Postpartum thrombophlebitis is an obstetric complication characterized by inflammation of the walls of the veins, thrombosis in the pelvis and lower extremities, developing in women after childbirth. The disease is manifested by an increase in body temperature, tachycardia, local pain. The diagnosis is made on the basis of anamnestic data, the results of a clinical examination, ultrasound examination of vessels with duplex scanning, coagulogram. The main method of treatment is anticoagulant therapy, with a high risk of arterial thromboembolism, surgical intervention is indicated.
ICD 10
O87.0 Superficial thrombophlebitis in the postpartum period
General information
Postpartum thrombophlebitis is an acute venous disease in maternity women with the formation of blood clots in the lumen, an inflammatory process, and a violation of venous blood flow. The incidence of venous thrombosis with associated or primary phlebitis in the postpartum period is 3.5%, almost an order of magnitude higher than the prevalence of thrombotic complications during pregnancy. Pathology can develop in women of any age, but it is more often registered in women over 35 years old. When a vein is obstructed by a thrombus, unlike arterial thromboembolism, ischemia is extremely rare, but thrombosis of the inferior vena cava system is the main source of embolism of the pulmonary artery basin.
Causes
Postpartum thrombophlebitis has a multifactorial nature. A favorable background for the occurrence of pathology are physiological changes in the body of a pregnant woman: compression of the vena cava by the pregnant uterus, slowing of the peripheral blood flow rate and an increase in blood clotting potential, most pronounced by the end of pregnancy. Significant risk factors for thrombotic complications after childbirth:
- Complicated labor. Childbirth accompanied by soft tissue ruptures (especially with massive bleeding), surgical delivery often lead to thrombophlebitis of the deep veins of the thigh and lower leg. With extensive injuries, tissue thromboplastin enters the bloodstream, aggravating the activation of blood clotting characteristic of late pregnancy.
- The pathological course of pregnancy. The probability of developing postpartum thrombotic complications is significantly increased by gestosis. This pathology is accompanied by vascular spasm with damage to the endothelium, the release of biologically active substances, entailing the loss of thrombo-resistant properties of blood vessels.
- Inflammation of the uterus. Postpartum metroendometritis triggers thrombosis in the uterine, pelvic and ovarian veins. The mechanism of development of thrombosis is similar to that of gestosis: the result of alteration is the release of prostaglandins, which are transformed into thromboxane A2, stimulating the activation and aggregation of platelets.
- Extragenital pathologies. Venous thrombosis is prone to maternity women suffering from diseases accompanied by circulatory disorders – cardiac pathologies (especially rheumatic), hypertension. The main risk factors also include vasculitis of any etiology, malignant neoplasia.
- Taking hormonal medications. The long-term use of hormonal contraception (especially with a high content of estrogens) can aggravate the hemostatic changes associated with pregnancy. The probability of thrombosis is increased in women who have become pregnant after hormonal induction of ovulation (with or without IVF).
- Hemostasis defects. Postpartum thrombophlebitis often develops in women with congenital mutation of factor V Leiden and the prothrombin gene, congenital hyperhomocysteinemia, deficiency of antithrombin III and proteins C, S or acquired thrombophilia (antiphospholipid syndrome, hyperhomocysteinemia against the background of vitamin B12, B9, B6, B1 deficiency).
Other risk factors include physical inactivity (when working standing or sitting, long flights, long bed rest), heavy physical activity (overweight, regular weight lifting), late reproductive age. Intravenous infusions and smoking increase the risk of thrombosis. One of the main predisposing conditions for the development of complications unrelated to gestation is nonspecific connective tissue dysplasia, the signs of which include varicose veins of the lower extremities, hemorrhoids that occurred before pregnancy.
Pathogenesis
The mechanism of thrombus formation is based on the so-called Virchow triad, which includes changes in hemostasis (increased blood clotting) and hemodynamics (decreased venous blood flow), damage to the venous wall. Thrombogenesis can occur against the background of hypercoagulation (phlebothrombosis) with the subsequent development of reactive inflammation, or vice versa, a thrombus occurs due to damage and then inflammation of the endothelium. A blood clot is fixed to the vascular wall at the site of its lesion, its further evolution follows one of three paths.
The first pathway is characterized by the growth of a blood clot, the second by its spontaneous lysis, the third by the organization of thrombotic masses (their germination by connective tissue and capillaries). The process is accompanied by the formation of cavities in the clot, spontaneous recanalization of the thrombus due to fibrinolysis. In small vessels, occlusive thrombi are formed more often, completely blocking the lumen, in large vessels – floating, washed with blood. The latter are embologenic – with a high probability of separation, movement through the inferior vena cava and the right atrium into the arterial bloodstream.
