A rare cause of pulmonary embolism: septic pelvic thrombophlebitis

SESSION TITLE: Pulmonary Vascular Disease Case Report Posters 4 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 12:00 pm - 12:45 pm INTRODUCTION: Septic pelvic thrombophlebitis(SPT) is a well known but rare complication of pregnancy, infrequently seen with spontaneous vaginal deliveries(SVD) compared to deliveries by caesarean section. It can cause complications like pulmonary embolism(PE) ,retrograde migration of thrombosis from the iliofemoral system into the legs, extension proximally to the diaphragm and distally to the femoral vein, free-floating thrombosis in the vena cava, renal vein thrombosis, and ureteral obstruction. We present a case of postpartum female presenting with pulmonary embolism and right ovarian septic thrombophlebitis. CASE PRESENTATION: A 23 year old female patient with past medical history of preeclampsia came to the hospital 7 days post-partum after a normal vaginal delivery with fevers, chills, abdominal pain, shortness of breath, pleuritic chest pain. chest tightness, nausea and vomiting. Vitals on admission were Temperature 39.2, Heart rate 119, respiratory rate 20, blood pressure 113/72 and oxygen saturation 96 on room air. Physical exam was significant for tenderness, rebound and guarding in the lower abdominal quadrants. Lab work was significant for a white blood cell count of 18200. Computed Tomography(CT) scan with intravenous contrast of the abdomen was done which was suggestive of an enlarged uterus with infiltration of the parametrial soft tissues suggestive of endometritis and thrombus within the right ovarian vein. A diagnosis of Pelvic septic thrombophlebitis was made. CT angiography of the chest exhibited segmental left lower lobe pulmonary embolism. Patient was started on appropriate antibiotics and anti-coagulation leading to subsequent improvement in her overall clinical condition. DISCUSSION: Pulmonary embolism in the setting of SPT occur rarely, in about 2 percent of cases They are usually small and do not cause hypoxia and are asymptomatic. The overall incidence of SPT is 1:3000 deliveries; 1:9000 after vaginal delivery and 1:800 after caesarean section. The incidence peaks around postpartum day 2 for full-term deliveries and occurs within 10 days postpartum in 90% of cases. However, fever or pain heralding ovarian vein thrombosis may occur up to 10 weeks postpartum. Our case is rare as it happened after SVD and had symptoms of PE. Physiologic changes of pregnancy consisting of hypercoagulability and stasis of blood flow contribute to development of ovarian vein thrombus and subsequent PE. Right ovarian vein is commonly involved. If not diagnosed and treated , retrograde or distal propagation of thrombus can also cause catastrophic consequences like multi- organ failure and even death. CONCLUSIONS: Although rare after SVD, SPT should always be in the differential in a postpartum female presenting with fever and abdominal pain. Physicians should also be cognizant of its potential life-threatening complications. REFERENCE #1: Klima, David A.; Snyder, Thomas E. MD. Postpartum Ovarian Vein Thrombosis. Obstetrics & Gynecology 111(2 Part 1):p 431-435, February 2008. | DOI: 10.1097/AOG.0b013e318162f6c0 REFERENCE #2: https://doi.org/10.1016/S0002-9378(99)70450-3 REFERENCE #3: https://pubmed.ncbi.nlm.nih.gov/14855228/ DISCLOSURES: No relevant relationships by Kuldeepsinh Atodaria No relevant relationships by Aakash Goyal No relevant relationships by Kumar Sarvottam No relevant relationships by Mihir Shah