eMedicine Specialties > Radiology > Obstetrics/Gynecology
Ovarian Vein Thrombosis
Updated: Aug 4, 2009
Introduction
Background
Ovarian vein thrombosis is an uncommon but potentially serious disorder that is associated with a variety of pelvic conditions—most notably, recent childbirth, but also pelvic inflammatory disease, malignancies, and pelvic surgery. Recognition and treatment of this condition is needed to avoid the morbidity and mortality that are related both to the thrombosis and to any associated infection/sepsis.1,2,3,4,5
Contrast-enhanced computed tomography scan in a postpartum patient with fever that demonstrates bilateral ovarian vein thrombosis.
Subsequent contrast-enhanced computed tomography scan in a postpartum patient with fever and bilateral ovarian vein thrombosis (same patient as in Image 1)
Recent study
Salomon et al performed a prospective study on the incidence and risk factors for postpartum ovarian vein thrombosis (POVT) in 13 women with POVT over 4 years. Based on the study findings, the authors noted that the risk for maternal POVT is increased by cesarean section delivery of twins and that investigations for thrombophilia may be unnecessary when POVT is the sole manifestation of thrombosis. Each patient underwent a CT scan followed by a profile for congenital and acquired thrombophilia. The incidence of POVT was 4 of 30,749 vaginal deliveries, 9 of 9,604 cesarean deliveries, and 6 of 906 twin deliveries by cesarean section. The odds ratio for developing POVT was 21.37 for twin delivery versus singleton and 7.2 for cesarean section versus vaginal delivery. Of the 13 women with POVT, infection was found in 7 women (53%) and other clinical risk factors in 4 (30%). Only 3 (23%) of the patients were found to have thrombophilia,and 1 developed POVT while on enoxaparin. 4
Pathophysiology
Ovarian vein thrombosis arises out of the coincident conditions of venous stasis and hypercoagulability, which are commonly present in the recently postpartum patient. Other conditions that are associated with hypercoagulability, such as recent surgery, malignancy, and Crohn disease,6 also increase the patient's risk for ovarian vein thrombosis. Some clinicians believe septic pelvic thrombophlebitis is part of a continuum of related illnesses that is distinguished mainly by the presenting manifestations of fever without pain. Both ovarian vein thrombosis and septic pelvic thrombophlebitis are influenced by the Virchow triad of vessel wall injury, stasis, and hypercoagulability.1
Frequency
United States
Ovarian vein thrombosis occurs in 0.02-0.18% of pregnancies and is diagnosed on the right side in 80-90% of the affected postpartum patients.
Mortality/Morbidity
Complications include ovarian vein thrombophlebitis, which can result in sepsis; thrombosis of the inferior vena cava and renal veins, which can lead to pulmonary embolism (25%); and death (5% of complicated cases, with an estimated 18 deaths per million pregnancies).
Race
Ovarian vein thrombosis has no racial predilection.
Sex
Ovarian vein thrombosis is observed in females. However, thrombosis of the gonadal vein can occur in male patients who have malignancy or other hypercoagulable conditions. Thrombophlebitis of the gonadal vein with serious complications is rare in men.
Age
Ovarian vein thrombosis can occur in females of any age, but postpartum ovarian vein thrombosis occurs in women of childbearing age.
Anatomy
The ovarian veins form a plexus near the ovary within the broad ligament and communicate with the uterine plexus. These veins ascend in pairs in the retroperitoneum adjacent to the psoas muscle, then combine to form a single vein before their termination. The right ovarian vein terminates in the inferior vena cava at an acute angle; the left ovarian vein terminates in the left renal vein at a right angle. Occasionally, valves are present in the ovarian veins. The veins enlarge greatly during pregnancy to accommodate increased blood volume; following childbirth, a period of venous stasis occurs.
Presentation
The typical patient with ovarian vein thrombosis (ie, thrombophlebitis) presents with pelvic pain, fever, and a right-sided abdominal mass.7 The combination of anticoagulant and intravenous (IV) antibiotic therapy is the treatment of choice. In cases of clinically significant thrombosis, inferior vena cava (IVC) filter placement should be considered. (Note that patients who have undergone total abdominal hysterectomy and bilateral salpingo-oophorectomy with retroperitoneal lymph node dissection can incidentally demonstrate ovarian vein thrombosis on contrast-enhanced computed tomography [CT] scanning.8 )
Preferred Examination
Ultrasound (US), magnetic resonance imaging (MRI), and CT scanning are the best radiologic modalities for making the diagnosis of ovarian vein thrombosis. US can provide a quick and inexpensive initial examination, without risk to the patient. However, US is frequently limited by overlying bowel gas.
MRI allows the examiner to avoid the use of ionizing radiation and IV iodinated contrast material. CT scanning can be obtained more easily than MRI at most institutions. However, although these 2 cross-sectional modalities are more sensitive and specific than US,9 they are more time consuming and expensive.
