Ovarian Vein Thrombosis: Incidence of Recurrent Venous Thromboembolism and Survival

Epidemiology, natural history, diagnosis, and management of ovarian vein thrombosis: a scoping review

Ovarian vein thrombosis (OVT) is a rare but potentially serious condition. We conducted a scoping review of published data to provide a better understanding of OVT management. MEDLINE and Cochrane databases were searched. The eligibility criterion was original articles including women with OVT until May 2024. Quantitative data were pooled via Comprehensive Meta-Analysis software (Biostat, Inc). Quality of the primary studies was assessed via the Newcastle‒Ottawa Scale. Out of 1007 identified records, 19 primary studies including 1128 patients were selected. Mean age at OVT diagnosis was 37 years old. Frequency of OVT depended on the clinical situation: cancer (37%) and postpartum (0.06%), including cesarean (0.19%), or persistent fever despite antibiotics (23%). Magnetic resonance imaging was associated with the best diagnostic performance, followed by computed tomography. Pulmonary embolism and extension to the iliac vein, inferior vena cava, or left renal vein occurred in 6.5%, 5.9%, 10.3%, and 9.6% of patients, respectively. Among anticoagulants, low-molecular-height heparin with/without oral anticoagulant was preferred for 3 to 6 months. Among the women tested, thrombophilia was present in 18% of the patients. Recanalization, recurrent thrombosis, or major bleeding occurred in 70%, 8%, and 2% of patients, respectively. The majority of studies had poor evidence. This scoping review provides a comprehensive evaluation of available data. Frequency of OVT depends on the clinical setting. Physicians should be aware of OVT in postpartum women with persistent fever despite the use of antibiotics. OVT belongs to the spectrum of venous thromboembolism and should be considered both in puerperal settings and in cancer patients.

Pelvic vein thrombosis in patients with pelvic venous disorders

OBJECTIVE

To assess the incidence of pelvic vein thrombosis (PVT) and outcomes of anticoagulant therapy for PVT in patients with pelvic venous disorders (PeVDs).

METHODS

This prospective cohort study included 588 female patients with PeVDs underwent clinical examination followed by duplex ultrasound of the pelvic veins in 2021-2023. Patients with PVT were administered with anticoagulant therapy in an outpatient setting using low molecular weight heparins at a therapeutic dose.

RESULTS

PVT was detected in 7.6% of patients with PeVDs and was symptomatic in 28.8% of them. The majority of asymptomatic patients had thrombosis in only one of the parametrial veins (90.6%). Anticoagulant therapy resulted in the PVT symptoms relief in all patients within 10 days and recanalization of the pelvic veins in 1-3 months.

CONCLUSION

In our study, PVT was diagnosed in 7.6% of patients with PeVDs. Anticoagulant therapy is effective and safe in resolving PVT symptoms.

Intra-abdominal Venous Thromboses and Their Management

While a plethora of articles discuss management of deep venous thromboses in extremities, there is a relative scarcity of literature comprehensively describing intra-abdominal venous thromboses, and their management. Intra-abdominal venous thromboses include iliocaval venous obstruction (ICVO), hepatic venous thrombosis (HVT), portal venous thrombosis (PVT), renal vein thrombosis (RVT), splenic vein thrombosis (SVT), and gonadal vein thrombosis (GVT); each of which provides unique microenvironmental challenges to management. Doppler ultrasound is the first line imaging modality for diagnosis, and computed tomography and magnetic resonance imaging can help define the extent of thrombus burden and aid with interventional planning. Systemic anticoagulation remains the common medical treatment for intra-abdominal venous thrombosis, however, catheter directed thrombolysis and thrombectomy show positive outcomes in ICVO, HVT, PVT, and RVT, with transjugular intrahepatic portosystemic shunt (TIPS) creation especially beneficial in HVT and PVT. In this review article, we describe pathophysiology, clinical features, imaging findings, and current management options for intra-abdominal venous thromboses.

Safety and efficacy of anticoagulant treatment in patients with ovarian vein thrombosis: a systematic review and meta-analysis of observational studies

Background

The role of anticoagulation in ovarian vein thrombosis (OVT) is uncertain.

Objectives

We aimed to evaluate safety and efficacy of anticoagulant treatment in OVT patients.

Methods

A systematic search was conducted in MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases up to April 2024. Eligible studies included randomized controlled trials and observational studies enrolling at least 10 adult patients with objectively diagnosed OVT and treated with any anticoagulants. The protocol was prospectively registered in the International Prospective Register of Systematic Reviews (CRD42021270883).

