Persistent puerperal infections can be evaluated using computed tomography (CT) or magnetic resonance (MR) imaging. Brown and associates (1991) used CT imaging in74 women in whom pelvic infection was refractory to antimicrobial therapy given for 5 days. hey found at least one abnormal radiological inding in 75 percent of these women, and in most, these were nonsurgical lesions. In most cases, imaging can be used to dissuade surgical exploration. Uterine incisional dehiscence such as shown in Figure 37-4 can sometimes be confirmed based on CT scanning images. hese indings must be interpreted within the clinical context because apparent uterine incisional defects thought to represent edema can be seen even after uncomplicated cesarean delivery (Twickier, 1991). Shown in 37-5 is a necrotic hysterotomy incision that leaked into the peritoneal cavity.
FIGURE 37-5 Necrotic hysterotomy infection. Severe cellulitis of the uterine incision resulted in dehiscence with subsequent leakage into the peritoneal cavity. Hysterectomy was required for sufficient debridement of necrotic tissue.
Occasionally, a parametrial phlegmon may suppurate, forming a fluctuant broad ligament mass that may point above the inguinal ligament. hese abscesses can dissect anteriorly as shown in Figure 37-4 and be amenable to CT-directed needle drainage. Occasionally they dissect posteriorly to the rectovaginal septum, where surgical drainage is easily efected by colpotomy. Apsoas abscess is rare, and despite antimicrobial therapy, percutaneous drainage may be required to efectively treat it (Shahabi, 2002; Swanson, 2008).
Suppurative thrombophlebitis was a frequent complication in the preantibiotic era, and septic embolization was common. However, with the advent of antimicrobial therapy, the mortality rate and need for surgical therapy for these infections diminished. Septic phlebitis arises as an extension along venous routes and may cause thrombosis as shown in Figure 37-6. Lymphangitis often coexists. he ovarian veins may then become involved because they drain the upper uterus and therefore the placental implantation site. The experiences of Witlin and Sibai (1995) and Brown and coworkers (1999) suggest that puerperal septic thrombophlebitis is likely to involve one or both ovarian venous plexuses. In a fourth of women, the clot extends into the inferior vena cava and occasionally to the renal vein.
The incidence of septic phlebitis has varied in several reports.
In a 5-year survey of 45,000 women who were delivered at Parkland Hospital, Brown and associates (1999) found an incidence of septic pelvic thrombophlebitis in 1 per 9000 gravidas following vaginal delivery and 1 per 800 after cesarean delivery. he overall incidence of 1 per 3000 deliveries was similar to the 1 per 2000 reported by Dunnihoo and colleagues (1991). In large studies of women with cesarean delivery, the incidence was 1 in 400 to 1 in 1000 surgeries (Dotters-Katz, 2017; Rouse 2004). Chorioamnionitis, endometritis, and wound complications were other risks.
Women with septic thrombophlebitis usually have symptomatic improvement with antimicrobial
Inferior vena cava treatment, however, they continue to have fever. Although pain occasionally is noted in one or both lower quadrants, patients are usually asymptomatic except for chills. As shown in