Septic pelvic thrombophlebitis is a rare puerperal complication. It is an important differential diagnosis of postpartum fever and abdominal pain and although the condition is well known its diagnosis can be challenging. We report a case of a 41-year-old woman with fever and right abdominal pain three days after an uncomplicated caesarean delivery. Clinical, laboratory and imaging exams were unremarkable and the patient was treated for endometritis. In the absence of improvement despite an antibiotic adjustment, a clinical diagnosis of septic pelvic thrombophlebitis was made, and the patient presented a good response to anticoagulation in conjunction with broad-spectrum antibiotic therapy.

inclusion criteria for methotrexate treatment of tubal ectopic pregnancies are: Haemodynamically stable, not ruptured, serum ␤hCG of <4000 IU/L on day 0 or ␤hCG ratio at 48 h of >0.8 (␤hCG 48 h:hCG 0 h), normal haematological, liver and renal blood profiles, ectopic mass <4 cm, not live ectopic and good compliance with treatment. Second dose of methotrexate is considered if there is suboptimal fall of ␤hCG (<15% at day 7 follow up of methotrexate). Patients who develop significant pain, signs of haemoperitoneum or persistent elevated ␤hCG level would proceed to surgical treatment. Data was collected using our Image Reporting System and cross-referenced with treatment allocation and hospital database.Results: In our sample of 276 women, 87 (31.5%) had methotrexate treatment and 74 (85.1%) were successful. 20 (23%) women required a second dose of methotrexate with successful outcome. The conversion rate to surgery was 10.3% which is 9 women. 4 (4.6%) women were lost to follow up. In the women who had surgery, 4 (4.6%) women were found to have haemoperitoneum at laparoscopy. The amount of blood loss ranged from 150 ml to 1500 ml. There was no maternal mortality or significant morbidity requiring intensive care. The median initial ␤hCG value at start of treatment was 1416 IU/L (IQR 494.5-2214.5) and the median progesterone level was 18.8 ). Our median duration for follow up was 30 days.Discussion: The role of methotrexate in ␤hCG levels of 2000-4000 IU/L is controversial. Our success rate despite higher ␤hCG levels are similar to the success rate reported in the RCT comparing methotrexate to expectant management by van Mello et al. (2012) which used the cut off of ␤hCG <1500 IU/L. This study has shown that when strict criteria are followed with senior input and careful patient selection; methotrexate is as effective at higher ␤hCG levels. This therefore offers a fertility sparing option. However, further larger studies are needed to re-evaluate cut off ␤hCG levels that are safe and effective for methotrexate treatment.