Heparin therapy in postcesarean septic pelvic thrombophlebitis

Eleven cases of septic pelvic thrombophlebitis and persistant fever following cesarean section and cesarean hysterectomy are presented. Addition of heparin to the antibiotic regimen of these patients produced a clinical response within 1--5 days, except in two patients who developed septic pulmonary emboli, which finally resolved with continued heparin therapy. An incidental finding was a high incidence of pelvic thrombophlebitis following hypogastric artery ligation. The results justify a trial of heparin therapy, before resorting to exploratory laparotomy, in postpelvic surgery patients who have unexplained fever.     

Diagnosis of septic pelvic thrombophlebitis by measurement of fibrinopeptide A

Septic pelvic thrombophlebitis is an uncommon but potentially life-threatening complication of puerperal endometritis. The lack of specific physical findings necessitates a diagnosis based by exclusion on the patient's response to anticoagulation. Fibrinopeptide A (FPA) is the first peptide cleaved from fibrinogen during thrombin-mediated fibrin generation. Because of its short half-life, FPA accurately reflects the level of ongoing fibrin generation. In a preliminary study of 40 puerperal patients, FPA successfully differentiated puerperal fever secondary to endometritis or abscess from fever responsive to a heparin trial. The mean FPA level in patients presumed to have septic pelvic thrombophlebitis was 23.8 ng/ml as opposed to 7 ng/ml in patients with endometritis. No patient with septic pelvic thrombophlebitis as diagnosed by her response to a heparin trial had a level of FPA less than 14 ng/ml. There was no overlap of FPA levels between patients with endometritis or abscess and septic pelvic thrombophlebitis. The data suggest further prospective evaluation of FPA for the diagnosis of septic pelvic thrombophlebitis is warranted.     

A case report of acute pelvic thrombophlebitis missed by magnetic resonance imaging of the pelvic veins

A 29-year-old woman presented post-natally with pulmonary hypertension. Peripheral venous thrombosis was not detected by duplex ultrasound or conventional MRI. Despite anticoagulation, the patient arrested. Autopsy revealed right iliac vein thrombosis. The ability of conventional MRI to detect acute pelvic thrombophlebitis depends on obtaining appropriate views.     

Puerperal septic pelvic thrombophlebitis: incidence and response to heparin therapy.

OBJECTIVE: Before the availability of modern imaging studies the diagnosis of septic pelvic thrombophlebitis causing prolonged puerperal fever was difficult to confirm without surgical exploration. With the use of computed tomography infection-related pelvic phlebitis can now be confirmed, and this study was designed to determine its incidence after delivery. We also designed a randomized clinical trial to evaluate the efficacy of heparin added to antimicrobial therapy for treatment of women with septic phlebitis. STUDY DESIGN: We studied women who had pelvic infection and fever that persisted after 5 days despite adequate antimicrobial therapy with clindamycin, gentamicin, and ampicillin. After giving consent study participants underwent abdominopelvic computed tomographic imaging. Women with pelvic thrombophlebitis were randomly assigned to 1 of 2 management schemes that included continuation of antimicrobial therapy, either alone or with the addition of heparin, until the temperature was .5). The 54 women with persistent fever but without computed tomographic evidence of septic pelvic thrombophlebitis were hospitalized for a mean of 12.0 +/- 4.1 days, compared with 10.9 +/- 2.9 days for women in whom thrombosis was diagnosed (P =.14). These women were followed up for >/=3 months post partum and none showed evidence of reinfection, embolic episodes, or postphlebitic syndrome. CONCLUSIONS: The overall incidence of septic pelvic thrombophlebitis was 1:3000 deliveries. The incidence was about 1:9000 after vaginal delivery and 1:800 after cesarean section. Women given heparin in addition to antimicrobial therapy for septic thrombophlebitis did not have better outcomes than did those for whom antimicrobial therapy alone was continued. These results also do not support the common empiric practice of heparin treatment for women with persistent postpartum infection.     

Puerperal pelvic thrombophlebitis: impact on diagnosis and treatment using x-ray computed tomography and magnetic resonance imaging

The clinical diagnosis of puerperal pelvic thrombophlebitis was confirmed by x-ray computed tomography in 11 women, and further documented in six by magnetic resonance imaging. Venous thrombi were demonstrated in ovarian, iliofemoral, and inferior vena caval vessels. In six women with ovarian vein involvement and no evidence of iliofemoral thrombophlebitis, resolution followed intravenous antimicrobial therapy alone, and in three of these, resolution was confirmed by x-ray tomography. In contrast, three of five women with symptomatic iliofemoral thrombophlebitis had a prolonged febrile course despite antimicrobial and heparin therapy. The clinical courses of these 11 women were consistent with the observation that pelvic thrombophlebitis is associated with pelvic infection. Disease manifested within a few days after parturition was more likely due to ovarian vein involvement, whereas disease with later onset of symptoms was more likely due to iliofemoral thrombosis, with or without vena caval extension. Through the use of x-ray computed tomography and magnetic resonance imaging, the natural course of pelvic thrombophlebitis can be better elucidated and therapeutic regimens more clearly evaluated.     

