Pelvic Vein Thrombophlebitis

Aka: Pelvic Vein Thrombophlebitis, Iliac Vein Thrombophlebitis, Postpartum Pelvic Thrombophlebitis, Septic Pelvic Thrombophlebitis, Suppurative Pelvic Thrombophlebitis, Ovarian Vein Thrombophlebitis

1. Causes
   1. Common
      1. Pelvic Inflammatory Disease
      2. Postpartum Complication (e.g. Postpartum Endometritis)
         1. Cesarean Section (1 in 800 deliveries)
         2. Vaginal Delivery (1 in 9000 deliveries)
   2. Uncommon
      1. Post-operative Hysterectomy
      2. Pelvic Neoplasm
2. Types
   1. Deep Septic Pelvic Thrombophlebitis (DSPT)
   2. Ovarian Vein Thrombophlebitis (OVT)
3. Findings:
   1. Fever
      1. Onset within 3-5 days of delivery for DPST, and within 7 days of delivery for OVT
      2. Postpartum Fever is often the only presenting symptom in Deep Septic Pelvic Thrombophlebitis (DSPT)
      3. Fever is often refractory to antibiotics
   2. Abdominal Pain
      1. Often absent for Deep Septic Pelvic Thrombophlebitis (DSPT)
      2. Unilateral abdominal or Pelvic Pain, back pain or Flank Pain
4. Labs
   1. Complete Blood Count
      1. Mild Leukocytosis
   2. Blood Culture
      1. Test Sensitivity <33%
5. Imaging
   1. Precautions
      1. Negative imaging does not exclude Pelvic Vein Thrombophlebitis
   2. Ultrasound
      1. Evaluate for other causes of Postpartum Fever
   3. CT or MRI (esp. MRI Venography)
      1. Pelvic Vein intraluminal filling defect
6. Differential Diagnosis
   1. Appendicitis
   2. Postpartum Endometritis
   3. Urinary infection
   4. Ovarian Torsion
   5. Pelvic abscess
   6. Pelvic Inflammatory Disease
7. Management
   1. Anticoagulation
      1. Limited evidence for adequate duration (2-6 weeks)
      2. Start with Heparin (e.g. Enoxaparin)
      3. Transition to Warfarin or DOAC (e.g. Apixaban)
   2. Antibiotic Management
      1. Similar to Postpartum Endometritis
      2. Preferred regimens
         1. Piperacillin-Tazobactam (Zosyn) 4.5 g IV every 8 hours OR
         2. Ceftriaxone 2 g IV every 24 hours and Metronidazole 500 mg IV every 8 hours OR
         3. Imipenem or Meropenem if ESBL or other multi-drug resistant Gram Negative Bacteria suspected
      3. Alternative regimens
         1. Ciprofloxacin 400 mg IV every 12 hours and Metronidazole 500 mg IV every 8 hours
8. Complications
   1. Venous Thromboembolism (uncommon)
9. References
   1. (2018) Sanford Guide, accessed on IOS, 10/7/2019
   2. da Silva Cunha (2018) Case Rep Womens Health 17: 5–7 [PubMed]
      1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5869062/