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Chin Med J (Taipei) 1997;60:224-7.
A Case Report
1Department of Obstetrics and Gynecology, Tri-Service General Hospital, National Defense Medical Center, Taipei;
2Department of Obstetrics and Gynecology, Tzu-Chi Medical College Hospital, Hualien;
3Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C.
Postpartum thrombophlebitis is an infrequent disorder in Chinese women. A case is reported of extensive postpartum thrombophlebitis involving 23 cm of the femoral and pelvic veins. This 25-year-old splenectomized victim of beta-thalassemia was bedridden for 12 weeks because of threatened premature labor before Cesarean delivery. During the operation, placenta increta with massive bleeding was encountered. To save the uterus, ten percent of the placenta was retained. Duplex color Doppler imaging was performed for the diagnosis and follow-up of the thrombosis and vigorous anticoagulation therapy successfully cured this patient.
[Chin Med J (Taipei) 1997;60:224-7.]
Keywords: placenta increta, reactive thrombocytosis, thrombophlebitis
Received: August 26, 1996.
Accepted: August 15, 1997.
Address reprint requests to: Chi-Huang Chen, M.D., Department of Obstetrics and Gynecology, Tri-Service General Hospital and National Defence Medical Center, No. 40, Sec. 3, Tin-Chou Rd., Taipei, Taiwan, R.O.C.
Thrombophlebitis is a significant and fatal complication of pregnancy within the western population and warrants prophylactic heparinization for patients at risk. On the contrary, this disorder is so infrequent in Chinese parturients that prophylactic heparinization is seldom used. A rare case of extensive deep vein thrombophlebitis with reactive thrombocytosis is reported. Multifold predisposing risk factors contributed to the occurrence of this unusual case.
The victim was a 25-year-old G2P1 Chinese woman of beta-thalassemia minor who had lost her spleen at age 9 after an accident. Three years before this pregnancy, the patient had had a molar pregnancy, and underwent dilatation and curettage along with methotrexate therapy. She was on bed rest most of the third trimester of this pregnancy receiving tocolytics for preterm labor. Cesarean section was performed at 40 weeks gestation due to breech presentation. Unfortunately, placenta increta with atonic uterus and massive bleeding was encountered. The uterus was saved by manually removing part of the placenta, then using intrauterine gauze packing, oxytocics and 500 ml of blood transfusion. Ten percent of the placenta was retained within the uterus. Parenteral antibiotics were administered with ampicillin 1.0 gm every six hours and gentamicin 80 mg every eight hours for seven days. The packed gauze was removed smoothly the following day. A transient low grade (38OC) fever developed on the fourth postpartum day but subsided upon metronidazole treatment. The patient was then discharged one week later. On the 16th postpartum day, she was admitted again complaining of chills, fever, lower abdominal pain, swollen left leg and a palpable induration over the left femoral triangle area. Thrombocytosis up to 890,000/cumm was noted. A duplex Doppler ultrasonography revealed absence of blood flow over the left external iliac and common iliac veins (Figure 1). A pelvic computerized tomography (CT) disclosed a 23 cm-long filling defect extending from the left superficial femoral vein to the common iliac vein, with perivascular inflammatory change (Figure 2). Bone marrow aspiration demonstrated an increased number of megakaryocytes. An unusually high level of fibrinogen (522.6 mg/dl) was noted. The patient underwent anticoagulant therapy with intravenous Urokinase 60000 units/hour for three days, followed by parenteral heparin in a dose of 16000 to 24000 units daily; the dosage was adjusted to maintain a partial thromboplastin time 1.5 to 2 times of the baseline. The heparinization was changed to coumadin 5 mg daily on the 41th postpartum day after clinical symptoms and signs were improved. Before discharge, pelvic CT showed significant improvement of the patency of the deep pelvic veins (Figure 3). Intrauterine necrotic tissue was disclosed by hysteroscopy and pathology. At this time, the patient remains robust under coumadin medication.