Results

We included 17 observational studies (621 anticoagulated and 376 nonanticoagulated OVT patients); 9 studies enrolled mainly pregnancy/puerperium-related OVT. Most patients received heparins alone (45.7%) or proceeded to vitamin K antagonists (39.2%). The average treatment duration was ≤3 months in 8 studies (47.1%), >3 to ≤6 months in 6 studies (35.3%), and >6 months in 3 studies (17.6%). In treated patients, mortality rate was 2.43% (95% CI, 0.54%-5.41%; I2 = 53.8%; 12/406 patients; 13 studies), major bleeding was 1.27% (95% CI, 0.48%-2.38%; I2 = 2.5%; 7/583 patients; 15 studies), recurrent venous thromboembolism (VTE) was 3.49% (95% CI, 1.12%-6.95%; I2 = 63.5%; 22/482 patients; 15 studies), and vessel recanalization was 89.4% (95% CI, 74.6%-98.6%; I2 = 80.6%; 163/184 patients; 8 studies). The rate of recurrent VTE in untreated patients was 8.65% (95% CI, 2.61%-17.35%); however, the difference compared with treated patients was not statistically significant (risk ratio, 0.70; 95% CI, 0.36-1.37). At subgroup analyses, the rates of major bleeding and recurrent VTE were 0.80% (95% CI, 0.0-2%.17%) and 3.81% (95% CI, 0.42%-9.63%) in pregnancy/puerperium-related OVT, respectively, and 1.12% (95% CI, 0.32%-2.34%) and 1.78% (95% CI, 0.62%-3.46%), respectively, when analyzing only full-text studies.

Conclusion

There is paucity of literature regarding OVT. Our results suggest that anticoagulation is associated with low rates of major bleeding and recurrent VTE.

Ovarian vein thrombus in a pediatric patient: A case study

Acute abdominal pain is a very common chief complaint in the pediatric population, accounting for 5-10% of emergency department (ED) visits. Etiology differentiation is determined by complete history and physical examination, basic laboratory studies, and a variety of imaging study options. In this case report, we present an 8-year-old female with an unusual etiology of acute lower abdominal pain. She presented with tachycardia, hypertension, and bilateral lower quadrant abdominal tenderness without peritonitis. Laboratory studies were unremarkable and appendix ultrasound was indeterminate. CT with contrast revealed right ovarian vein thrombosis. Hematology evaluation did not reveal hypercoagulability. She was discharged on rivaroxaban, which was discontinued after a 3 month course and negative follow-up MRI. Ovarian vein thrombosis (OVT) most commonly develops in the peripartum time frame, with an estimated 20%-40% of cases not related to pregnancies. However, patients with nonpregnancy related OVT were determined to be significantly older than patients with pregnancy related OVT. This case report demonstrates the youngest documented case of OVT. This patient was not in the peripartum period and did not have any identifiable risk factors. Given this unprovoked OVT in a pediatric patient, in patients presenting with abdominal pain with unspecified etiology, advanced imaging studies may be helpful in establishing a diagnosis.

Cancer-Associated Abdominal Vein Thrombosis

Cancer is associated with an increased risk of developing venous thromboembolism, due to its direct influence on the three pillars of Virchow's triad (e.g., compression on the blood vessels by the tumour, blood vessels invasion, and cytokine release), together with the effect of exogenous factors (such as chemotherapy, radiotherapy, surgery). In cancer patients, the risk of thrombosis at unusual sites, such as splanchnic, ovarian and renal vein thrombosis, is also increased. Abdominal vein thromboses are frequently incidental findings on abdominal imaging performed as part of the diagnostic/staging workup or the follow-up care of malignancies. There is little evidence on the management of unusual site venous thromboembolism in cancer patients since there are only a few specific recommendations; thus, the management follows the general principles of the treatment of cancer-associated deep vein thrombosis and pulmonary embolism. This narrative review summarises the latest evidence on cancer-associated abdominal vein thrombosis, i.e., thrombosis of the splanchnic, ovarian and renal veins.

Group B Streptococcus infection-induced ovarian vein thrombosis identified during cesarean section: A case report and a literature review

RATIONALE

Ovarian vein thrombosis (OVT) is a rare yet potentially life-threatening condition associated with thromboembolic events. Group B Streptococcus (GBS) is a type of β-hemolytic Gram-positive bacterium known for asymptomatic colonization in the lower genital and gastrointestinal tracts. Here we reported a 35-year-old multiparous woman with gestational diabetes who suffered from placental abruption, stillbirth, OVT, septic shock, and renal failure due to severe GBS infection.