Postabortal paracervical abscess as a complication of paracervical block anesthesia. A case report

A paracervical abscess occurred after paracervical block anesthesia was administered for induced abortion in an 18-year-old multigravida. She presented with vaginal, low abdominal and low back pain and with nausea, vomiting, chills and fever. Incision and drainage of the abscess were performed and a vaginal drain inserted under antibiotic coverage. Cultures of the abscess contents revealed multiple anaerobic organisms. Laparoscopy showed normal pelvic organs, and the peritoneal fluid cultures were negative. Postoperatively the patient became afebrile and was discharged after three days on antibiotics. To our knowledge, this case report is the first one on paracervical abscess as a complication of induced abortion with paracervical block anesthesia.     

Rare pelvic tumors. A case report

Two cases of rare pelvic masses of obscure origin are presented. The first was a giant pyometra, simulating an ovarian cyst, detected accidentally 13 years after conisation. The second was hematoma of lower parts of rectus muscles, also detected accidentally. The woman had a history of long-lasting anticoagulation, but couldn't remember any trauma. The difficulties of differential diagnosis are discussed.     

Diagnosis of puerperal ovarian vein thrombophlebitis by computed tomography

A case of puerperal ovarian vein thrombophlebitis diagnosed by computed tomography is presented. Resolution after treatment with antibiotics and anticoagulation is demonstrated. The obstetrician must be aware of the role of computed tomography in making a prompt and accurate diagnosis in such cases.     

Large paravaginal pelvic lipoma. A case report.

BACKGROUND: Pelvic lipoma is an extremely rare problem. Current imaging techniques are very helpful in diagnosis and assessment. CASE: A 36-year-old woman, gravida 2, para 3, presented with pelvic pressure and a bulging perineum on the left side. Pelvic examination revealed an 8 x 10-cm, soft mass filling the left hemipelvis. Pelvic ultrasound and computed tomography delineated the mass and suggested a fatty tumor without invasion of surrounding structures. Via laparotomy, a 400-g lipoma was removed from the left paravaginal/ paravesical/pararectal space. The patient had an uneventful recovery. CONCLUSION: Pelvic lipoma should be considered in the differential diagnosis of a soft, solid tumor filling the lateral pelvis. Ultrasonography and computed tomography are very helpful in assessing the nature of the mass. Removal can be done with a transperineal approach.     

Actinomycosis mimicking a pelvic malignancy. A case report

BACKGROUND: Pelvic actinomycosis is difficult to diagnose preoperatively. The chronic infection is locally infiltrative and causes a profound induration of infected tissue planes. This induration, combined with absence of fever and leukocytosis, can mimic a pelvic malignancy. CASE: A 55-year-old woman was diagnosed with a pelvic mass after a two-month history of intermittent lower abdominal pain. The patient had had an intrauterine device for 12 years; it was removed two months prior to an exploratory laparotomy for the symptomatic mass. The mass was highly suggestive of colorectal cancer, with the rectosigmoid colon indurated and adherent to the uterus and sacrum. The induration of the colon extended caudally to within 3 cm of the anal verge. An abdominoperineal resection was performed along with a total abdominal hysterectomy, bilateral salpingo-oophorectomy and colostomy. Pathology revealed acute and chronic endometritis, left tuboovarian abscess and extensive, acute inflammation of the rectosigmoid colon without evidence of diverticuli. Actinomycosis was diagnosed based on the characteristic sulphur granules seen on hemotoxylin and eosin staining. CONCLUSION: Actinomycosis can mimic pelvic and abdominal malignancies. Surgeons should be aware of this infection to potentially spare women morbidity from excessive surgical procedures.     

Endometrial carcinoma diagnosed by positron emission tomography: a case report

BACKGROUND: Positron emission tomography (PET) scanning utilizes the recognized tumor metabolic property of increased glycolysis with the radioactive decay of 2-[(18)F]fluoro-2-deoxy-D-glucose (FDG) and generation of gamma radiation to provide quantitative tumor imaging. PET scanning has proven useful in the evaluation and staging of malignancies including malignant melanoma. CASE REPORT: As part of the preoperative staging evaluation a PET scan was performed in a 76-year-old white female with a biopsy-proven malignant melanoma on the posterior thorax. Physiologic uptake was delineated, and in addition, an area of increased uptake of FDG in the pelvis anatomically consistent with the uterus was observed. Subsequent endometrial sampling revealed a moderately differentiated endometrioid adenocarcinoma. Surgical staging revealed a stage IB, grade 2 lesion. CONCLUSION: This is the first case report of an endometrial carcinoma diagnosed incidentally by positron emission tomography in an asymptomatic patient.     

