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Septic pelvic thrombophlebitis

INTRODUCTION

Septic pelvic thrombophlebitis was first described in the late 1800s by Von Recklinghausen [1]. He proposed surgical excision as the treatment of choice, although subsequently Trendelenburg described successful management with pelvic vein ligation. Medical therapy has since become the preferred treatment approach.

There are two types of septic pelvic thrombophlebitis (SPT): ovarian vein thrombophlebitis (OVT) and deep septic pelvic thrombophlebitis (DSPT). These two entities share common pathogenic mechanisms and often occur together, but they may differ in their clinical presentations and diagnostic findings.

Patients with OVT usually present with fever and abdominal pain within one week after delivery or surgery, and thrombosis of the right ovarian vein is visualized radiographically in about 20 percent of cases. Patients with DSPT usually present within a few days after delivery or surgery with unlocalized fever that persists despite antibiotics, in the absence of radiographic evidence of thrombosis.

PATHOGENESIS

The physiologic conditions in the setting of septic pelvic thrombophlebitis fulfill Virchow's triad for the pathogenesis of thrombosis (ie, endothelial damage, venous stasis, and hypercoagulability) (see "Overview of the causes of venous thrombosis"):

  • Endothelial damage can occur as a result of intrapartum trauma to vascular structures or as a result of uterine infection. The pathophysiology of SPT was first described in the 1950s in a series of reports describing a cohort of 70 women with fever following obstetric or gynecologic procedures [2-5]. In each case, the diagnosis of SPT was confirmed by exploratory laparotomy, which demonstrated grossly palpable intravenous thrombi and seropurulent fluid. Histopathologic evaluation showed perivascular and intimal inflammatory exudate and frequent microabscesses but rare bacteria.
  • Venous stasis occurs as a result of pregnancy-induced ovarian venous dilatation and low postpartum ovarian venous pressures [6]. These changes can lead to retrograde (left to right) ovarian venous flow, perhaps explaining why OVT is observed more frequently on the right than on the left [7-9].
  • The hypercoagulable state of pregnancy completes Virchow's triad for the pathogenesis of thrombosis [1,6,10,11]. (See "Deep vein thrombosis in pregnancy: Epidemiology, pathogenesis, and diagnosis", section on 'Pathogenesis'.)

            

