Obstetrics & Gynecology>>>>>The Puerperium, Lactation, and Immediate Care of the Newborn
Question 9#

A 26-year-old G1P1 is now postoperative day (POD) 6 after a lowtransverse cesarean delivery for arrest of active phase. On POD 2, the patient developed a fever of 39°C (102.2°F) and was noted to have uterine tenderness and foul-smelling lochia. She was started on broad-spectrum antibiotic coverage for endometritis. The patient states she feels fine now and wants to go home, but continues to spike fevers each evening. Her lung, breast, and cardiac examinations are normal. Her abdomen is nontender with a firm, nontender uterus below the umbilicus. On pelvic examination, her uterus is appropriately enlarged, but nontender. The adnexa are nontender without masses. Her lochia is normal. Her white blood cell count is 12 with a normal differential. Blood, sputum, and urine cultures are all negative for growth after 3 days. Her chest x-ray is negative.

Which of the following statements accurately describes this patient’s condition?

A) It usually involves both the iliofemoral and ovarian veins
B) Antimicrobial therapy is usually ineffective
C) Fever spikes are rare
D) Heparin therapy is always needed for resolution of fever
E) Vena caval thrombosis may accompany either ovarian or iliofemoral thrombophlebitis

Correct Answer is E

Comment:

The patient described has SPT. SPT may involve the ovarian vein, or other deep pelvic veins. The clinical presentation is usually that of pain and fever; therefore, it is usually diagnosed as endometritis, and antibiotic therapy is started. Following antimicrobial therapy, clinical symptoms usually resolve, but fever spikes persist. Patients typically do not appear clinically ill between fevers. The diagnosis of ovarian vein thrombosis is made by computerized tomography (CT) or magnetic resonance imaging (MRI). Deep septic pelvic thrombophlebitis that does not involve the ovarian vein is usually a diagnosis of exclusion, and should be suspected in patients with persistent postpartum fever despite antibiotics, with normal imaging. The treatment of choice is anticoagulation. There are no studies documenting the optimal time for anticoagulation, but most institutions recommend 6 weeks.