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Septic pelvic thrombophlebitis
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Septic pelvic thrombophlebitis
Septic pelvic thrombophlebitis (SPT), also known as suppurative pelvic thrombophlebitis, is a rare 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 or parametritis. After 48 hours of unresolved postpartum endometritis (notably 48 hours of fever that is unaffected by antibiotics), SPT is assumed until proven otherwise (with pelvic radiography). Imaging studies can be helpful in patient refractory to broad-spectrum parenteral antibiotics to look for abscess, retained products, or septic pelvic thrombophlebitis. Current treatments consist of a combination of antibiotics selected based on suspected pathogen(s), and anticoagulants.
Though the greatest risk factors involve delivery or delivery-related complications, in some rare cases, SPT may arise after abortion procedures and in non-pregnant people with pelvic infections, pelvic surgeries, uterine fibroids, or underlying cancer.
SPT can also be further subcategorized into ovarian vein thrombosis (OVT) or puerperal ovarian vein thrombophlebitis (POVT) and deep septic pelvic thrombosis (DSPT).
Septic pelvic thrombophlebitis (SPT) is an inflammatory process that, in conjunction with the physiological conditions of postpartum and proximity with potentially infected tissues (e.g. endometrium, chorion, amniotic fluid), leads to the formation of a clot blocking the ovarian vein. Injury of the ovarian vein endothelium during delivery or pelvic operations and bacterial invasion from nearby tissues triggers an inflammatory response within the vein wall. Bacteria, viruses and physical trauma can trigger prothrombic processes within the body through inflammation and tissue factor expression on endothelial cells and monocytes that activates the intrinsic coagulation pathway.
In addition to the intravascular vessel wall damage, Virchow's triad of thrombogenesis is completed by the hypercoagulable state of pregnancy up to 6 weeks postpartum and blood stasis from both laying down in a hospital bed for an extended amount of time without walking and pregnancy-induced ovarian venous dilatation. Deep vein thrombosis is generally a concern in operations involving the pelvis or lower extremities wherein during recovery, a person's ability to ambulate is limited after the operation. Blood stasis and thrombogenesis within the ovarian vein specifically is especially of concern after cesarean sections due to the combination of inevitable physical trauma to the intima of pelvic blood vessels, the three-fold increase in diameter if the ovarian veins, and that pooling of the blood in the pelvis as this is the lowest part of the person while laying in a hospital bed. Notably, most cases of SPT involve the right ovarian vein rather than the left ovarian vein due to its greater length, weaker valves, and left-to-right venous flow in the pelvic region while sitting in the upright position.
Ovarian veins have close connections with the uterine and vaginal venous plexuses that are in proximity to tissues commonly host to pathogens, notably in cases of vaginosis or endometritis. Pathogens from these adjacent tissues infect the forming clot, and contributing to a positive feedback loop of inflammation. Bacterial organisms associated with SPT include anaerobic and aerobic streptococci, Proteus species, Bacteriodes species, staphylococci, E. coli, and Klebsiella. Sepsis occurs after the pathogens infect and proliferate in the thrombus within the lumen, leading to persistent bacteremia. Fatal complications include septic shock and septic pulmonary embolism, leading to acute respiratory distress syndrome.
Septic pelvic thrombophlebitis (SPT) is often difficult to diagnose due to the absence of physical signs and symptoms. SPT initially and most commonly presents as a fever anywhere from 5 to 21 days after delivery. Temperatures of fever have been reported to be within 103 °F to 104 °F.
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Septic pelvic thrombophlebitis
Septic pelvic thrombophlebitis (SPT), also known as suppurative pelvic thrombophlebitis, is a rare 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 or parametritis. After 48 hours of unresolved postpartum endometritis (notably 48 hours of fever that is unaffected by antibiotics), SPT is assumed until proven otherwise (with pelvic radiography). Imaging studies can be helpful in patient refractory to broad-spectrum parenteral antibiotics to look for abscess, retained products, or septic pelvic thrombophlebitis. Current treatments consist of a combination of antibiotics selected based on suspected pathogen(s), and anticoagulants.
Though the greatest risk factors involve delivery or delivery-related complications, in some rare cases, SPT may arise after abortion procedures and in non-pregnant people with pelvic infections, pelvic surgeries, uterine fibroids, or underlying cancer.
SPT can also be further subcategorized into ovarian vein thrombosis (OVT) or puerperal ovarian vein thrombophlebitis (POVT) and deep septic pelvic thrombosis (DSPT).
Septic pelvic thrombophlebitis (SPT) is an inflammatory process that, in conjunction with the physiological conditions of postpartum and proximity with potentially infected tissues (e.g. endometrium, chorion, amniotic fluid), leads to the formation of a clot blocking the ovarian vein. Injury of the ovarian vein endothelium during delivery or pelvic operations and bacterial invasion from nearby tissues triggers an inflammatory response within the vein wall. Bacteria, viruses and physical trauma can trigger prothrombic processes within the body through inflammation and tissue factor expression on endothelial cells and monocytes that activates the intrinsic coagulation pathway.
In addition to the intravascular vessel wall damage, Virchow's triad of thrombogenesis is completed by the hypercoagulable state of pregnancy up to 6 weeks postpartum and blood stasis from both laying down in a hospital bed for an extended amount of time without walking and pregnancy-induced ovarian venous dilatation. Deep vein thrombosis is generally a concern in operations involving the pelvis or lower extremities wherein during recovery, a person's ability to ambulate is limited after the operation. Blood stasis and thrombogenesis within the ovarian vein specifically is especially of concern after cesarean sections due to the combination of inevitable physical trauma to the intima of pelvic blood vessels, the three-fold increase in diameter if the ovarian veins, and that pooling of the blood in the pelvis as this is the lowest part of the person while laying in a hospital bed. Notably, most cases of SPT involve the right ovarian vein rather than the left ovarian vein due to its greater length, weaker valves, and left-to-right venous flow in the pelvic region while sitting in the upright position.
Ovarian veins have close connections with the uterine and vaginal venous plexuses that are in proximity to tissues commonly host to pathogens, notably in cases of vaginosis or endometritis. Pathogens from these adjacent tissues infect the forming clot, and contributing to a positive feedback loop of inflammation. Bacterial organisms associated with SPT include anaerobic and aerobic streptococci, Proteus species, Bacteriodes species, staphylococci, E. coli, and Klebsiella. Sepsis occurs after the pathogens infect and proliferate in the thrombus within the lumen, leading to persistent bacteremia. Fatal complications include septic shock and septic pulmonary embolism, leading to acute respiratory distress syndrome.
Septic pelvic thrombophlebitis (SPT) is often difficult to diagnose due to the absence of physical signs and symptoms. SPT initially and most commonly presents as a fever anywhere from 5 to 21 days after delivery. Temperatures of fever have been reported to be within 103 °F to 104 °F.