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Literature review current through: Nov 2014. | This topic last updated: Aug 15, 2013.
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References
Top
  1. Garcia J, Aboujaoude R, Apuzzio J, Alvarez JR. Septic pelvic thrombophlebitis: diagnosis and management. Infect Dis Obstet Gynecol 2006; 2006:15614.
  2. Collins CG. Suppurative pelvic thrombophlebitis. A study of 202 cases in which the disease was treated by ligation of the vena cava and ovarian vein. Am J Obstet Gynecol 1970; 108:681.
  3. COLLINS CG, AYERS WB. Suppurative pelvic thrombophlebitis. III. Surgical technique; a study of 70 patients treated by ligation of the inferior vena cava and ovarian veins. Surgery 1951; 30:319.
  4. COLLINS CG, MacCALLUM EA, NELSON EW, et al. Suppurative pelvic thrombophlebitis. I. Incidence, pathology, and etiology; a study of 70 patients treated by ligation of the inferior vena cava and ovarian vessels. Surgery 1951; 30:298.
  5. COLLINS CG, NELSON EW, COLLINS JH, et al. Suppurative pelvic thrombophlebitis. II. Symptomatology and diagnosis; a study of 70 patients treated by ligation of the inferior vena cava and ovarian veins. Surgery 1951; 30:311.
  6. HODGKINSON CP. Physiology of the ovarian veins during pregnancy. Obstet Gynecol 1953; 1:26.
  7. Chidekel N, Edlundh KO. Transuterine phlebography with particular reference to pelvic varicosities. Acta Radiol Diagn (Stockh) 1968; 7:1.
  8. Munsick RA, Gillanders LA. A review of the syndrome of puerperal ovarian vein thrombophlebitis. Obstet Gynecol Surv 1981; 36:57.
  9. Brown TK, Munsick RA. Puerperal ovarian vein thrombophlebitis: a syndrome. Am J Obstet Gynecol 1971; 109:263.
  10. Dykhuizen RF, Roberts JA. The ovarian vein syndrome. Surg Gynecol Obstet 1970; 130:443.
  11. Lotze EC, Kaufman RH, Kaplan AL. Postpartum ovarian vein thrombophlebitis. Obstet Gynecol Surv 1966; 21:853.
  12. Witlin AG, Sibai BM. Postpartum ovarian vein thrombosis after vaginal delivery: a report of 11 cases. Obstet Gynecol 1995; 85:775.
  13. French RA, Cole C. An "enigmatic" cause of back pain following regional anaesthesia for caesarean section: septic pelvic thrombophlebitis. Anaesth Intensive Care 1999; 27:209.
  14. Josey WE, Staggers SR Jr. Heparin therapy in septic pelvic thrombophlebitis: a study of 46 cases. Am J Obstet Gynecol 1974; 120:228.
  15. Witlin AG, Mercer BM, Sibai BM. Septic pelvic thrombophlebitis or refractory postpartum fever of undetermined etiology. J Matern Fetal Med 1996; 5:355.
  16. SCHULMAN H, ZATUCHNI G. PELVIC THROMBOPHLEBITIS IN THE PUERPERAL AND POSTOPERATIVE GYNECOLOGIC PATIENT. OBSCURE FEVER AS AN INDICATION FOR ANTICOAGULANT THERAPY. Am J Obstet Gynecol 1964; 90:1293.
  17. Dunn LJ, Van Voorhis LW. Enigmatic fever and pelvic thrombophlebitis. Response to anticoagulants. N Engl J Med 1967; 276:265.
  18. Brown CE, Lowe TW, Cunningham FG, Weinreb JC. Puerperal pelvic thrombophlebitis: impact on diagnosis and treatment using x-ray computed tomography and magnetic resonance imaging. Obstet Gynecol 1986; 68:789.
  19. Magee KP, Blanco JD, Graham JM. Massive septic pelvic thrombophlebitis. Obstet Gynecol 1993; 82:662.
  20. Hassen-Khodja R, Gillet JY, Batt M, et al. Thrombophlebitis of the ovarian vein with free-floating thrombus in the inferior vena cava. Ann Vasc Surg 1993; 7:582.
  21. Toland KC, Pelander WM, Mohr SJ. Postpartum ovarian vein thrombosis presenting as ureteral obstruction: a case report and review of the literature. J Urol 1993; 149:1538.
  22. Bahnson RR, Wendel EF, Vogelzang RL. Renal vein thrombosis following puerperal ovarian vein thrombophlebitis. Am J Obstet Gynecol 1985; 152:290.
  23. Brown CE, Stettler RW, Twickler D, Cunningham FG. Puerperal septic pelvic thrombophlebitis: incidence and response to heparin therapy. Am J Obstet Gynecol 1999; 181:143.
  24. Wysokinska EM, Hodge D, McBane RD 2nd. Ovarian vein thrombosis: incidence of recurrent venous thromboembolism and survival. Thromb Haemost 2006; 96:126.
