Imaging studies can be helpful in patient refractory to broad-spectrum parenteral antibiotics to look for abscess, retained products, or septic pelvic thrombophlebitis.
[5] 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.
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.
[6] 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.
[8] 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.
Clinical signs include: In rare cases, more serious postpartum complications may occur as a result of SPT such as pulmonary embolism.
[13] Septic pelvic thrombophlembitis (SPT) occurs most often in bedridden patients after giving birth, or after having undergone a Caesarean section.
The main risk factor of developing SPT is postpartum endometritis, which in turn is most commonly caused by a Caesarean section.
[10] Once the scan confirms the presence of a clot in addition to inflammation indicating thrombosis, it can be inferred looking at the blood cultures and symptoms that SPT is present.
[23] Septic pelvic thrombophlebitis will show laboratory results reflective of active inflammation such as elevated C-reactive protein (CRP) and white blood cell count (WBC).
[21] There are many other conditions that can mimic SPT, for example deep vein thrombosis (DVT) or other symptoms commonly experienced by cancer therapy patients.
[21] 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.
Although there is stronger evidence supporting the clinical efficacy of the clindamycin and gentamicin combination to treat postpartum endometritis, economic factors play a large role when selecting the best treatment regimen for a person.
[28] A report revealed a rare case where a person developed a pulmonary embolism as a result of SPT and were successfully treated with warfarin.
[27] In a study which looked at forty-six postpartum persons with SPT who received heparin in addition to penicillin or chloramphenicol, over ninety percent responded with favorable outcomes such as reduced fever by no more than seven days.
The study concluded that there was no statistically significant difference in clinical outcomes, such as the length of fever and duration of their hospital stay.
Furthermore, the advances in diagnostic tools (e.g. computed tomography and magnetic resonance imaging) and understanding of the disease contributed to improving treatment outcomes.
Antibiotic therapy is still the preferred treatment if SPT is expected, but adding on heparin is still up for debate because of conflicting evidence of whether or not it provides a therapeutic benefit.