Deep vein thrombophlebitis is responsible for a significant role of puerperal fever in western countries where obstetricians are aware of this complication. The development of severe thrombophlebitis in this case can be attributed to multiple risk factors, i.e. thalassemia, splenectomy, pregnancy, prolonged bed rest and retained placenta.
Constitutional factors of splenectomy and beta-thalassemia underlie intensively to spontaneous platelet aggregation and deformity of erythrocytes. More adenosine diphosphate is released by erythrocytes; this promotes the tendency of platelet adhesiveness and aggregability [1,2].
The hemodynamic changes of pregnancy, such as hypercoagulability, decreased fibrinolytic activity and stasis of venous flow, contribute to a coagulopathy. The involvement of left side pelvic and femoral veins in this case is consistent with published reports [3], and reflects compression by the gravid uterus [4,5]. During the immediate postpartum period, a hypercoagulability rather than fibrinolytic tendency ensures a safeguard against peripartum hemorrhage at the expense of increased risk of thromboembolism [6]. In long-term bedridden pregnancy, the patient also took a great risk of inducing an imbalance of several complex systems of endothelial vessel motion, thrombocytes, hemostatic, fibrinolytic system and their inhibitors. All these factors contribute to the development of thrombosis.
On the other hand, the retained placenta comprises rich thromboplastic tissue which readily activates the coagulation cascade and results in thrombosis. The greater the consumption of platelets, the more the production of platelets by hemopoietic system. This further counteracts the spontaneous hemostatic crisis and leads to reactive thrombocytosis.
Other primary hypercoagulable states, not present in this particular case include inherited abnormalities of coagulation such as antithrombin III deficiency, protein C and protein S deficiency, abnormalities of the fibrinolytic system and dysfibrinogenemias; additional secondary hypercoagulable states including malignancy, use of oral contraceptives, myeloproliferative disorders, hyperlipidemia and diabetes mellitus [7].
A definite diagnosis of thrombophlebitis must be made before subjecting a patient to the risks associated with anticoagulant therapy. In this case, a duplex Doppler ultrasound combining B-mode, pulse Doppler and color flow was very helpful. It was a relatively simple, non-invasive, inexpensive and definitive procedure. The addition of color allows visualization of variable manners of hemodynamic flow throughout the entire image, and improves the sensitivity and specificity of the duplex imaging examination [8]. A pulsed Doppler signal can be obtained selectively at any location on the image. This, together with the imaging of ultrasound, allows more direct visualization of the extent and anatomic level of a thrombus than does impedance plethysmography or portable Doppler studies. In this case, CT assessed clearly the image of the pelvic vessels and provided information of related abnormal anatomic change in a long area of thrombophlebitis. Three criteria were present for the diagnosis: enlargement of the thrombosed vein, low-density lumen and a sharply defined wall [9].
The most common regimen used for the treatment of patients with acute deep vein thrombosis is heparin followed by coumadin. The use of heparin, however, does not prevent the dissolution of a thrombus or the formation of emboli, but prevents the formation of a new thrombus and thus permits the fibrinolytic system to work more effectively. A heparin dose adjusted to keep the partial thromboplastin time at a level of 1.5 to 2 times the control value worked effectively and safely in this case. The treatment was followed by oral sodium warfarin before allowing the patient to be discharged. Generally, fibrinolytic agents are helpful only for patients whose blood clot extends proximally beyond the origin of the deep femoral vein [10], as in the presented case. The effects of this fibrinolytic agent should be monitored closely by the fibrinogen level and partial thromboplastin time. The coagulated deep veins usually do well in the long run, grating to the collateral circulations [10].
The case presented demonstrates the multiple risk factors contributing to the development of puerperal thrombophlebitis and emphasizes the importance of proper prophylaxis and management of this condition.
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Copyright: 1997, Chinese Medical Association (Taipei)