Septic pelvic thrombophlebitis
- Katherine T Chen, MD, MPH
Katherine T Chen, MD, MPH
- Professor of Obstetrics, Gynecology, and Reproductive Science
- Icahn School of Medicine at Mount Sinai
Septic pelvic thrombophlebitis was first described in the late 1800s by Von Recklinghausen . 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.
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 . 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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