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Septic pelvic thrombophlebitis

Author
Katherine T Chen, MD, MPH
Section Editors
Daniel J Sexton, MD
Charles J Lockwood, MD, MHCM
Deputy Editor
Allyson Bloom, MD

INTRODUCTION

Septic pelvic thrombophlebitis (SPT) can occur in the setting of pelvic vein endothelial damage, venous stasis, and hypercoagulability. It is usually associated with postpartum parametritis following cesarean deliveries in the setting of chorioamnionitis but can also occur with other conditions, such as pelvic surgery or underlying malignancy. SPT was first described in the late 1800s by Von Recklinghausen [1] and was further elucidated in the 1950s by a series of reports describing a cohort of 70 women who had fever following obstetric or gynecologic procedures and had grossly palpable intravenous thrombi and seropurulent fluid in the pelvis on exploratory laparotomy [2-5]. Surgical excision or ligation of the thrombosed vein was the initial treatment of choice, although medical therapy has since become the preferred approach.

The clinical manifestations, diagnosis, and treatment of septic pelvic thrombophlebitis are discussed here. Suppurative thrombophlebitis of other veins is discussed elsewhere. (See "Suppurative (septic) thrombophlebitis" and "Pylephlebitis" and "Septic dural sinus thrombosis".)

EPIDEMIOLOGY

Incidence — Septic pelvic thrombophlebitis (SPT) is a rare complication of pregnancy. One survey in the United States suggested that the incidence of SPT was 1 in 3000 deliveries (1 in 9000 vaginal deliveries and 1 in 800 cesarean deliveries) [6]. Similarly, in one study of over 73,000 women who underwent cesarean delivery or vaginal delivery after prior cesarean, only 89 (0.1 percent) had suspected or documented SPT [7].

Risk factors — SPT is largely a disease of postpartum women. The risk is higher with cesarean compared with vaginal delivery. Women with peripartum or postpartum pelvic infections, such as endometritis or chorioamnionitis, are also at higher risk for SPT. As an example, in one case control study of over 73,000 women in a pregnancy registry, cesarean delivery and chorioamnionitis were each independently associated with SPT (adjusted odds ratios 6.3 and 4.8, respectively) [7].

Other pregnancy-related risk factors include [4,7-14]:

