Septic pelvic thrombophlebitis

Septic pelvic thrombophlebitis (SPT) is a postpartum complication which consists of a persistent postpartum fever that is not responsive to broad-spectrum antibiotics in which pelvic infection leads to infection of the vein wall and intimal damage leading to thrombogenesis in the ovarian veins (left or right, although right is more common due to dextroversion of the uterus). The thrombus is then invaded by microorganisms. Ascending infections cause 99% of postpartum SPT.

Septic pelvis thrombophlembitis is a cause of post-operative fever from untreated postpartum endometritis. After 48 hours of uncured postpartum endometritis (notably 48 hours of fever that is unaffected by antibiotics), one could diagnose SPT until proven otherwise (with pelvic radiography). Imaging studies can be helpful in patient refractory to broad-spectrum parenteral antibiotics to look for an abscess, retained products, or septic pelvic thrombophlebitis.[1]

Septic pelvic thrombophlembitis (SPT) occurs most often in bedridden patients after giving birth, or after having undergone a Caesarean section. The blood often pools in the pelvis as this is the lowest part of the patient while laying in a hospital bed.

Risk factors

The main risk factor of developing SPT is post-partum endometritis, which in turn is most commonly caused by a Caesarean section. Other risk factors for developing endometritis, and subsequently SPT include:

  • Bacterial vaginosis
  • Manual removal of the placenta
  • Prolonged labor
  • Large amount of meconium in amniotic fluid
  • Multiple cervical examinations

Symptoms

The symptoms of septic pelvic thrombophlebitis are similar to those of endometritis. Clinical signs include:

  • fever
  • pain on palpation of uterus
  • midline lower abdominal pain
  • malodorous lochia (vaginal discharge)
  • tachycardia

Laboratory results

Septic pelvic thrombophlebitis will have elevated CRP and WBC (evidence of inflammation).

Diagnosis

Since septic pelvic thrombophlebitis is a diagnosis of exclusion, other causes of postpartum fever must be considered, such as infection of cesarean section wounds, episiotomy or laceration sites as well as endometritis, endomyometritis, mastitis, and physiologic breast engorgement.[2]

Treatment

With low uterine size retention, treat endometritis and SPT with ice packs, broad-spectrum antibiotics and analgesics.

With high uterine size retention, treat the thrombophlebitis with D&C aspiration under ultrasonogram because of increased risk of placental tissue retention in the myometrium.

References
  1. Callaghan, Tamara. Blueprint Obstetrics and Gynecology.
  2. Callaghan, Tamara (2013). Blueprints Obstetrics and Gynecology. Baltimore: Lippincott Williams & Wilkins. p. 237. ISBN 978-1-4511-1702-8.


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