Right Ovarian Vein Thrombosis : A diagnosis that will not go in

vain

Abstract ID no.  IRIA - 1073

INTRODUCTION

• Ovarian vein thrombosis is an uncommon but potentially life threatening disorder.(1)

• It is most commonly identified in the puerperium and is also seen in association with malignancy, pelvic infections, surgery and other pathologies which cause thrombophilia. (1)

• Usual presentation is fever with right iliac fossa pain.

Case Report• History and clinical features :

– A 22 year old primipara post LSCS day 14 one day history of right iliac fossa pain and low grade fever.

– past history, antepartum and immediate post partum period were otherwise unremarkable

– On examination:– RIF tenderness + No rigidity– lab reports: mild leucocytosis– Refered for abdomino-pelvic ultrasound to rule

out acute appendicitis or a tuboovarian pathology

Case Report

• USG

– tubular hypoechoic structure in the right iliac fossa with an enlarged and echogenic right ovary noted

– As findings were inconclusive CECT abdomen and pelvis was done

Case Report

• CECT– An enlarged right ovary with adjacent fat

stranding was noted in the RIF.

– A tubular structure was noted extending from the right ovary into the IVC with perivascular inflammatory changes and filling defects.

– A diagnosis of right ovarian vein thrombosis extending into to IVC was thus established.

Enlarged right ovary

Tubular non enhancing linear structure extending from RIF into IVC lumen

Oblique coronal MPR in delayed phase delineating thrombosed right ovarian vein

Discussion• Ovarian vein thrombosis:

- post partum OVT 1 in 600 to 1 in 2000 (2,3,4)

- right ovarian vein involved in 80-90% - Etiology:

- increased length of the right ovarian vein and incompetent valves induce venous stasis. (5,6)

- compression of the right ovarian vein at the pelvic brim by the enlarged dextrorotated uterus and a retrograde flow in the left ovarian vein (7,8,9)

- Virchow’s triad - stasis, hypercoagulability and endothelial injury, commonly seen in postpartum patient

- hypercoagulability associated with pelvic inflammatory disease, malignancy and pelvic surgery. (7,9,10)

Discussion- Etiology:

- Puerperal endometritis has been postulated as a possible cause of pueperal OVT.

- Anaerobic bacteria in the lower genital tract cause endothelial injury and stasis with secondary thrombosis of the pelvic veins. The bacteria gain access to the ovarian veins from the septic endometrium by crossing the uterine and vaginal venous, and lymphatic plexus. (11)

- Presentation- Fever with RIF pain- DD’s – acute appendicitis, tubo-ovarian pathology, ureteric

colic, pelvic hematoma / infections (12,13,14)

Discussion- Complications:

- extension of the thrombosis into IVC- pulmonary embolism develops in 13 - 33% cases (4,15)

- 4% mortality (15)

- Diagnosis- Radiological investigations such as ultrasonography, doppler , CT,

and MRI are useful in the diagnosis of OVT. (13,14,16)

Normal Course of Ovarian veins• venous plexus of the broad ligament and the uterine plexus, join

and course anterior to the psoas muscle and ureter.• The right ovarian vein drains into the IVC and the left ovarian

vein into the left renal vein (17,18) Ovarian veins normally measure about 3–4 mm (19)

Discussion- Ultrasound with doppler

- non-invasive- less expensive - can delineate the location and extent of the thrombus - ease of imaging in any plane

- the thrombosed ovarian vein appears as an anechoic to hypoechoic tubular structure extending superiorly from the adnexa, lateral to the IVC or aorta retroperitoneally

-

Discussion- Ultrasound with doppler

- On Doppler typical findings are absence of color-flow filling and spectral waveform .(20,21)

- bowel gas may limit visualisation and the differentiation of the ovarian vein thrombosis from appendicitis or hydroureter.

- For detection of ovarian vein thrombosis the sensitivity of USG is 56%.(6,21) Sonography may have a role for follow-up imaging in patients previously diagnose with the condition. (9,22,23)

Discussion- CT and MRI

- more sensitive CT - 100% and MRI - 92%- more specific CT - 99% and MRI – 100%. (9,21) - CT findings of venous thrombosis are :

- a tubular retroperitoneal mass with central low attenuation extending cephalad to the inferior vena cava (IVC), it may show perivascular inflammatory changes.(6,22)

- A delayed scan done during the excretory phase of the kidneys would be useful to differentiate a ureter from the ovarian vein.

- As in our patient, the CT scan was important to confirm the diagnosis and to demonstrate the extension to the IVC.(24)

Discussion- Managament

- Conservative- anticoagulation (for about 6 months) and follow up

of the case- Antibiotics are usually given in postpartum

patients presenting with fever and abdominal pain as an empirical treatment for endometritis . (6,20)

Conclusion

- Right lower quadrant pain poses a diagnostic dilemma, especially in the female patient.

- common causes are- ureteric colic, acute appendicitis, tubo-ovarian

abscess, ectopic pregnancy and an ovarian torsion- Rarely the cause may be a thrombosed ovarian

vein- However it is more common in a patient in the puerperal

period.

Conclusion

- A high index of suspicion is required in order to make the diagnosis as the patient may present with vague symptoms and initial imaging may be unremarkable.

- It is imperative to make the diagnosis, however, as the condition has a high index of mortality and morbidity with the incidence of pulmonary thromboembolism reported to be as high as 33%(6) of which 4% may be fatal.(4,25)

Oblique coronal MPR in delayed phase delineating thrombosed right ovarian vein

A contrast enhanced CT scan must be performed which can elegantly demonstrate a filling defect in the ovarian vein.

Conclusion

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