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Unusually early presentation of septic pelvic thrombophlebitis after TXA for postpartum hemorrhage
Abstract Number: S1D-6
Abstract Type: Case Report/Case Series
Intro. Tranexamic acid (TXA) has recently gained traction for postpartum hemorrhage (PPH) after demonstrating a reduction in death due to bleeding in the WOMAN trial (1). However, in higher-resource settings where TXA and its effect on maternal morbidity and mortality remains vague, uncertainty may remain whether administration in this setting is linked to unmitigated thromboembolic events.
Case. 31 y/o G4P3013 with a history of systemic lupus erythematosus presented at 38 weeks and 6 days gestation with preeclampsia without severe features. A repeat cesarean delivery was performed under spinal anesthesia. Atony was reported despite an infusion of 20 IU per hour of oxytocin and a subsequent increase to 36 IU per hour, two 200 microgram doses of intramuscular carboprost and 10 units of oxytocin into the uterine musculature. TXA 1 gm was given intravenously. A B-Lynch suture resulted in adequate hemostasis. Estimated blood loss after the procedure was 1750 mL. Postoperatively, atony continued with copious clots on fundal exam. She underwent bilateral uterine artery embolization. On postpartum day 2, she became progressively tachycardic with fevers. CT of the chest, abdomen, and pelvis did not show evidence for pulmonary embolism. However, thrombosis of the right gonadal vein with extension into the IVC was noted. A diagnosis of septic pelvic thrombophlebitis was made. She was started on a 6-month course of anticoagulation with low-molecular weight heparin after a negative workup for bleeding disorders.
Discussion. Septic pelvic thrombophlebitis (SPT) is a diagnosis of exclusion and a rare condition affecting 1:800 cesarean deliveries and 1:9000 vaginal deliveries, typically diagnosed 1-2 weeks postpartum (2). Suspicion for SPT in this patient was raised given her risk factors and presentation: cesarean delivery, a dextro-occluded ovarian vein seen on CT, and a constellation of symptoms including unabating fever, tachycardia, and abdominal pain. However, one may question if TXA provoked or exacerbated early thrombus formation in this case. This concern for uncontrolled clotting is universally prefaced in many studies and is the focus of a French case series by Frimat et al. where 18 cases of renal cortical necrosis were identified in patients given TXA for PPH, albeit at high doses (3). With data thus far suggesting modest effect size of TXA for PPH on maternal mortality in higher-resource settings (4), the question of benefit over harm in these environments may remain a legitimate point of investigation.
1. Lancet. 2017 May 27; 389 (10084):2105-16
2. Am J of Obstet and Gynecol. 1999;181(1):143-148
3. Am J of Kidney Dis. 2016 Jul; 68(1)50–57
4. PLoS ONE. 2017 Nov 6; 12(11):e018755