Metrothrombophlebitis is thrombosis and inflammation of the venous vessels of the uterus, which are a complication of postpartum or postoperative endometritis. Metrothrombophlebitis is characterized by fever, copious and prolonged bloody discharge from the genital tract, aching abdominal pain, tachycardia, weakness. Diagnosis includes gynecological examination on a chair, hemostasis examination, ultrasound. Treatment of metrothrombophlebitis is carried out inpatient; requires active antimicrobial therapy, the appointment of anticoagulants and antiplatelet agents; in case of septic complications or massive bleeding – removal of the uterus.
In gynecology, metrothrombophlebitis refers to the number of postpartum or postoperative septic complications. When infectious pathogens enter the venous network of the uterus, the vascular walls and surrounding tissues are affected with the development of periflebitis. Inflammation of the uterine veins creates a favorable background for thrombosis. In the future, with metrothrombophlebitis, both local and generalized septic and thromboembolic complications can develop – suppuration of blood clots, exfoliating metritis, infarction-pneumonia, PE, thrombophlebitis of the veins of the lower extremities and pelvis, sepsis.
According to research conducted by modern gynecology, in almost all cases, the background for the subsequent development of metrothrombophlebitis is metroendometritis, which arose after recently undergone and more often complicated childbirth, obstetric, gynecological or urological operations.
Postpartum metrothrombophlebitis develops more often in women with late pregnancy toxicosis, discoordinated labor activity, prolonged anhydrous interval, massive blood loss during childbirth. Various obstetric aids (cesarean section, fist massage of the uterus, manual separation of the placenta, suturing of deep ruptures of the cervix) are also risk factors for the development of postpartum metrothrombophlebitis. In gynecological practice, metrothrombophlebitis can be a complication of conservative myomectomy, surgical termination of pregnancy, operations for excision of endometriosis foci, reconstructive interventions for uterine abnormalities.
Metrothrombophlebitis often develops in patients with a history of indications of varicose veins and thrombophlebitis of the veins of the lower extremities. The causative agents of infection with metrothrombophlebitis can be gram-negative microbial flora (E. coli, klebsiella, proteus), gram-positive bacteria (staphylococci, enterococci, streptococci), non-sporo-forming anaerobic microorganisms (peptococci, bacteroids, peptostreptococci) and their associations.
The most important link in the pathogenesis of metrothrombophlebitis is the activation of procoagulant and platelet components of hemostasis, characterized by a decrease in antithrombin, an increase in fibrinogen, structural and chronometric hypercoagulation. In addition, the development of metrothrombophlebitis is facilitated by the suppression of cellular and humoral immunity (a decrease in the number of B and T lymphocytes with a violation of their functions, as well as the concentration of IgG).
The manifestation of postpartum metrothrombophlebitis occurs 6-9 days after delivery, sometimes after the woman’s discharge from the hospital. There is a slight increase in temperature, abundant, not decreasing in volume of lochia, deterioration of the condition and sleep, lethargy, weakness, abdominal pain of a nagging nature. Typical is pronounced sinus tachycardia that does not correspond to body temperature (up to 100-120 beats. in min.), labile, soft pulse. Against the background of antimicrobial treatment of endometritis, the clinic of metrothrombophlebitis may be erased, but even in this case, tachycardia and subinvolution of the uterus persist, bloody discharge from the genital tract does not stop for a long time.
Postoperative metrothrombophlebitis is usually accompanied by pain in the depth of the pelvis and lower abdomen, fever, impaired bladder and bowel functions, sometimes – symptoms of irritation of the peritoneum. The progression of metrothrombophlebitis can lead to suppuration of blood clots, which is accompanied by deterioration of the patient’s condition, high fever (up to 40 ° C) with chills, the development of exfoliating metritis and septicopiemia. Hematogenic infection from the uterus can spread to the veins of the pelvis and lower extremities with the development of progressive thrombophlebitis.
In the diagnosis of metrothrombophlebitis, it is important to clarify the factors contributing to inflammation and venous thrombosis, as well as the analysis of clinical manifestations. With a bimanual gynecological examination, a painful, enlarged uterus with a soft consistency is determined. The pharynx of the cervical canal remains open by the 2nd week after delivery. When examining the uterus, a gynecologist can palpate convoluted compacted venous cords that give the surface of the uterus an uneven structure. With thrombophlebitis of the pelvic veins, infiltrates in the parametral fiber may be detected. Clinical data for metrothrombophlebitis are confirmed during pelvic ultrasound.
The general blood test for metrothrombophlebitis is characterized by a decrease in Hb, moderate leukocytosis and an increase in ESR. The study of the coagulogram shows a shortening of the clotting time, inhibition of fibrinolytic activity, an increase in PTI and fibrinogen concentration, shortening of AVR, signs of hypercoagulation according to thrombotest.
All internal examinations for metrothrombophlebitis are performed extremely carefully in order to avoid disruption of the integrity of the thrombus and the development of embolism, as well as the spread of septic infection. Metrothrombophlebitis in the process of diagnosis is differentiated with placental polyps and endomyometritis.
Therapy of metrothrombophlebitis is carried out inpatient. With metrothrombophlebitis, bed rest, ice on the lower abdomen are shown. Antimicrobials (sulfonamides, antibiotics), NSAIDs, anticoagulants of indirect (phenindion, acenocumarol) and direct (heparin) action, antiplatelet agents (acetylsalicylic acid, pentoxifylline, nicotinic acid), rheological drugs (dextran) are prescribed. Anticoagulant therapy requires monitoring of PTI and general urinalysis: a decrease in the prothrombin index and hematuria indicate the accumulation of drugs.
With chronic metrothrombophlebitis, physiotherapy is performed: ozokeritotherapy, paraffin treatment, mud treatment, diathermy, hydrogen sulfide baths. With metrothrombophlebitis complicated by suppuration of blood clots or profuse bleeding, removal of the uterus – hysterectomy or supravaginal amputation may be indicated.
With hematogenic transfer of infection, thrombophlebitis can spread to the veins of the pelvis and lower extremities. Thromboembolic complications of metrothrombophlebitis include PE, infarction pneumonia.
With a severe course of metrothrombophlebitis, suppuration of blood clots, the development of necrosis of the uterine wall, exfoliating metritis, abundant uterine bleeding, sepsis is possible. In advanced cases, partial or complete gangrene of the uterus, the formation of abscesses of the uterine wall is possible.
Prognosis and prevention
Only in case of timely therapy with the use of anticoagulants, antiplatelet agents and antibiotics, it is possible to avoid complications. Significantly worsen the prognosis of late initiation of treatment of metrothrombophlebitis, suppuration of blood clots and thromboembolic complications.
Prevention of metrothrombophlebitis requires rational management of childbirth and the postpartum period, compliance with the norms of asepsis during abortions, gynecological and obstetric interventions, timely treatment of endomyometritis.