PATIENT CONCERNS

A 35-year-old woman with gestational diabetes presented with acute and sustained lower abdominal cramping, vaginal bleeding, and fever at 35 gestational weeks.

DIAGNOSES

Based on preoperative ultrasound and intraoperative findings, the patient was diagnosed with placental abruption, intrauterine fetal demise, and right OVT. GBS was cultured from the amniotic fluid obtained during cesarean section.

INTERVENTIONS

The patient underwent a right adnexectomy during a cesarean section and received intravenous antibiotics. Subsequently, an ultrasound-guided uterine curettage was performed due to recurrent fever.

OUTCOMES

After a prolonged course of intravenous antibiotics for over a month, the patient recovered and was discharged from the hospital.

LESSONS

This case underscores the need for early initiation of anticoagulant protocols in cases of OVT, particularly when GBS infection is identified as a predisposing factor. Further research and awareness are warranted to better understand the relationship between GBS infection and OVT and to optimize management strategies in such cases.

Ovarian Vein Thrombosis: An Unusual Cause of Abdominal Pain in Breast Cancer

Ovarian vein thrombosis (OVT) is a rare but potentially life-threatening complication that is usually seen in the intrapartum or postpartum period but can also be seen in patients with risk factors for venous thromboembolism. When symptomatic, it usually presents with abdominal pain and other vague constitutional symptoms, hence it is important for healthcare professionals to be aware of this condition when evaluating patients with risk factors. We present a rare case of OVT in a patient with breast cancer. Due to a lack of clear guidelines regarding the treatment and duration of treatment in non-pregnancy-related OVT, we followed the guidelines for the treatment of venous thromboembolism and started the patient on rivaroxaban for a three-month duration with close outpatient follow-up.

A 10-year Australian experience of rare intraabdominal venous thrombosis with comparison to deep vein thrombosis and pulmonary embolism

OBJECTIVE

Intra-abdominal venous thromboembolism is rare with heterogeneous management. We aim to evaluate these thrombosis and compare them to deep vein thrombosis and/or pulmonary embolism.

METHOD

A 10-year retrospective evaluation of consecutive venous thromboembolism presentations (January 2011-December 2020) at Northern Health, Australia, was conducted. A subanalysis of intraabdominal venous thrombosis involving splanchnic, renal and ovarian veins was performed.

RESULTS

There were 3343 episodes including 113 cases of intraabdominal venous thrombosis (3.4%) - 99 splanchnic vein thrombosis, 10 renal vein thrombosis and 4 ovarian vein thrombosis. Of the splanchnic vein thrombosis presentations, 34 patients (35 cases) had known cirrhosis. Patients with cirrhosis were numerically less likely to be anticoagulated compared to noncirrhotic patients (21/35 vs. 47/64, P  = 0.17). Noncirrhotic patients ( n  = 64) were more likely to have malignancy compared to those with deep vein thrombosis and/or pulmonary embolism (24/64 vs. 543/3230, P  < 0.001), including 10 patients diagnosed at time of splanchnic vein thrombosis presentation. Cirrhotic patients reported more recurrent thrombosis/clot progression (6/34) compared to noncirrhotic patients (3/64) (15.6 vs. 2.3 events/100-person-years; hazard ratio 4.7 (95% confidence interval 1.2-18.9), P  = 0.030) and other venous thromboembolism patients (2.6/100-person-years; hazard ratio 4.7, 95% confidence interval 2.1-10.7; P  < 0.001) with comparable major bleeding rates. All renal vein thrombosis were provoked including five malignant-related cases while three ovarian vein thrombosis occurred postpartum. No recurrent thrombotic or bleeding complications were reported in renal vein thrombosis and ovarian vein thrombosis.

CONCLUSION

These rare intraabdominal venous thromboses are often provoked. Splanchnic vein thrombosis (SVT) patients with cirrhosis have a higher rate of thrombotic complications, while SVT without cirrhosis was associated with more malignancy. Given the concurrent comorbidities, careful assessment and individualized anticoagulation decision is needed.

Venous Thromboembolism After Interventions on the Ovarian Veins in Patients With Pelvic Venous Disorder

BACKGROUND

Ovarian vein resection (OVR) and ovarian vein embolization (OVE) are effective options for treating patients with pelvic venous disorder (PeVD). However, due to in an abrupt cessation of blood flow in the ovarian veins (OVs), these interventions can be complicated by pelvic vein thrombosis (PVT). The aim of this study was to assess venous thromboembolism (VTE) rates after OVR and OVE in patients with PeVD.

