Teaching Case

A 23-year-old patient, G2 P3 presented with abdominal pain for 1 day.
A 37-year-old patient, G6 P4+1 presented with fever for 6 days.
A 27-year-old patient, G4 P4 presented with fever for 1 day.
A 26-year-old patient, G5 P4+1 presented with abdominal pain and fever for 1 day.

Fig 1, TA US showes an elongated inhomogeneous vascular mass in the left iliac fossa. CE-CT abdominal shows left gonadal vein thrombosis in the left iliac fossa adjacent to the left adnexa. No bowel obstruction.

Fig 2, CE-MRI of small bowel shows no inflammatory disease of the small bowel and right renal hydronephrosis. CE-CT abdomen shows bilateral ovarian vein thrombosis extending from ovaries to renal vein. No bowel obstruction.

Fig 3, TV US shows left flank containing an inhomogeneous mass from the left kidney to the lower left iliac fossa. CE-CT abdomen shows the left ovary enlarged with left ovarian vein thrombosis and involves the left renal vein. No bowel obstruction.

Fig 4, TA US shows a right adnexal tubular structure between the uterus and the right ovary, while the ovaries are normal. CE-CT abdomen shows postpartum uterus and extensive stranding around the right adnexa and thrombosis in the right ovarian vein extending up to IVC, while the renal veins are normal. Right renal hydronephrosis. No bowel obstruction.

Ovarian vein thrombosis (OVT) is an uncommon condition in postpartum women [1]. Coexisting conditions of venous stasis and hypercoagulability contribute to the pathophysiology of OVT, which are frequent in the postpartum period. Furthermore, other conditions such as recent surgery and malignancy increase the risk of thrombosis [2].

During pregnancy the right ovarian vein compression at the pelvic brim by the enlarged uterus and a retrograde flow in the left ovarian vein further contribute for this disease [2].

OVT occurs in the first 7 days postpartum [1]. Up to 80 percent of women will complain of fever during the postpartum period, but only half will complain of right lower quadrant abdominal pain. About 90 percent of cases affect the right ovarian vein [1].

Non-invasive testing, namely ultrasonography with Doppler examination, is less expensive and requires no contrast material. [2].

CT or MR studies are more sensitive (100% and 92%) and specific (99% and 100%) [2]. A tubular retroperitoneal mass with a central low attenuation extending cephalad to the inferior vena cava (IVC) are the expected findings of OVT in CT examination [1].

MR imaging is appropriate in the diagnosis and follow-up of OVT. MR allows multiplanar acquisitions and better depicts tissue contrast without IV contrast material [1] MR supersedes CT in differentiating flowing blood, acute thrombus and subacute thrombus because of its sensitivity to blood flow and to the paramagnetic effects of iron [2].

OVT complications can result in sepsis; inferior vena cava and/or renal vein thrombosis, which can lead to pulmonary embolism (25%) [2]. Also, fatal cases have been reported (5% of complicated cases, with approximately 18 deaths per million pregnancies) [2].

Both anticoagulant and intravenous (IV) antibiotic therapy are the treatment of choice for ovarian vein thrombosis [1]. Surgical treatment is considered—such as thrombectomy or ligation of the ovarian vein, inferior vena cava filter placement [3]—in clinically significant cases of thrombosis or inefficiency of medical therapy after 5 days [2].