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Septic Pelvic Thrombophlebitis with Rare Associated Pulmonary Embolism
Abstract Number: F 78
Abstract Type: Case Report/Case Series
Sepsis and embolic events are leading causes of maternal mortality worldwide. Septic pelvic thrombophlebitis (SPT) is a rare complication of the puerperium, with an incidence of 1 in 3000 deliveries. We describe a case of SPT associated with overwhelming septic emboli, obfuscating preoperative evaluation prior to hysterectomy.
A 28 year old healthy G3P1 had an uncomplicated vaginal delivery. On postpartum day 6 she presented with altered mental status and bleeding gums. Evaluation showed fever, tachycardia, leukocytosis, platelets 5k, acute kidney injury, and liver failure. She was intubated and started on antibiotics and vasopressors for septic shock and also diltiazem for acute-onset atrial fibrillation. Foul smelling vaginal discharge was noted and after endometrial biopsy, concern was raised for primary group A streptococcal endometritis. Urgent hysterectomy was planned.
On arrival to the operating room the team was notified by page that a previously obtained renal artery ultrasound (US) showed an inferior vena cava (IVC) thrombus. Vascular surgery was consulted and remarked on disseminated clots on a liver US. A bedside transthoracic echocardiogram revealed signs of possible right ventricular thrombus. Surgery was aborted given these findings which suggested the possibility of early-DIC induced pulmonary embolism (PE) as an explanation for her clinical picture.
A CT chest was negative for massive PE but showed evidence of septic pulmonary emboli, and a head CT revealed a small punctate hemorrhage in the right frontal lobe.
Cyclical fevers continued, and hysterectomy proceeded; laparotomy revealed a necrotic uterus, ischemic left ovary and thrombi within the ligaments. An IVC filter was placed and she was started on therapeutic heparin. She had persistent fevers and tachycardia and on day 18, she progressed to PEA arrest; although pulse was regained following six minutes of chest compressions, the event resulted in anoxic brain injury.
SPT is characterized by a persistent postpartum fever with or without abdominal pain. Intimal damage of pelvic veins is thought to lead to thrombogenesis. Early reports of SPT named surgical excision of the thrombosed vein as the treatment of choice; current therapy consists of antibiotics conjunction with systemic anticoagulation.
Pulmonary emboli occur in only 2% of SPT cases and usually do not cause hypoxemia. Mortality is very low; a study that included 69 cases of SPT out of 45,000 deliveries observed no deaths. In this case, the patient’s devastating systemic infection due to her overwhelming septic clot burden likely lead to her demise.
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