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Radiol Case Rep
Radiol Case Rep
Radiology Case Reports
1930-0433
Elsevier

S1930-0433(24)00654-X
10.1016/j.radcr.2024.07.063
Case Report
Ovarian vein thrombosis in a postpartum female: A case report
Jha Anamika a
Khatiwada Abhikanta avikant12@gmail.com
a⁎
KC Sharada b
a Department of Radiology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
b Department of Internal Medicine, NAIHS, Kathmandu, Nepal
⁎ Corresponding author. avikant12@gmail.com
10 8 2024
11 2024
10 8 2024
19 11 47594761
9 5 2024
12 7 2024
13 7 2024
© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Ovarian vein thrombosis (OVT), while uncommon, is a serious complication that can arise from pregnancy, pelvic inflammatory disease, oncological conditions, and pelvic surgeries. Here we discuss a case of a 37-year-old woman who, during her postpartum period, experienced lower abdominal pain and fever. Utilizing imaging findings, she was ultimately diagnosed with right ovarian vein thrombosis. The puerperium represents a hypercoagulable state, heightening the risk of OVT, particularly following a cesarean section. Despite its rarity, OVT should invariably be considered in the differential diagnosis when evaluating patients who present with postpartum abdominal pain and/or fever.

Keywords

Pregnancy
Puerperium
Hypercoagulable state
Serpiginous adnexal lesions
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pmcIntroduction

Postpartum ovarian vein thrombosis (OVT) is an uncommon condition, with an incidence of 1:600 to 1:2000 deliveries [1]. Either one or both ovarian veins can be involved, with the majority (80%-90%) affecting the right side, 6% involving the left, and the remaining 14% being bilateral [2]. Multiple hypotheses exist regarding the right-sided predilection of ovarian vein thrombosis. Some major theories include the longer course of the right ovarian vein with incompetent valves [3], the acute angle between the right ovarian vein and the inferior vene cava (IVC) [4], and dextrorotation of the enlarged uterus during pregnancy causing compression of the right ovarian vein, thus resulting in stasis [5].

Here we present a rare case of a 37-year-old woman who presented with lower abdominal pain and fever in her postpartum period and was diagnosed with right OVT with the aid of imaging findings.

Case presentation

A 37-year-old woman, para 2, experienced severe right-sided lower abdominal pain and fever on the third postoperative day following a cesarean section. She was previously healthy, a nonsmoker, nonalcoholic, and had an unremarkable antenatal history. The cesarean section was uneventful, and she was admitted to the postoperative ward. There was no past medical history or family history of hypercoagulability. Her vital signs were unremarkable, except for a raised temperature (101 degrees Fahrenheit). Her physical examination revealed mild tenderness on palpation of the right lower quadrant of the abdomen. A pelvic examination revealed cervical and right adnexal tenderness. Laboratory tests showed an elevated white blood cell count (14,000 cells/mm³) with neutrophilia and elevated C-reactive protein (169 mg/dL).

Ultrasound revealed tubular hypoechoic lesions in the right adnexa, adjacent to the bulky postpartum uterus. An abdomen and pelvic contrast-enhanced computed tomography (CT) scan revealed hyperdense nonenhancing serpiginous tubular lesions in the right adnexa (Figs. 1B and 2B), contiguous with a distended, nonenhancing right ovarian vein (Figs. 1A and 2A). The filling defect extended just up to the IVC without obvious extensions into the IVC lumen. Soft tissue strandings were seen around the thrombosed ovarian vein. Enhancement was noted in the right uterine wall in the venous phase images, possibly due to venous congestion. Considering the clinical and radiological findings, a diagnosis of postpartum right ovarian vein thrombosis was made.Fig. 1 (A) This coronal image from an abdomen and pelvic plain CT scan displays a hyperdense tubular lesion in the right adnexa and flank region, indicative of a distended and thrombosed right ovarian vein (blue arrow). (B) An axial view from an abdomen and pelvic plain CT scan reveals a hyperdense serpiginous lesion in the right adnexa, representing a distended and thrombosed right ovarian vein (blue arrow).

Fig 1

Fig. 2 (A) A coronal reformatted image from an abdomen and pelvic contrast-enhanced (venous phase) CT scan showcases a distended right ovarian vein with a nonenhancing filling defect (blue arrow) and surrounding inflammatory changes. Notably, there is enhancement of the uterine myometrium, likely resulting from venous congestion. (B) This axial image from an abdomen and pelvic contrast-enhanced (venous phase) CT scan illustrates a distended and tortuous right ovarian vein with a nonenhancing filling defect (blue arrow), accompanied by surrounding inflammatory changes. Note the enhancement of the uterine myometrium, suggesting venous congestion.

Fig 2

The patient began treatment with enoxaparin and intravenous broad-spectrum antibiotics for 5 days. She was discharged on the nineth postpartum day and advised to continue enoxaparin for at least 3 months, with outpatient follow-up with hematology. After completion of 3 months of therapy, her symptoms had completely resolved, and a pelvic ultrasound showed unremarkable results.

Discussion

Although typically associated with pregnancy, other conditions responsible for OVT include pelvic inflammatory disease, oncological conditions, and pelvic surgeries [6]. The basic pathogenesis of OVT can be explained by Virchow's triad, which includes blood flow stasis, hypercoagulability, and endothelial injury. The puerperium is a hypercoagulable state affecting all these 3 factors. The endothelial injury is usually inflicted by an infectious process extending from the uterus to the ovarian veins [1].

OVT classically presents with acute pelvic pain and fever in the postpartum period and sometimes as a palpable abdominal mass. The symptoms usually occur within the first week postpartum [7]. Associated complications include thrombus progression into the IVC or the left renal vein, pulmonary embolism, and pelvic congestion syndrome [7].

Ultrasonography is the initial imaging modality in suspected cases of OVT and its sensitivity varies widely from 50% to 100% [8]. The findings include hypoechoic serpiginous adnexal lesions without obvious color flow on the Doppler study [8], which plays an important role in follow-up for resolution as well. Contrast-enhanced computed tomography (CT) scan is the best modality to detect OVT, where the lesion appears as a tubular structure with an enhancing wall and a low-attenuation thrombus in the expected location of the ovarian vein [9]. Enlargement of the ovarian vein with surroundings inflammatory changes are commonly associated findings. One common differential for OVT on imaging is hydroureter; however, these 2 can be easily differentiated on a CT scan by tracing their usual course.

Treatment in these cases consists of broad-spectrum antibiotics and anticoagulants [7], with a recommended duration of anticoagulant treatment usually being 3 to 6 months [7]. Mortality has significantly reduced nowadays due to a treatment combination of anticoagulation and parenteral broad-spectrum antibiotics [10].

Conclusion

Puerperium is a hypercoagulable state, and the risk for ovarian vein thrombosis is even higher in cases with a cesarean section. OVT, though rare, should always be considered in the differential diagnosis for patients presenting with postpartum abdominal pain and fever. While ultrasound Doppler is generally the first imaging choice, a CT scan is often recommended to confirm the presence and extent of OVT.

Patient consent

Written informed consent was obtained from the patients for publication of this case report and any accompanying images.

Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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