METHODS

This retrospective cohort study included 272 patients with PeVD who underwent OVR (n = 122) or OVE with coils (n = 150). The rates and clinical manifestations of VTE were assessed in each group on days 1 and 3 after the intervention using duplex ultrasonography. Vein patency, blood flow velocity, and localization of thrombi in the pelvic (parametrial, uterine, and ovarian), iliac, superficial, and deep veins of the lower extremities were examined. PVT was defined as the formation of blood clots in nontarget (i.e. not intended to intervention) veins of the pelvis (parametrial, uterine veins, or tributaries of the internal iliac veins).

RESULTS

VTE after OVR and OVE was identified in 52 (19%) out of 272 patients. In the OVR group, PVT and calf deep vein thrombosis were detected in 9% and 1% of patients, accordingly, while in the OVE group their rates were almost three times higher (24% and 3%; both P = 0.001). In both groups, the most common VTE was PVT. The odds ratio for developing VTE with coils was 10 times higher (95% confidence interval: 2.35-56.43) after OVE than after OVR. Clinical manifestations of PVT were observed in 2.5% of patients, and the rest patients were asymptomatic. No cases of pulmonary embolism occurred.

CONCLUSIONS

VTE after interventions of the ovarian vein in patients with PeVD occurs in every fifth patient. OVE is associated with a higher incidence of PVT.

Diagnosis and management of ovarian vein thrombosis after laparoscopic -assisted vaginal hysterectomy with bilateral salpingectomy: A case report and literature review

OBJECTIVE

We present a case who developed ovarian vein thrombosis (OVT) after laparoscopic-assisted vaginal hysterectomy with bilateral salpingectomy to share our experience.

CASE REPORT

A 46-year-old woman came to our hospital due to severe dysmenorrhea induced by adenomyosis. Medical treatments were given but with unsatisfactory effect. As the patient had completed family planning, a hysterectomy was scheduled. However, on the sixth postoperative day, the patient complained of low abdominal pain with fever on and off. After a series of examinations, right OVT was diagnosed. The patient was treated with antibiotics only. Under close surveillance, the OVT resolved spontaneously, and the patient was discharged.

CONCLUSION

Diagnosis of OVT requires highly suspicion owing to its rarity and non-specific presentation. OVT is a potentially serious venous thromboembolism that sometimes can be life threatening. Anticoagulant treatment is still controversial. Conventional Tomography with contrast medium could detect early OVT with high sensitivity and specificity.

Postpartum Septic Pelvic Thrombophlebitis in a Tertiary Maternity Hospital in Dubai, UAE

Septic pelvic thrombophlebitis (SPT) is a well-known condition, yet it remains a rare postpartum complication. It can be divided into two types: deep septic pelvic thrombophlebitis (DSPT) and ovarian vein thrombosis (OVT). In this case series, we present three cases diagnosed with ovarian vein thrombosis that were managed in our tertiary care hospital, Latifa Women and Children Hospital (LWCH), in Dubai, UAE. It is a 440-bed public tertiary care center that specializes in maternal and neonatal services, with a range of 3500 to 4000 deliveries per year. The three cases represent the total number diagnosed with this condition in the period between 2018 and 2022 among the total obstetric population during this period. The three cases developed a fever in the postpartum period, which for several days did not respond to the standard antibiotics used for endometritis. Two cases were following a cesarean section, and the third case was following vaginal delivery complicated with severe postpartum hemorrhage and hysterectomy. The clinical suspicion and awareness of the condition paved the way to reach the proper diagnosis and initiate the therapeutic dose of anticoagulants, along with broad-spectrum antibiotics, in a timely manner. The prompt diagnosis with early intervention led to optimal patient outcomes and prevented the morbidity and mortality associated with this condition.

Acute Abdominal Pain as a Result of an Isolated Left Ovarian Vein Thrombosis

Ovarian vein thrombosis (OVT) is a rare thromboembolic condition. It involves the right ovarian vein in 70-80% of cases. The risk factors for the development of OVT are pregnancy or puerperium, hormone therapy with estrogen, recent surgery or hospitalization, malignancy, pelvic inflammatory diseases, thrombophilia and idiopathic OVT. We present a rare case of left OVT in a young, non-pregnant woman in her 30 s. A high degree of suspicion is necessitated in patients with the triad of young-middle-aged female, pain abdomen in lower quadrant and hematuria to diagnose OVT. Contrast enhanced computer tomography (CT-venography) is the diagnostic modality of choice. The patient was initially treated with low molecular weight heparin and then switched to direct oral anticoagulants. At 6-monthsfollow-up the patient was free from any symptoms.

