Septic Pelvis Thrombophlebitis in Postpartum Period: Diagnosis by Clinical and Magnetic Resonance Imaging Findings

Abstract

Septic Pelvic Thrombophlebitis (SPT) is a rare condition in the postpartum period which is characterized by persistent fever, despite the antimicrobial therapy, and diffuse abdominal pain and in the legs. SPT is more frequent after caesarean section delivery. The diagnosis can be performed by ultrasound, computed tomography and magnetic resonance imaging, being this last imaging diagnostic method of chosen because it is better to visualizing of soft tissue, edema and inflammatory signs. The treatment is based on heparin and oral anticoagulation drug until six months after delivery. We showed a case of primiparous which developed SPT after caesarean section delivery and presented good prognosis with heparin therapy.

Keywords: Septic pelvic thrombophlebitis; Cesarean section; Postpartum; Heparin; Magnetic resonance imaging

Introduction

Septic Pelvic Thrombophlebitis (SPT) still is a condition under diagnosed and poorly managed. The 1960’s brought a more clinical approach, and with the advent of broad-spectrum antibiotics regimens, development of newer diagnostic tools and a better understanding of the pathophysiology of disease, mortality and incidence significantly decreased [1]. Nowadays the incidence is growing again with more caesarean sections being performed. We present a case to illustrate how SPT may clinically present, be diagnosed and treated.

Case Presentation

A 34-year-old gravida 2 para 0 pregnant woman at 38 6/7 weeks gestation was admitted to our service in labor with clear signs of chorioamnionitis (maternal and fetal tachycardia, fever, foul smelling amniotic fluid and uterine tenderness). During the labor conduction, signs of acute fetal distress were observed (persistent fetal tachycardia) and a caesarean section delivery was performed. A male newborn, birth weight of 3615g and Apgar score of 9/9 was delivered. In the postpartum, woman received a broad-spectrum antibiotic therapy (penicillin, gentamicin and metronidazole) and uterotonic agents, with clinical improvement. On the 4^th day postpartum, however, the patient was still febrile, despite the antimicrobial therapy, and with a diffuse abdominal pain that was worse in the lower levels of the abdomen. Pelvic and transvaginal ultrasonography were performed without significant findings, raising suspicion of SPT. Anticoagulation with enoxaparin 1mg/kg twice a day was initiated. She underwent a magnetic resonance angiography, which confirmed the clinical suspicion, finding a filling defect in the middle third of the right internal iliac artery suggestive of thrombus (Figure 1). After 2 days of anticoagulant therapy with enoxaparin, patient became afebrile, and then decided to keep warfarin for anticoagulation maintenance. Later, the patient had no further complications in the puerperium, being discharge home with a target International Normalized Ratio (INR) between 2 and 3. The warfarin therapy was maintained during 6 months after delivery.

    

    

    Figure 1:  Angio-magnetic resonance imaging in the coronal view with T1-
weighted sequences after contrast injection, showing filling defect in the
middle third of the right internal iliac artery suggestive of thrombus (red circle).