates reported among postabortal patients. Ramsay in 1949 documented the organism in the genital tract of 190 of 965 women presenting with postabortal sepsis (19.7%); most cases presented with mild disease.

Without evidence of infection, the organism usually has no clinical significance. However, C perfringens may cause major morbidity through the production of many different exotoxins. The alpha toxin is the most common and most lethal because it destroys lecithin in human cell membranes, which can lead to severe hemolysis, hemoglobinuria, jaundice, renal failure, or shock. If left untreated, clostridial sepsis may be fatal.

Most case reports describing postabortal clostridial sepsis were published prior to 1973; illegal abortions were the leading cause of ascending clostridial infections. However, rare cases still occur and have been recently documented after medical and spontaneous abortions with C perfringens and C sordelli identified as the major culprits. We identified only 1 other case report of C perfringens sepsis immediately following a molar pregnancy. The report described a 51 year old who died days after extrusion of a molar pregnancy. Postmortem autopsy revealed an invasive molar pregnancy associated with full-thickness uterine necrosis.

Antibiotic therapy is the first-line treatment for clostridial endometritis and sepsis, but surgical treatment (ie, hysterectomy) is debated. This case report suggests that there should be a lower threshold to surgically manage suspected clostridial infection in the presence of a molar pregnancy, especially in the presence of imaging showing gas within the uterus. As Ramsay (1949) described, most patients with clostridial infection will have mild disease, but molar pregnancy may be an identifiable risk factor to predict severe disease. Prompt recognition and treatment will increase patient survival.