Ovarian Vein Thrombosis Complicating Puerperal Group ‘A’ Streptococcal Sepsis

Keywords

Group A streptococcus • Ovarian vein thrombosis • Puerperal sepsis

Introduction

Group A Streptococcus (GAS) can be very infectious. Usually, the patient presents herself to the hospital in the first week after delivery with fever and abdominal pain [1]. Transmission occurs by contact with body secretions (including droplets, vaginal secretions). Transmission can occur within the hospital (usually if develops infection within the first week) or from the community (if infection occurs after the first week) [2]. Complications of GAS infections can be pneumonia, endometritis, wound infection, necrotising fasciitis, septicaemia, toxic shock syndrome, Ovarian Vein Thrombosis and/ or even death [3]. The majority of those patients might need admission to intensive care units for aggressive intravenous fluids and antibiotics and early transfer to the theatre [4]. In the following paragraphs, we present a case of GAS puerperal sepsis complicated by ovarian vein thrombosis.

Case Presentation

A 36-year-old Para 2 (two vaginal deliveries before) was admitted at Term+11 days to induce labour. Subsequently, she had an uneventful delivery of a baby girl weighing 4.3 kg. She was discharged home well with her baby on the 2^nd day. However, she presented herself the following day with a fever, severe abdominal pain, vomiting and diarrhoea. Her vital signs were markedly impaired (pyrexia of 38.3 degrees Centigrade, tachycardia of 122 BPM, low Oxygen saturation of 91% and hypotension of 92/48 mmHg). Physical examination revealed abdominal distension, generalised abdominal tenderness, guarding and rebound tenderness. We fixed a Central line and initiated aggressive fluid and Antibiotics therapy with little response. Her initial HB was 8.9 g/dl, with WBCS-12.9, CRP-94 and Serum Lactate-2.4. Symptoms were vague, and the clinical signs were non-specific. Abdominal/Pelvic CTScan raised the possibility of Acute Appendicitis or Right-Sided Ovarian Vessel Thrombosis. A Laparotomy revealed necrotic, congested and gangrenous Right-Ovary and Right-Fallopian Tube, all removed. Blood cultures returned positive for GAS infection. Aggressive antibiotic therapy was instituted with input from the Microbiology Department and included Tazocin, Clindamycin, Gentamycin and Metronidazole (for a total of 15 days) and Low Molecular Weight Heparin (for six months).

The patient was nursed in the Intensive Care Unit with invasive ventilation for 48 hours. Then, she was transferred to an Isolation room on day six postoperatively. We screened her family and close contacts for GAS, as per the Public Health team's input. The baby was treated with appropriate antibiotics by the Neonatology team. The Nutrition, Physiotherapy and Social working teams were all involved in her care. She was discharged home well on day 11 after an initial debriefing. Apart from her GP and social support teams, we also linked her with perinatal Mental Health Services. We reviewed her two months postnatally and comprehensively debriefed about the postpartum events. One year after that, she had a further pregnancy and uneventful delivery (Figures 1 and 2).

Figure 1. Transverse view of a Pelvic CT - Scan raising the suspicion of ovarian vein thrombosis).

Figure 2. Longitudinal view of Abdominal/Pelvic CT-Scan raising the possibility of ovarian vein thrombosis or acute appendicitis.

Discussion

Approximately 11,000 to 13,000 GAS infection cases per year occur in the United States [3]. There is a 20-fold increased incidence of invasive GAS in pregnant ladies than non-Pregnant; this could be due to the reduced immunity during pregnancy [4-7]. The symptoms might be vague at presentation, and hence senior involvement should be sought early. Confirmation of the diagnosis is by blood or other body fluids' culture [8]. The Ovarian vein thrombosis was considered a sequela of endometritis from GAS infection [9]. A low threshold for laparotomy is beneficial in patients who do not respond to fluids and antibiotics. Moreover, laparotomy should be the main surgical approach, especially if the patient is haemodynamically unstable. Hysterectomy is the mainstay in severe cases with severe invasive infection involving the ovarian veins and uterus [10,11]. Personal hygiene is paramount in prevention. Patients with GAS infection should be kept in an isolation room. 'In the event of the screening of a healthcare worker being positive, antibiotics must be commenced for eradication [8-12].

Conclusion

Although it is a rare infection, the incidence of GAS puerperal sepsis is increasing. Ovarian Vein Thrombosis is considered a rare complication of GAS infection. Aggressive antibiotic therapy and the management of fluid and electrolyte balance and surgical intervention are indicated together with escalation to intensive care, which is the mainstay of treatment. Multidisciplinary input, as detailed above, is of paramount importance.

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