Pseudomonas aeruginosa-infected IUD associated with pelvic inflammatory disease. A case report

BACKGROUND: While pelvic infection is known to be an infrequent complication of intrauterine device (IUD) use, infections are usually related to microorganisms introduced at the time of insertion or by sexual contact. CASE: We diagnosed a 35-year-old woman with an IUD for 6 years with pelvic inflammatory disease (PID) and implemented antibiotic therapy. Her clinical course worsened, and exploratory surgery revealed a right tuboovarian abscess with multiple loculated pelvic abscesses. Culture of the IUD found heavy growth of Pseudomonas aeruginosa. CONCLUSION: P aeruginosa has not previously been described in association with infections of the upper female genital tract. Double coverage with appropriate antipseudomonal agents is essential for proper treatment of pseudomonal infections.     

Preoperative evaluation of pelvic masses with combined F-fluorodeoxyglucose positron emission tomography and computed tomography

OBJECTIVE: To prospectively evaluate the diagnostic value of combined 18F-fluorodeoxyglucose position emission tomography and computed tomography (FDG-PET/CT) to discriminate malignant or borderline malignant tumors from benign pelvic masses. METHODS: A prospective study of 30 women with suspected ovarian cancer who presented from July 2006 through August 2007. Selection was based on evidence from ultrasound, magnetic resonance imaging, and rising tumor marker levels. All patients underwent FDG-PET/CT prior to standard debulking surgery for a pelvic mass. Results: The sensitivity and specificity of FDG-PET/CT to detect malignant or borderline malignant pelvic tumors were 71.4% and 81.3%, respectively. The sensitivity and specificity of FDG-PET/CT to detect ovarian cancer were 100% and 85.0%, respectively. The maximum standardized uptake value in borderline tumors was significantly lower compared with malignant tumors, but not significantly different compared with benign tumors. CONCLUSION: FDG-PET/CT had a high diagnostic value in differentiating between malignant and benign tumors, and a low diagnostic value in differentiating between borderline malignant and benign tumors.     

The diagnosis of puerperal ovarian vein thrombophlebitis by computed axial tomography scan

The diagnosis of puerperal ovarian vein thrombophlebitis by computed axial tomography (CAT) scan is reported. The characteristic finding, ie, a soft tissue mass with a diameter of 2 cm and length of 14 cm, extending from the uterine cornua to the level of the renal vein, can be seen by CAT scan. The near total resolution of the mass on follow-up CAT scan confirmed successful treatment with antibiotics and heparin. Observation of these findings will allow future cases to be definitively diagnosed and treated without invasive procedures.     

Hydatid of morgagni with torsion diagnosed during cesarean delivery. A case report

BACKGROUND: Hydatids of Morgagni are benign, pedunculated, cystic structures arising from müllerian vestiges below the fallopian tube near the fimbria. They usually are of no clinical significance unless the pedicle becomes twisted and infarction occurs. CASE: A 39-year-old primigravida at 41 weeks and 5 days' gestation underwent primary cesarean delivery for macrosomia and failure to descend during labor. A 4 x 3-cm hydatid of Morgagni with torsion of the pedicle was found on the left fallopian tube. Ligation of the pedicle and excision of the infarcted cyst were performed. Histology of the specimen demonstrated cuboidal epithelium with extensive hemorrhage and necrosis, consistent with an infarcted hydatid of Morgagni. All pain and symptoms experienced by the patient during the previous day were associated with the onset of labor. No specific left lower quadrant pain was reported. CONCLUSION: Hydatids of Morgagni are common findings at pelvic surgery and usually of no clinical significance. Torsion of a hydatid of Morgagni is rarely reported and most likely is a rare occurrence. In this patient, torsion of the hydatid of Morgagni was possibly pregnancy related, and symptoms associated with torsion were probably masked by labor pain.     

Hemolytic anemia and benign pelvic tumors. A case report

BACKGROUND: Hemolytic anemia associated with benign pelvic neoplasms is very rare. Sixteen cases have been reported in the English-language literature. CASE: A 27-year-old woman complained of dizziness, fatigue and headache. Physical examination revealed jaundice and mild tachycardia. Laboratory evaluation indicated intravascular hemolysis, and workups for hematologic and infectious disease etiologies were negative. Multiple blood transfusions and steroids failed. Computed tomography showed a large, complex pelvic mass (10 x 10 x 6 cm). Exploratory laparotomy and excision of bilateral dermoid cysts were performed, and the anemia resolved. The patient was healthy, without recurrence, seven years later. CONCLUSION: It is important to seek to identify pelvic tumors in patients presenting with hemolytic anemia because this condition is often resistant to standard medical therapy and resolves only after removal of the neoplasm.