Clinical Characteristics and Management of Ovarian Vein Thrombosis: A Case Series

Background

Ovarian vein thrombosis (OVT) is an uncommon condition, occurring in ~1 in every 600–2,000 pregnancies. It is associated with various conditions, including thrombophilia, malignancy, sepsis, intra-abdominal and pelvic inflammatory conditions, pregnancy, and the postpartum period, and specific surgical interventions, particularly gynecological surgeries. Thus, this study aims to identify the associated factors for OVT and elaborate on the standard treatment strategies for its management.

Methods

Retrospective data collection was used. Our study consists of 18 patients diagnosed with OVT between 2005 and 2016; the data was collected from the Health Information Management system at King Fahad Medical City, Riyadh, Saudi Arabia using a standard format.

Results

Our study found that OVT involves the right ovarian vein more often than the left and mainly occurs in women during their postpartum period. These patients other associated factor included hypertension, diabetes, and a higher body mass index (BMI) of above 25 kg/m². The most frequently presenting complaints were abdominal pain and fever. The most common treatment was the administration of enoxaparin (a low molecular weight heparin) for an average duration of one to three months, which resulted in a low recurrence rate of OVT.

Conclusions

Physicians should be vigilant for suspicion of OVT in female patients presenting with lower abdominal pain and fever in their postpartum period. Additionally, it is suggested to use low molecular weight heparin as initial therapy for OVT for one to three months, resulting in a high remission rate.

Potential critical risks of pulmonary thromboembolism from an asymptomatic postpartum ovarian vein thrombosis: a case report

Background

Ovarian vein thrombosis (OVT) may cause maternal mortality by inducing pulmonary thromboembolism (PTE). However, the prevalence, etiology, risk factors, prognosis, and optimal treatments for asymptomatic OVT during and after pregnancies are unclear, which therefore requires a high clinical index of suspicion for certain diagnoses due to its vague presentation. We herein present a case of asymptomatic postpartum OVT that extended toward the inferior vena cava (IVC), resulting in a potential risk of PTE.

Case presentation

A 30-year-old postpartum woman presented with slight dyspnea after an uneventful vaginal delivery at 40 weeks of gestation. We checked her laboratory data to exclude lethal thrombosis; D-dimer levels were 85.6 μg/mL. We performed computed tomography (CT) to search the presence of PTE and deep vein thrombosis (DVT); although no signs of PTE and DVT in her legs were detected, CT and trans-abdominal ultrasonography (TAUS) revealed a right OVT. Heparin was administered, and D-dimer levels decreased; warfarin at a dose of 2 mg/day was subsequently administered to control anti-coagulopathy. However, D-dimer was re-elevated despite adequate anticoagulation treatment, and extension of the right OVT to the IVC was detected by CT and TAUS. With warfarin administration, CT and TAUS showed the disappearance of right OVT. The patient was discharged from the hospital 17 days after delivery.

Conclusions

Even asymptomatic postpartum OVT may lead to PTE. Universal screening guidelines and optimal treatment strategies for asymptomatic OVT in pregnant and postpartum women should be established through future studies.

Ovarian Vein Thrombosis as an Uncommon Cause of Postpartum Fever: A Case Report

Postpartum ovarian vein thrombosis (POVT) is an uncommon cause of postpartum fever. Because POVT is sometimes complicated by pulmonary embolism, preventing diagnostic delay is critical. Nonetheless, the diagnostic delay of POVT is common due to its rarity. Antibiotics along with anticoagulants are recommended as the standard therapy for POVT, but this recommendation is based on older, low-quality literature. Here, we present a case of POVT, presenting with a persistent postpartum fever, which was treated by anticoagulants without antibiotics. Our case highlights the importance of awareness of POVT as a differential diagnosis and the need for studies to investigate the role of antibiotics in POVT.

Laparoscopic diagnosis of idiopathic left ovarian vein thrombosis in a 27-year-old woman

Idiopathic left ovarian vein thrombosis was diagnosed in a 27-year-old woman at the time of a diagnostic laparoscopy performed because of a suspected ovarian torsion.