                 
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Literature review current through: Nov 2017. | This topic last updated: Dec 07, 2017.
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References
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  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. Wysokinska EM, Hodge D, McBane RD 2nd. Ovarian vein thrombosis: incidence of recurrent venous thromboembolism and survival. Thromb Haemost 2006; 96:126.
  7. Dotters-Katz SK, Smid MC, Grace MR, et al. Risk Factors for Postpartum Septic Pelvic Thrombophlebitis: A Multicenter Cohort. Am J Perinatol 2017; 34:1148.
  8. Witlin AG, Sibai BM. Postpartum ovarian vein thrombosis after vaginal delivery: a report of 11 cases. Obstet Gynecol 1995; 85:775.
  9. Josey WE, Staggers SR Jr. Heparin therapy in septic pelvic thrombophlebitis: a study of 46 cases. Am J Obstet Gynecol 1974; 120:228.
  10. Witlin AG, Mercer BM, Sibai BM. Septic pelvic thrombophlebitis or refractory postpartum fever of undetermined etiology. J Matern Fetal Med 1996; 5:355.
  11. 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.
  12. 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.
  13. Simons GR, Piwnica-Worms DR, Goldhaber SZ. Ovarian vein thrombosis. Am Heart J 1993; 126:641.
  14. Isler CM, Rinehart BK, Terrone DA, et al. Septic pelvic thrombophlebitis and preeclampsia are related disorders. Hypertens Pregnancy 2004; 23:121.
  15. 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.
  16. Haynes MC, Lu BY, Winkel AF. Ovarian vein thrombophlebitis related to large uterine myoma. Obstet Gynecol 2014; 123:450.
  17. HODGKINSON CP. Physiology of the ovarian veins during pregnancy. Obstet Gynecol 1953; 1:26.
  18. Chidekel N, Edlundh KO. Transuterine phlebography with particular reference to pelvic varicosities. Acta Radiol Diagn (Stockh) 1968; 7:1.
  19. Munsick RA, Gillanders LA. A review of the syndrome of puerperal ovarian vein thrombophlebitis. Obstet Gynecol Surv 1981; 36:57.
  20. Brown TK, Munsick RA. Puerperal ovarian vein thrombophlebitis: a syndrome. Am J Obstet Gynecol 1971; 109:263.
  21. Dykhuizen RF, Roberts JA. The ovarian vein syndrome. Surg Gynecol Obstet 1970; 130:443.
  22. Lotze EC, Kaufman RH, Kaplan AL. Postpartum ovarian vein thrombophlebitis. Obstet Gynecol Surv 1966; 21:853.
  23. Dunnihoo DR, Gallaspy JW, Wise RB, Otterson WN. Postpartum ovarian vein thrombophlebitis: a review. Obstet Gynecol Surv 1991; 46:415.
  24. Parino E, Mulinaris E, Saccomano E, et al. Postpartum Ovarian Vein Thrombophlebitis with Staphylococcal Bacteremia. Case Rep Infect Dis 2015; 2015:589436.
  25. 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.
  26. Dunn LJ, Van Voorhis LW. Enigmatic fever and pelvic thrombophlebitis. Response to anticoagulants. N Engl J Med 1967; 276:265.
  27. 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.
  28. Magee KP, Blanco JD, Graham JM. Massive septic pelvic thrombophlebitis. Obstet Gynecol 1993; 82:662.
  29. 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.
  30. 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.
  31. Bahnson RR, Wendel EF, Vogelzang RL. Renal vein thrombosis following puerperal ovarian vein thrombophlebitis. Am J Obstet Gynecol 1985; 152:290.
  32. Haidar A, Haddad A, Naqvi A, et al. Streptococcus constellatus Causing Septic Thrombophlebitis of the Right Ovarian Vein with Extension into the Inferior Vena Cava. Case Rep Infect Dis 2015; 2015:495898.
  33. 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.
  34. 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.
  35. Johnson SC, Esclapes M. Sonography of postpartum ovarian vein thrombophlebitis. J Clin Ultrasound 1998; 26:143.
  36. 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.
  37. Angel JL, Knuppel RA. Computed tomography in diagnosis of puerperal ovarian vein thrombosis. Obstet Gynecol 1984; 63:61.
  38. Isada NB, Landy HJ, Larsen JW Jr. Postabortal septic pelvic thrombophlebitis diagnosed with computed tomography. A case report. J Reprod Med 1987; 32:866.
  39. Plowman RS, Javidan-Nejad C, Raptis CA, et al. Imaging of Pregnancy-related Vascular Complications. Radiographics 2017; 37:1270.
  40. Martin B, Mulopulos GP, Bryan PJ. MRI of puerperal ovarian-vein thrombosis (case report). AJR Am J Roentgenol 1986; 147:291.
  41. 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.
  42. James AH. The natural history of pelvic vein thrombosis: the natural history of involution? Am J Obstet Gynecol 2012; 206:276.
  43. Ledger WJ, Peterson EP. The use of heparin in the management of pelvic thrombophlebitis. Surg Gynecol Obstet 1970; 131:1115.
  44. Rottenstreich A, Da'as N, Kleinstern G, et al. Pregnancy and non-pregnancy related ovarian vein thrombosis: Clinical course and outcome. Thromb Res 2016; 146:84.
  45. Miller CJ. Ligation or excision of the pelvic veins in the treatment of puerperal pyaemia. Surg Gynecol Obstet 1917; 25:431.
  46. ROBINSON LS. The collateral circulation following ligation of the inferior vena cava; injection studies in stillborn infants. Surgery 1949; 25:329.
  47. 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.
  48. Malkamy H. Heparin therapy in postcesarean septic pelvic thrombophlebitis. Int J Gynaecol Obstet 1980; 17:564.
  49. Duff P, Gibbs RS. Pelvic vein thrombophlebitis: diagnostic dilemma and therapeutic challenge. Obstet Gynecol Surv 1983; 38:365.
  50. Klima DA, Snyder TE. Postpartum ovarian vein thrombosis. Obstet Gynecol 2008; 111:431.