Necrotizing myometritis following vaginal delivery complicated by retained placenta and uterine artery embolization:...

Necrotizing myometritis (NM) is a rare but life-threatening postpartum infection. Although most reported cases are attributed to Group A Streptococcus (GAS), NM can also arise as a polymicrobial process in the setting of uterine ischemia, particularly after uterine artery embolization (UAE), and this phenotype often follows a slower, more insidious course that may require different diagnostic and therapeutic strategies. We describe NM due to Enterococcus faecium, Klebsiella pneumoniae, and Eggerthella lenta after retained placenta and UAE. In contrast to the fulminant trajectory typical of GAS-associated NM, this case evolved over 48 days with intermittent symptom remission and ultimately required hysterectomy despite multiple courses of antibiotics and repeated curettage. This case highlights the need to broaden empiric antibiotics to include coverage for anaerobes and enterococci, which are frequently resistant to standard postpartum regimens, and indicates that sonographic findings such as myometrial heterogeneity, hypoperfusion, and tissue discontinuity may provide earlier diagnostic clues than clinical signs alone and should prompt early MRI evaluation. Early recognition of these atypical features is critical to avoid diagnostic delay and improve maternal outcomes.