The diagnosis was confirmed by abdominal computed tomography scanning. Subsequent magnetic resonance imaging showed no signs of an abdominal or pelvic mass nor enlarged lymph nodes. The patient was treated with systemic anticoagulation therapy for 3 months and made a good recovery. During follow-up it became clear that the patient was already diagnosed with familial hypercholesterolemia before the occurrence of the ovarian vein thrombosis. It remains unclear if familial hypercholesterolemia played a role in the occurrence of ovarian vein thrombosis in our patient.

Ovarian vein thrombosis: a rare but not to be forgotten cause of abdominal pain

A healthy 38-year-old woman, with no significant medical or surgical history, was referred to the gynaecology emergency department with acute low quadrant abdominal pain and nausea. On examination, painful palpation of right iliac fossa, abdominal guarding and positive Blumberg's sign were noted. An abdominal-pelvic CT scan showed a hypodense tubular structure with peripheral enhancement to the right of the inferior vena cava, suggestive of thrombosis of the right ovarian vein. The only risk factor identified was the use of the combined contraceptive pill.

Postpartum ovarian vein thrombosis

Objectives

Postpartum ovarian vein thrombosis (POVT) is a rare pathology that can lead to severe complications such as sepsis, extension of the thrombus leading to organ failure, and pulmonary embolism. It therefore requires early recognition and prompt treatment.

Case presentation

A patient with right POVT presented four days after delivery with acute right-sided abdominal pain and fever. Appendicitis was initially considered, before an abdominal-pelvic computed tomography raised the suspicion of POVT, subsequently confirmed through transabdominal ultrasound. Antibiotics and anticoagulation were initiated, with rapid clinical improvement and complete resolution of the thrombus three months later.

Conclusions

Diagnosing POVT is challenging as it clinically mimics other more frequent conditions. It is rare but life-threatening and should be considered in all females presenting with abdominal pain and fever in the postpartum period.

Postpartum ovarian vein thrombosis manifesting as acute appendicitis: a case report

BACKGROUND

Postpartum ovarian thrombosis is an uncommon condition. It appears with the nonspecific, predominantly right-sided abdominal symptoms and must be differentiated from other acute visceral conditions. If left untreated, postpartum ovarian thrombosis can have severe consequences, including sepsis, pulmonary embolism, and even death. Momentarily, there are no specific guidelines for postpartum ovarian thrombosis management. We present a case of postpartum ovarian thrombosis admitted to our hospital with symptoms of acute appendicitis. CASE PRESENTATION : A 39-year-old Omani obese multiparous woman of Afro-Arab origin was admitted with acute symptoms, mainly abdominal pain, fever, and vomiting 1 week postpartum. Clinical picture and biochemical profile did not exhibit a recognizable pattern. Ultrasonography excluded retained products of conception. Computerized scan for abdomen and pelvis with oral and intravenous contrast reported a dilated tubular structure in the right adnexa extending up to the right renal hilum level with surrounding inflammation. Those findings were consistent with the thrombophlebitis of the right ovarian vein. Blood cultures and sensitivity showed group A β-hemolytic streptococci sensitive to penicillin G and clindamycin. The patient was treated successfully with antibiotics and therapeutic anticoagulants and discharged home 3 days later; follow-up was arranged.

CONCLUSION

This pathology is an exceptional entity in Oman. Therefore, awareness of this unique condition is required so that clinicians will be vigilant, exploring similar cases with imaging and avoiding unnecessary surgical interventions.

Idiopathic Ovarian Vein Thrombosis: A Rare Cause of Abdominal Pain

Ovarian vein thrombosis (OVT) is a rare entity. It is usually seen in hypercoagulable states such as pregnancy, peripartum period, active malignancy, recent pelvic surgeries, pelvic infections, and inherited or acquired thrombophilias. Idiopathic OVT is exceedingly rare. We report a case of OVT in a healthy 42-year-old post-menopausal female presenting with right lower quadrant abdominal pain for four days. The patient denied any recent pelvic surgery, pelvic infection, or any family history of thrombophilia. Right ovarian vein thrombosis was found on a computed tomography scan of the abdomen and pelvis. Laboratory workup including hypercoagulability studies was normal. The patient was treated with a therapeutic dose of lower molecular weight heparin and later transitioned to rivaroxaban for three to six months. This case emphasizes OVT as a differential diagnosis of lower abdominal pain in healthy females. Currently, there are no standard guidelines for the duration of anticoagulation in OVT, however based on literature review, deep venous thrombosis treatment guidelines can be followed.