Limitations of Techniques
US is useful for the initial study and follow-up imaging of ovarian vein thrombosis; however, the limitations of US include obscuration of the gonadal/ovarian vein by overlying bowel gas. Furthermore, operator dependence is always a concern when using US for any diagnosis. Color Doppler US is a helpful tool for the assessment of blood flow in the imaged vessels.
CT scanning and MRI findings usually allow a definitive diagnosis of ovarian vein thrombosis and the exclusion of other clinical diagnostic possibilities.
Differential Diagnoses
Appendicitis
Leiomyoma, Uterus (Fibroid)
Nephrolithiasis/Urolithiasis
Ovarian Torsion
Other Problems to Be Considered
Broad ligament phlegmon or hematoma
Pyelonephritis
Hydroureter
Thrombosed inferior mesenteric vein
Degenerated pedunculated leiomyoma
Pelvic, abdominal, or tubo-ovarian abscess
Endometritis
More on Ovarian Vein Thrombosis |
 Overview: Ovarian Vein Thrombosis |
| Imaging: Ovarian Vein Thrombosis |
| Follow-up: Ovarian Vein Thrombosis |
| Multimedia: Ovarian Vein Thrombosis |
| References |
| Further Reading |
| Next Page » |
References
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Takach TJ, Cervera RD, Gregoric ID. Ovarian vein and caval thrombosis. Tex Heart Inst J. 2005;32(4):579-82. [Medline]. [Full Text].
González-Bosquet E. [Ovarian vein thrombosis. Risk factors, diagnosis and treatment.]. Medicina (B Aires). 2009;69(3):347-9. [Medline].
Salomon O, Dulitzky M, Apter S. New observations in postpartum ovarian vein thrombosis: experience of single center. Blood Coagul Fibrinolysis. Jul 7 2009;[Medline].
Johnson A, Wietfeldt ED, Dhevan V, Hassan I. Right lower quadrant pain and postpartum ovarian vein thrombosis. Uncommon but not forgotten. Arch Gynecol Obstet. Jun 24 2009;[Medline].
Marcovici I, Goldberg E. Ovarian vein thrombosis associated with Crohn's disease: a case report. Am J Obstet Gynecol. Mar 2000;182(3):743-4. [Medline].
Salomon O, Apter S, Shaham D, et al. Risk factors associated with postpartum ovarian vein thrombosis. Thromb Haemost. Sep 1999;82(3):1015-9. [Medline].
Yassa NA, Ryst E. Ovarian vein thrombosis: a common incidental finding in patients who have undergone total abdominal hysterectomy and bilateral salpingo-oophorectomy with retroperitoneal lymph node dissection. AJR Am J Roentgenol. Jan 1999;172(1):45-7. [Medline]. [Full Text].
Twickler DM, Setiawan AT, Evans RS, et al. Imaging of puerperal septic thrombophlebitis: prospective comparison of MR imaging, CT, and sonography. AJR Am J Roentgenol. Oct 1997;169(4):1039-43. [Medline]. [Full Text].
Giraud JR, Poulain P, Renaud-Giono A, et al. Diagnosis of post-partum ovarian vein thrombophlebitis by color Doppler ultrasonography: about 10 cases. Acta Obstet Gynecol Scand. Sep 1997;76(8):773-8. [Medline].
Callen PW. Ultrasonography in Obstetrics and Gynecology. 4th ed. Philadelphia, Pa: WB Saunders Co; 2000:873-4.
Gray H. Gray's Anatomy: The Classic Collector's Edition. Descriptive and Surgical Anatomy. 15th ed, rev. New York, NY: Gramercy; 1977:618.
Haaga JR, Sartoris, DJ, Zerhouni EA, Lanzieri CF. Computed Tomography and Magnetic Resonance Imaging of the Whole Body. Vol 1. 3rd ed. Philadelphia, Pa: Mosby-Year Book; 1994:1387.
Kubik-Huch RA, Hebisch G, Huch R, et al. Role of duplex color Doppler ultrasound, computed tomography, and MR angiography in the diagnosis of septic puerperal ovarian vein thrombosis. Abdom Imaging. Jan-Feb 1999;24(1):85-91. [Medline].
Quane LK, Kidney DD, Cohen AJ. Unusual causes of ovarian vein thrombosis as revealed by CT and sonography. AJR Am J Roentgenol. Aug 1998;171(2):487-90. [Medline]. [Full Text].
Zuckerman J, Levine D, McNicholas MM, et al. Imaging of pelvic postpartum complications. AJR Am J Roentgenol. Mar 1997;168(3):663-8. [Medline]. [Full Text].
Keywords
ovarian vein thrombosis, childbirth, recent childbirth, pregnancy-related thrombosis, thrombophlebitis, ovarian vein thrombophlebitis, pregnancy-related thrombophlebitis, septic pelvic thrombophlebitis
