A 32-year-old woman, gravida 2, para 2 who is 5 days postpartum is evaluated for persistent spiking fevers. She also reports a diffuse, constant, non-colicky pain in her pelvis and groin that began earlier in the day. The pregnancy and vaginal delivery were uneventful, and she developed fever 2 days after delivery and shortly before she was going to be discharged. Endometritis was suspected. Cultures of the endometrium, vagina, blood, and urine were obtained, and she was started empirically on intravenous clindamycin and gentamicin. The fevers persisted, and the cultures all came back negative. A CT scan of the abdomen and pelvis is performed and rules out pelvic abscess.
D) Start anticoagulation therapy with heparin and continue intravenous antibiotics
If a postpartum fever does not resolve with broad-spectrum antibiotics, there are two main etiologies to consider: progression to pelvic abscess or septic pelvic thrombophlebitis. In this case, a CT scan has rules out pelvic abscess, and cultures have been negative. Septic pelvic thrombophlebitis is a known complication of the postpartum period and is characterized by diffuse, constant pelvic pain. The most appropriate next step is anticoagulation therapy with unfractionated heparin or low-molecular weight heparin to prevent thrombus propagation and embolization. Parenteral antibiotic therapy against streptococci, Enterobacteriacea, and anaerobes (such as clindamycin plus gentamicin) also is indicated though many patients will already be on antibiotics.
Answer choice A: Change to broader spectrum intravenous antibiotic, is incorrect. Antibiotics are not indicated for pelvic thrombophlebitis, as it is not an infectious process.
Answer choice B: Discharge home with pain management and oral antibiotics, is incorrect. Pelvic thrombophlebitis is a serious condition that requires hospitalization and anticoagulation.
Answer choice C: Perform exploratory laparotomy, is incorrect. Exploratory laparotomy is not indicated in the absence of findings suggestive of surgical pathology.
Answer choice E: Repeat CT scan in 48 hours, is incorrect. Repeating the CT scan is not necessary if the initial scan has ruled out a pelvic abscess and the patient's clinical presentation is consistent with pelvic thrombophlebitis.
Key Learning Point
Pelvic thrombophlebitis is a known complication of the postpartum period and requires anticoagulation therapy and intravenous antibiotics.
