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Question #156 (9/5/2026)

National Association of Medical Examiners 
Educational Activities Committee

Submitted by Dr. Morgan Andrade (PGY-2 Wake Forest Baptist Hospital) and Dr. Patrick Lantz (Medical Examiner, Atrium Health Wake Forest Baptist Regional Autopsy Center) both from Winston-Salem, NC, USA
1.A 38-year-old woman presented to the emergency department with abdominal pain and vaginal bleeding. Transvaginal ultrasound demonstrated a 14-week intrauterine fetus with no fetal cardiac activity. Subsequent dilation and curettage yielded foul-smelling necrotic tissue. During the procedure, she became hypotensive and required multiple pressors. Post-procedural ultrasound demonstrated free fluid around the uterus, concerning for a uterine perforation so an exploratory laparotomy was performed. While transitioning anesthetic equipment for the laparotomy, the patient coded. After achieving ROSC, the exploratory laparotomy found the uterus to be dark purple and extremely soft. The decision was made to forego hysterectomy as no uterine perforation was identified. Following the procedure, the patient rapidly progressed to septic shock with multiorgan failure and died later that same day.



At autopsy, the uterus, fallopian tubes, and ovaries were enlarged, soft, boggy, and necrotic with extensive gas production within the myometrium, as shown in the photos. Histology showed bacteria throughout the uterine, fetal, and placental tissue.



Which organism is the most likely cause?