OVT during the puerperium is a rare pathology that is characterised by inflammation or thrombosis of one or both ovarian veins.2
It occurs in the right ovarian vein in 80% to 90% of the cases.5
This is believed to be due, in part, to the commonly occurring dextrotorsion of the enlarging uterus, which causes compression of the right ovarian vein and right ureter as they cross the pelvic brim or to the incompetent valves of the right ovarian vein that are a cause for stasis.1
The right ovarian vein is also longer than the left and has many valves which may act as niduses for thrombus formation.1
In addition, during pregnancy there is an increase in the retrograde drainage from the left to right ovarian vein, which results in a greater number of bacteria entering the right ovarian vein.6
Furthermore, due to hormonal and mechanical changes that occur during gestation, a state of hypercoagulability persists from pregnancy up to 6 weeks after delivery.3
The typical presentation of OVT includes severe lower abdominal or flank pain on the affected side, fever and an abdominal mass. The mass is usually described as a firm, rope-like tender structure varying from 2 to 8 cm in diameter that extends along the adnexal lumbar gutter. Such a mass was found in 67% of the cases in one case series.6
Leukocytosis of more than 12 000/mm3
occurs in 70% to 100% of the cases.6 7
Patients usually present within 1 week of delivery. The presence of nausea, vomiting and illeus has also been reported. First case of postpartum OVT presenting as ureteral obstruction was reported in 1974.8
Differential diagnosis is extensive and includes appendicitis, pyelonephritis, endometritis, tubo-ovarian abscess and adnexal torsion, intussusception, volvulus and cholecystitis.
Prior to the advent of modern imaging tools, the only definitive way to diagnose OVT was by surgery, but the mortality was high.3
Ultrasound with Doppler is a useful, inexpensive tool for initial and follow-up examinations. A tubular mass is usually seen adjacent to the psoas muscle without evidence of blood flow.9
However, ultrasound is operator dependent and is limited by body habitus, abdominal tenderness and obscuring bowel gas. MRI has also been used to diagnose OVT but is of less value as patients are often unstable and is not as cost-effective as other imaging modalities. Contrast-enhanced CT scan is a reliable and accurate method for diagnosing OVT. Visualisation of the thrombus is improved with intravenous contrast where the thrombus is seen as a low-density area within an contrast-enhanced vessel lumen, clearly showing in some cases vena caval involvement.10
The sensitivities of ultrasound, MRI and CT for diagnosing OVT are 52%, 92% and 100%, respectively.1 11
OVT is treated initially with broad-spectrum antibiotics and intravenous heparin. Prompt resolution of symptoms, within 24 to 72 h, has been reported with therapeutic heparin therapy2 5
, as in our case. Once thrombolysis has begun, warfarin is introduced and continued for 3 weeks to 3 months. Antibiotics are continued for at least 1 week.12 13
Historically, early laparotomy for diagnosis and treatment was recommended once OVT was suspected. Currently, surgery is indicated in some cases after failure of conservative therapy or when the risk of pulmonary embolism is high.6
Potential serious complications of OVT include progression of thrombus in to the inferior vena cava, or the renal vein, and pulmonary embolism. Pulmonary embolism may complicate OVT in up to 13% of cases and has a mortality of approximately 4%.5
- Ovarian-vein thrombosis (OVT) is an uncommon disorder during pregnancy and puerperium, so a high index of suspicion is required to diagnose it.
- Knowledge of this entity should guide to appropriate diagnosis and treatment, avoiding misdiagnosis, unnecessary laparotomy and potential complications.
- Imaging modalities such as ultrasound, MRI and CT are useful for diagnosing OVT (with sensitivities of 52%, 92% and 100% respectively).
- The mainstay of treatment is anticoagulation.