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 </=37.5 degrees C for 48 hours.
RESULTS: During the 3-year study period 44,922 women were delivered at Parkland Hospital; among these 8535 (19%) were delivered by the cesarean route. There were 69 women who met criteria for prolonged
infection, and 15 (22%) of these were found to have septic pelvic
thrombophlebitis. Four had
infection after vaginal delivery and 11 had been delivered by the cesarean route. Of 14 women randomly assigned to
therapy, 8 were assigned to receive continued antimicrobial
therapy without the addition of
heparin and the other 6 were assigned to receive
heparin therapy in addition to the
antimicrobial agents. According to an intent-to-treat analysis there was no significant difference between the responses of women with
pelvic infection who were and were not given
heparin therapy. Specifically, women not given
heparin were febrile for 140 +/- 39 hours compared with 134 +/- 65 hours for women who received
heparin (P =.83). Duration of hospitalization was also similar between the 2 groups at 10.6 +/- 1.9 days for those with
thrombosis who were given
antimicrobial agents alone and 11.3 +/- 1.2 days for women who also received
heparin (P >.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.