Ovarian vein and IVC thrombosis due to normal vaginal delivery; a case report and literature review

INTRODUCTION AND IMPORTANCE

Ovarian vein thrombosis (OVT) is exceedingly rare, which commonly occurs in postpartum patients and can result in serious complication such as pulmonary emboli. With a presentation often mimicking that of acute abdomen, it can be often misdiagnosed and mistreated.

CASE PRESENTATION

A 30-year-old woman referred with right lower quadrant abdominal pain, nausea and anorexia, one week after normal vaginal delivery. Physical examination demonstrated tenderness and rebound tenderness at the right side of the abdomen, with a stable vital sign except 38 °C fever. She had no history of coagulation problems or thrombotic disorders. Patient was admitted on a suspicion of appendicitis and was prescribed antibiotics followed by pelvic and abdominal ultrasonography that indicated an 8 to 10-centimeter hypoechoic tubular structure on the right side, next to the IVC. CT scan with contrast showed clear dilatation and thrombosis of the right ovarian vein with spread to the IVC. Anticoagulant treatment was started with 1000 intravenous units of heparin per hour, along with aPTT control, with a disappearance of the symptoms after 72 h.

CONCLUSION

Suspicion of OVT should be high in cases where patients refer with abdominal pain after childbirth, this diagnosis should be taken into account. In the absence of proper and timely diagnosis, it may lead to serious complications or mortality of the mother. CT scan with contrast and at least 3- months anticoagulant therapy (in case of thrombosis spreading to the IVC, this period should be extended) is recommended in diagnosing and treatment of OVT.

Idiopathic bilateral ovarian vein thrombosis

Ovarian vein thrombosis (OVT) is a condition most commonly associated with malignancy, hypercoagulable disorders, pelvic surgery, trauma, inflammatory bowel disease and the postpartum period. Idiopathic bilateral OVT is extremely rare. We report the case of a 30-year-old African-American woman who presented with bilateral lower pelvic pain and nausea. She had no recent pelvic infections nor a personal or family history of malignancy or thrombophilia. Workup results for a hypercoagulable state was negative. A CT scan of the abdomen and pelvis revealed bilateral OVT. Treatment included novel oral anticoagulants or warfarin, with comparison studies showing a similar risk-benefit ratio. Repeat imaging is recommended after 40-60 days to determine the necessity for further anticoagulation. Emphasis is placed on starting anticoagulation early in order to reduce the risk of extension of the thrombus into the inferior vena cava, conversion to pulmonary embolism or increase in the risk of infection.

Direct oral anticoagulants for unusual-site venous thromboembolism

Direct oral anticoagulants (DOACs) are currently the preferred oral anticoagulant treatment for most of the patients with deep vein thrombosis of the lower extremities and/or pulmonary embolism. DOACs have several advantages over vitamin K antagonists, such as availability of fixed dosages, fewer drug interactions, faster onset of action, shorter half-life, and lower risk of major and intracranial bleeding. Although the evidence on the use of DOACs in patients with unusual-site venous thromboembolism (VTE) is limited to a few, small randomized controlled trials, these drugs are increasingly used in clinical practice, and several observational cohort studies have been published recently. This narrative review will describe the latest evidence for the use of the DOACs in patients with thrombosis in atypical locations (splanchnic, cerebral, upper extremity, ovarian, and renal vein thrombosis) and will provide some practical advice for their use in patients with unusual-site VTE.

Ovarian Vein Thrombosis: A Narrative Review

Ovarian vein thrombosis (OVT) is a rare type of venous thromboembolism. The most common risk factors for OVT include pregnancy, oral contraceptives, malignancies, recent surgery, and pelvic infections; however, in 4 to 16% of cases, it can be classified as idiopathic. Most of the available information regards pregnancy-related OVT, which has been reported to complicate 0.01 to 0.18% of pregnancies and to peak around 2 to 6 days after delivery or miscarriage/abortion. The right ovarian vein is more frequently involved (70-80% of cases). Clinical features of OVT include abdominal pain and tenderness, fever, and gastrointestinal symptoms. The most typical finding is the presence of a palpable abdominal mass, although reported in only 46% of cases. OVT can be the cause of puerperal fever in approximately a third of women. Ultrasound Doppler is the first-line imaging, because of its safety, low cost, and wide availability. However, the ovarian veins are difficult to visualize in the presence of bowel meteorism or obesity. Thus, computed tomography or magnetic resonance imaging is often required to confirm the presence and extension of the thrombosis. In oncological patients, OVT is often an incidental finding at abdominal imaging. Mortality related to OVT is nowadays low due to the combination treatment of parenteral broad-spectrum antibiotics (until at least 48 hours after fever resolution) and anticoagulation (low-molecular-weight heparin, vitamin K antagonists, or direct oral anticoagulants). Anticoagulant treatment duration of 3 to 6 months has been recommended for postpartum OVT, while no anticoagulation has been suggested for incidentally detected cancer-associated OVT.

