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Thrombosis of the Left Ovarian Vein Postpartum Associated with an Ipsilateral Retro-aortic Renal Vein



Laurent Hermann Marion Ondima*, Soumia Arharas, Badr Boutakioute, Zoubida Belhadj, Fatiha Amenzouy, Ibtissam Zouita, Dounia Basraoui, Hicham Jalal, Meriem Ouali Idrissi, Najat Cherif Idrissi El Ganouni

Department of Radiology, CHU Mohammed VI, Cadi Ayyad University, Marrakech, Morocco

 

*Corresponding author: Laurent Hermann Marion Ondima, Department of Radiology, CHU Mohammed VI, Cadi Ayyad University, Marrakech, Morocco. Email: [email protected]

 

Received Date: 13 October 2022; Accepted Date: 18 October 2022; Accepted Date: 21 October 2022

Summary

Ovarian vein thrombosis is a rare and potentially serious entity, most often occurring postpartum. It manifests as an acute febrile pelvic pain syndrome. Abdominal ultrasound is requested for initial evaluation but CT and MRI have a higher diagnostic sensitivity. We report a case of left ovarian thrombophlebitis complicating an endometritis in a 20 year old postpartum patient with individualization on CT of a retro-aortic homolateral renal vein, which may favor their occurrence at this exceptional location.

 

Keywords: Thrombosis; Ovarian vein; Retro-aortic left renal vein; Post-partum

Introduction

Ovarian vein thrombosis is a rare complication that occurs preferentially in the immediate postpartum period and is most often manifested by persistent fever, an abdominal mass and pelvic pain [1].

Diagnosis is based on imaging: Doppler ultrasound, abdominal-pelvic CT or pelvic MRI [2]. Involvement of the right ovarian vein is described in 80% of cases [3]. If treatment (anticoagulant +/- antibiotic therapy) is not given in time, serious complications may develop (extension of the thrombus to the inferior vena cava, pulmonary embolism, septic shock) threatening the vital prognosis of the mother [3,4]. We report a case of thrombosis of the left ovarian vein following endometritis associated with an anatomical variant.

 

Observation

This is a 20 year old female patient with no specific pathological history. She was admitted to the maternal intensive care unit three days after a miscarriage for sepsis due to endometritis, with febrile pelvic pain and fetid lochia, complicated by consciousness disorders.

The clinical examination found an obnubilated patient with a Glasgow score of 14/15, febrile at 38°c, hemodynamically and respiratorily stable with pelvic sensitivity to abdominal palpation.

The biological workup showed a biological infectious syndrome with hyperleukocytosis at 16810/mm3 and an elevated CRP of 92.25 mg/L.

Ultrasound found an enlarged uterus with heterogeneous hypoechoic retention. The left ovary was swollen but vascularised on colour Doppler (Figure 1), with individualisation of a tubular structure between the ovary and uterus with hypoechoic content, not lighting up on colour Doppler suggestive of thrombosis of the left tubal vein (Figure 2). The left ovarian vein was not seen (the patient was meteoric). There was pelvic fat infiltration and a small anechoic pelvic effusion. Abdominal and pelvic angioscanner showed bilateral dilatation of the ovarian veins, pelvic varicose veins and thrombosis of the left ovarian vein (Figure 3), with individualization of a left renal vein with a retro-aortic course (Figure 4).

The patient was put on triple antibiotic therapy: amoxicillin clavulanic acid 1 g x 4/d, metronidazole 500 mg x 3/d for 10 days and gentamycin 5mg/kg/d for 5 days. Anticoagulant treatment with heparin therapy followed by anti-vitamin K for 3 months, with good clinical improvement and no detectable venous thrombosis on follow-up ultrasound.

 

Discussion

Ovarian vein thrombosis occurs most often in the postpartum period and its incidence varies in the literature from 1/2000 to 1/600 deliveries [4]. The pathophysiology is not clearly established; however, like all phlebitis, Virchow's triad is thought to be the cause of this complication [5,6]:

  1. The state of hypercoagulability results from an increase in the production of certain coagulation factors during pregnancy up to six weeks postpartum.
  2. Venous stasis is a consequence of the dilation of the ovarian veins during pregnancy.
  3. A slowing of venous blood flow occurring in the immediate postpartum period.

Thrombosis of the left ovarian vein, as found in our patient, is not frequently described in the literature, in contrast to the right location. The figures show 80% right, 16% left and 4% bilateral location [5].

The clinical picture of ovarian vein thrombosis is non-specific, with low abdominal pain, fever and a pelvic mass. Furthermore, in the absence of anything indicative of postpartum, the clinical picture is suggestive of another pathology (appendicitis, pyelonephritis, tubo-ovarian abscess or adnexal torsion) [1,7].

Imaging can confirm the diagnosis and clarify the characteristics of ovarian vein thrombosis. Ultrasound is frequently the first imaging modality for any suspicion of postpartum complications because of its availability and safety. The thrombosed ovarian vein is enlarged with an echogenic or hypoechoic thrombus, non-vascularised on colour Doppler and without flow detected on pulsed Doppler [8].

In addition, ultrasound exploration may be limited by the presence of intestinal gas but also by the fact that it cannot show the entire length of the vein in most cases due to the corpulence of certain patients [7,9]. In addition, it is operator dependent, hence the presence of false negatives [8]. In this case, a negative or equivocal ultrasound should be followed by cross-sectional imaging (CT or MRI).

CT is considered the examination of choice for ovarian venous thrombosis in the absence of contraindication. The thrombosed vein is manifested by a retroperitoneal tubular structure, enlarged, with hypodense contents, circumscribed by a peripheral contrast-enhanced border with or without infiltration of the surrounding fat. Coronal reconstructions allow assessment of thrombus extension to the IVC and renal vein [7,9].

On MRI, the thrombosed vein has the same characteristic as on CT. However, MRI can differentiate between acute and subacute thrombosis. Generally, ovarian venous thrombosis is subacute (between 1 week and 1 month), with T1 and T2 hypersignals [9]. After contrast injection on T1 sequences, there is peripheral enhancement with a hyposignal centre. Fat saturation sequences allow a better appreciation of the enhancement in relation to the retroperitoneal fat surrounding the vessel. In addition, contrast enhancement of this fat may be seen around the thrombosed vessel [7].

The treatment was medical in our case. The literature also reports that it is based on a combination of appropriate broad-spectrum antibiotic therapy and a low molecular weight heparin anticoagulant in curative doses followed by a relay of anti-vitamin K for at least 6 months [5,10]. In case of high-risk thrombus, some authors recommend surgery [10].

 

Conclusion

Ovarian thrombophlebitis is a dreaded postpartum complication, its strict left localisation is a rare entity. The endometritis and the retro-aortic left renal vein are factors favouring their occurrence in our patient. The diagnosis is based on imaging, which must be done in the presence of any fever and/or pelvic pain occurring in the postpartum period.

 

Declaration of interest

The authors declare that they have no conflicts of interest in relation to this article.

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Citation: Ondima LHM, Arharas S, Boutakioute B, Belhadj Z, Amenzouy F, et al. (2022) Thrombosis of the Left Ovarian Vein Postpartum Associated with an Ipsilateral Retro-aortic Renal Vein. Open J Case Rep 3: 165