Classification
Postpartum thrombophlebitis can be superficial, spreading to the subcutaneous veins of the lower extremities, and deep, with damage to the large main vessels of the legs, pelvis. By the nature of inflammation, purulent and non–purulent forms are distinguished, by the type of thrombus development – limited or segmental, with rapid differentiation, organization of a blood clot and progressive – with its further growth. According to localization, the following classification of pathology developed after childbirth has been adopted:
- Thrombophlebitis of the lower leg veins. Superficial thrombophlebitis is manifested by the defeat of the small, large subcutaneous veins of the lower leg and their tributaries, deep – tibial veins. Pathological changes in deep vessels can occur in isolation or spread from superficial vessels through communicants. With ascending thrombophlebitis, the femoral vein is involved in the process.
- Ilio-femoral (ileofemoral) thrombophlebitis. Starting with physiological thrombosis of the vessels of the placental site, it spreads to small tributaries of the internal iliac vein, then to its trunk and then to the common iliac vein. With occlusion of the latter, the deep and superficial vessels of the thigh are involved in the pathological process.
- Pelvic thrombophlebitis. The process of inflammation and thrombosis is exposed to the venous plexuses of the pelvis – the uterovaginal, vesicular, rectal, cluster-shaped plexus of the ovary. With progression, the iliac vein is affected, and then the femoral vein.
- Metrothrombophlebitis. Defeat of the main uterine veins originating from the uterine venous plexus. Thrombophlebitis of the uterine veins is almost always a consequence of postpartum endometritis.
- Thrombophlebitis of the ovarian vein. Pathology is characterized by changes in the cavity of the main vessel collecting blood from the venous plexus of the ovary. An extremely rare disease that develops almost exclusively after childbirth, most often against the background of congenital or acquired thrombophilia.
Symptoms of postpartum thrombophlebitis
Signs of a pathological condition can be detected as early as the fifth or sixth day after delivery, but more often the manifestation is noted in the second or third week after delivery. The harbingers of the disease are a long-lasting subfebrile temperature, an increasing heartbeat. The beginning is marked by a brief chill. Symptoms may vary depending on the location of the lesion.
Superficial thrombophlebitis is accompanied by the most vivid manifestations: tension, soreness, redness along the course of the affected vessels, local and general fever. With thrombophlebitis of the deep veins of the lower leg, there is swelling of the ankles (usually pronounced in the evenings, subsiding after a night’s sleep), pain in the calves during getting up and walking, as well as with back flexion of the foot (Homans symptom).
Pelvic vein thrombosis has no specific symptoms before the transition to the iliac and femoral vessels with the development of inguinal edema on the affected side. Prior to this, only a prolonged subfebrility with tachycardia is detected, pain during defecation, flatulence, and sometimes vomiting may be observed. Often patients complain of dyspareunia, general weakness, indefinite pelvic and lumbar pain.
Ileofemoral thrombophlebitis proceeds for a long time with uncertain symptoms – fever, tachycardia. Sometimes there are pains in the lower abdomen and sacral region, difficulty urinating. Complete occlusion of the iliac vein is accompanied by sudden pain in the iliac, inguinal regions radiating into the thigh, chills, swelling of the anterior abdominal wall, lower back, external genitals. The pain is accompanied by a feeling of bursting of the thigh and calf.
When deep femoral veins are involved, fever is detected, rapidly developing persistent edema of the limb (the volume of the affected thigh is increased by 5-15 cm or more), acute unbearable pain in the anterior inner thigh area along the vascular bundle. Inguinal-femoral lymph nodes are enlarged. The skin of the affected limb is pale, has a bluish-marble hue, its foot is colder than a healthy one. The general condition is serious.
Metrothrombophlebitis, which develops in the second week of the postpartum period, is accompanied by pelvic pain, bloody discharge from the genital tract, increasing by the end of the third week. The lesion of the ovarian veins has no pathognomonic symptoms. Spontaneous abdominal pains are recorded (usually right-sided, since 90% of women have thrombosis affecting the right ovary), radiating to the groin, pain when pressing on the ovary area, fever.
Complications
The most serious complication of venous thrombosis is pulmonary embolism (PE), detected in 40-50% of patients. In 10% of patients, the pulmonary trunk and large arterial branches are affected with the development of massive PE (usually due to thrombosis of the ilio-femoral or popliteal-femoral segment, less often pelvic venous plexuses), leading to acute cardiopulmonary insufficiency, death. When emboli blockage of smaller branches (the result of deep phlebothrombosis of the vessels of the lower leg), a heart attack-pneumonia is observed.
The consequence of widespread thrombosis is the occurrence of varicose veins, post-thrombophlebitic syndrome, leading to chronic venous insufficiency (CVI) and disability. The defeat of the ileofemoral segment with complete obstruction of vascular collaterals is accompanied by arterial spasm, can provoke limb ischemia, venous gangrene. Complications of ovarian vein thrombophlebitis include ovarian infarction, acute ureteral obstruction, acute renal and multiple organ failure.