  25. Simons GR, Piwnica-Worms DR, Goldhaber SZ. Ovarian vein thrombosis. Am Heart J 1993; 126:641.
  26. Jacoby WT, Cohan RH, Baker ME, et al. Ovarian vein thrombosis in oncology patients: CT detection and clinical significance. AJR Am J Roentgenol 1990; 155:291.
  27. Derrick FC Jr, Turner WR, House EE, Stresing HA. Incidence of right ovarian vein syndrome in pregnant females. Obstet Gynecol 1970; 35:37.
  28. Gibbs RS, Jones PM, Wilder CJ. Antibiotic therapy of endometritis following cesarean section. Treatment successes and failures. Obstet Gynecol 1978; 52:31.
  29. diZerega G, Yonekura L, Roy S, et al. A comparison of clindamycin-gentamicin and penicillin-gentamicin in the treatment of post-cesarean section endomyometritis. Am J Obstet Gynecol 1979; 134:238.
  30. Rouse DJ, Landon M, Leveno KJ, et al. The Maternal-Fetal Medicine Units cesarean registry: chorioamnionitis at term and its duration-relationship to outcomes. Am J Obstet Gynecol 2004; 191:211.
  31. Isler CM, Rinehart BK, Terrone DA, et al. Septic pelvic thrombophlebitis and preeclampsia are related disorders. Hypertens Pregnancy 2004; 23:121.
  32. Ledger WJ, Peterson EP. The use of heparin in the management of pelvic thrombophlebitis. Surg Gynecol Obstet 1970; 131:1115.
  33. Klima DA, Snyder TE. Postpartum ovarian vein thrombosis. Obstet Gynecol 2008; 111:431.
  34. American College of Obstetricians and Gynecologists. Postpartum hemorrhage. Prevention of deep vein thrombosis and pulmonary embolism. ACOG Practice Bulletin Number 21, 2000.
  35. Twickler DM, Setiawan AT, Evans RS, et al. Imaging of puerperal septic thrombophlebitis: prospective comparison of MR imaging, CT, and sonography. AJR Am J Roentgenol 1997; 169:1039.
  36. Martin B, Mulopulos GP, Bryan PJ. MRI of puerperal ovarian-vein thrombosis (case report). AJR Am J Roentgenol 1986; 147:291.
  37. Ross MG, Mintz MC, Tuomala R, Frigoletto FD Jr. The diagnosis of puerperal ovarian vein thrombophlebitis by computed axial tomography scan. Obstet Gynecol 1983; 62:131.
  38. Angel JL, Knuppel RA. Computed tomography in diagnosis of puerperal ovarian vein thrombosis. Obstet Gynecol 1984; 63:61.
  39. Isada NB, Landy HJ, Larsen JW Jr. Postabortal septic pelvic thrombophlebitis diagnosed with computed tomography. A case report. J Reprod Med 1987; 32:866.
  40. Johnson SC, Esclapes M. Sonography of postpartum ovarian vein thrombophlebitis. J Clin Ultrasound 1998; 26:143.
  41. Magee LA, Redman CW. A case report of acute pelvic thrombophlebitis missed by magnetic resonance imaging of the pelvic veins. Eur J Obstet Gynecol Reprod Biol 2000; 88:203.
  42. Silva PD, Glasser KE, Landercasper J. Laparoscopic diagnosis of puerperal ovarian vein thrombophlebitis. A case report. J Reprod Med 1993; 38:309.
  43. Dunnihoo DR, Gallaspy JW, Wise RB, Otterson WN. Postpartum ovarian vein thrombophlebitis: a review. Obstet Gynecol Surv 1991; 46:415.
  44. Khalil H, Avruch L, Olivier A, et al. The natural history of pelvic vein thrombosis on magnetic resonance venography after vaginal delivery. Am J Obstet Gynecol 2012; 206:356.e1.
  45. James AH. The natural history of pelvic vein thrombosis: the natural history of involution? Am J Obstet Gynecol 2012; 206:276.
  46. Miller CJ. Ligation or excision of the pelvic veins in the treatment of puerperal pyaemia. Surg Gynecol Obstet 1917; 25:431.
  47. ROBINSON LS. The collateral circulation following ligation of the inferior vena cava; injection studies in stillborn infants. Surgery 1949; 25:329.
  48. COLLINS JH, BOSCO JA, COHEN CJ. Pregnancy subsequent to ligation of the inferior vena cava and ovarian vessels. Am J Obstet Gynecol 1959; 77:760.
  49. Malkamy H. Heparin therapy in postcesarean septic pelvic thrombophlebitis. Int J Gynaecol Obstet 1980; 17:564.
  50. Duff P, Gibbs RS. Pelvic vein thrombophlebitis: diagnostic dilemma and therapeutic challenge. Obstet Gynecol Surv 1983; 38:365.