Diagnostics
Diagnosis of postpartum thrombophlebitis is usually difficult due to the absence of specific signs. The only exceptions are lesions of the superficial veins of the extremities with their vivid symptoms. The diagnosis is established with the participation of an obstetrician-gynecologist and a phlebologist. It is possible to suspect thrombotic complications by analyzing the anamnestic data, complaints of the patient. Further activities include:
- Clinical examination. Thrombophlebitis may be indicated by pronounced tachycardia combined with hyperthermia, sometimes not corresponding to body temperature values. During gynecological examination and general examination, in case of thrombotic complications, the affected vessels, represented by dense painful cords, are palpated in maternity patients.
- Ultrasound angioscanning. The most informative method of diagnosing thrombophlebitis in modern phlebology is Doppler ultrasound. The study makes it possible to determine the boundary and degree of organization of a blood clot, to assess the condition of valves, walls of deep and perforating veins.
- Coagulological studies. To clarify the causes of thrombophlebitis, two methods are used – thromboelastography and coagulometry. With the help of the first method, the changes in the coagulological cascade are studied integrally, with the help of the second, its individual chains are evaluated in detail. A comprehensive analysis allows you to determine which of the links of hemostasis is broken.
Differential diagnosis is carried out with other purulent-inflammatory diseases (appendicitis, parametritis, sepsis), pathologies of the urinary system (nephrotic syndrome, pyelonephritis, urolithiasis), skin and soft tissue diseases (erysipelas, cellulite, phlegmon). Thrombophlebitis should also be distinguished from regional metastases of external genital cancer.
Treatment of postpartum thrombophlebitis
Conservative therapy
The main objectives of therapeutic measures are to prevent the spread of thrombosis, relief of inflammation, prevention of relapse of the disease. Superficial thrombophlebitis is usually treated on an outpatient basis with the maximum possible activity of the patient (excluding static loads). Therapy of thrombophlebitis of the deep veins of the extremities and intra-phase localization is carried out on the basis of a surgical hospital. With floating blood clots, strict bed rest is prescribed in order to reduce the likelihood of thrombus detachment and the development of arterial thromboembolism.
- Anticoagulant treatment. Anticoagulants do not contribute to the resorption of a blood clot, however, they stop the progression of thrombosis. After diagnosis, systemic therapy with low molecular weight heparins is first used, after which they switch to long-term use of indirect anticoagulants.
- Antibiotic therapy. Antibacterial drugs are prescribed according to strict indications – for thrombophlebitis that has developed against the background of a purulent-inflammatory process. With reactive (aseptic) inflammation, antibiotic treatment is not only useless, but can also cause harm, since it increases blood clotting, leads to the progression of the disease.
- Anti-inflammatory treatment. Nonsteroidal anti-inflammatory drugs (ketoprofen, diclofenac) are used to treat aseptic phlebitis. These medications contribute to the relief of inflammation, eliminate pain, and have an antiplatelet effect. They are applied parenterally, internally and topically.
- Angioprotectors and microcirculation correctors. Agents such as rutoside and troxerutin reduce the permeability of the vascular wall, reducing the inflammatory response. They are prescribed inside, local application is ineffective. Intravenous administration of pentoxifylline improves the rheological properties of blood.
- Compression therapy. Elastic compression of the lower extremities is indicated for out-of-phase varicothrombosis. The bandage reduces venous congestion, which prevents further thrombosis. As a rule, bandaging is initially used, after the pain subsides, they switch to long-term wearing of compression stockings.
Surgical treatment
Surgical intervention is prescribed for contraindications to anticoagulant pharmacotherapy (danger of bleeding, idiosyncrasy to drugs), the presence of a floating thrombus and repeated episodes of PE, aimed at preventing thromboembolism from entering the arterial bed. Another indication for surgery is venous ischemia. Treatment is performed by an endovascular surgeon and includes the following methods:
- Recanalization of a thrombosed vessel. Removal of thrombotic masses in order to restore the patency of the vein is performed by mechanical (thrombectomy) or biochemical (regional selective thrombolysis) method. Since the introduction of thrombolytics can provoke the separation of the floating “tail” of the thrombus, the patient is pre-installed with a cava filter.
- Implantation of a cava filter. Fixation to the walls of the vena cava of a device that passes blood, but delays emboli in order to prevent PE. The method is limited in use in young patients planning further implementation of reproductive function due to the lack of data on long-term consequences. An alternative is suture filtration of the vessel.
- Stitching of the vein. It consists in the imposition of U-shaped sutures that capture both venous walls. As a result, a filter is formed that does not pass emboli. With thrombophlebitis, plication of the inferior vena cava, femoral veins, and iliac vein is practiced. The technique is used when it is impossible to implant a cava filter.
Prognosis and prevention
The prognosis depends on the prevalence and localization of the thrombotic process, the possibility of eliminating etiological factors, the age of the patient and the activity of her immune system. Relapses are recorded in 10-30% of patients. Primary prevention includes the fight against gynecological inflammatory diseases, drug correction of hemostasis in women at risk. Other measures include giving an elevated position to the legs in bed, early activation of patients after delivery, wearing compression knitwear.