Direct oral anticoagulants for the treatment and prevention of venous thromboembolism in patients with cancer: current evidence

Venous thromboembolic disease (VTED) is a common and clinically important complication in patients with cancer, contributing to its mortality and morbidity. Direct oral anticoagulant agents (DOACs), including direct thrombin inhibitors and direct factor Xa inhibitors, are as effective as vitamin K antagonists for the treatment of VTED and are associated with less frequent and severe bleeding. They have advantages over low-molecular-weight heparin, but comparative long-term efficacy and safety data are lacking for these compounds. Recent randomized clinical trials suggest a role for DOACs in the treatment of VTED in patients with cancer. This review will discuss the existing evidence and future perspectives on the role of DOACs in the treatment of VTE based on the current evidence about their overall efficacy and safety and the limited information in patients with cancer; in addition, we will briefly review their pharmacokinetic properties with special reference to potential interactions.

Postpartum left ovarian vein thrombosis

Left ovarian vein thrombosis is a very rare and infrequent thrombotic condition that mainly occurs in the postpartum or postoperative period. We report a case of a 25-year-old para-1 woman who presented with 2 weeks of postpartum fever and dull aching abdominal pain more on the left side. Before operation, the diagnosis was left adnexal mass secondary to questionable ovarian cyst torsion and she underwent laparotomy. Her intraoperative findings revealed a firm left broad ligament mass with extension to retroperitoneum and it was difficult to demarcate the proximal end. Moreover, on the second day of postoperation, abdominal Doppler ultrasound indicated enlargement of the left ovarian vein that was filled with thrombi having hypoechoic and intermediate echogenicity. After the confirmation of left ovarian vein thrombosis, the case was treated with anticoagulants and broad-spectrum antibiotics and then well improved. Our case climaxes an instant diagnosis and therapeutic significance concerning ovarian vein thrombosis to early manage/avert complications. Besides, the ovarian vein thrombosis diagnosis requires a high index of suspicion for a case presented with fever and abdominal pain.

Treatment of unusual thrombotic manifestations

Venous thrombosis rarely occurs at unusual sites such as cerebral, splanchnic, upper-extremity, renal, ovarian, or retinal veins. Clinical features, symptoms, and risk factors of rare thrombotic manifestations are heterogeneous and in large part differ from those typical of the commonest manifestations of venous thrombosis at the lower extremities. The therapeutic approach also varies widely according to the affected site, whether cerebral, abdominal, or extraabdominal. To date, anticoagulant therapy for thrombosis at unusual sites is generally accepted, but the optimal therapeutic approach remains challenging. This review is focused on the treatment of unusual thrombotic manifestations as reported in the most recent guidelines and according to the updated scientific literature.

Left Ovarian Vein Thrombosis Presenting as Acute Postpartum Pyelonephritis

Ovarian Vein Thrombosis (OVT) is an extremely rare and uncommon thrombotic condition commonly attributed to the postpartum period. We report a case of a 30 yr old P2002 who presented with one day history of fever, chills, vomiting, abdominal and left flank pain. Patient had a preterm vaginal birth at 34 weeks gestation, four days prior to her presentation. Patient was febrile on presentation with left CVA tenderness and diffuse abdominal tenderness. Pelvic Ultrasound showed enlarged uterus 14.7cm x 10.9cm x 8.5cm consistent with a postpartum uterus, with heterogeneous endometrium 2.3 cm, no retained products and normal adnexa. CT scan with contrast showed fluid along the anterior aspect of the left anterior kidney, left psoas muscle and extending down to the left side of the uterus and extending to the region of the left renal vein which confirmed left ovarian thrombosis. A CT Chest with contrast and bilateral lower extremity Doppler ruled out pulmonary embolism and deep vein thrombosis, respectively.The patient was admitted, treated with antibiotics and therapeutic dose of low molecular weight heparin (Enoxaparin) and responded well. Patient was discharged home on oral apixaban. The clinical presentation of OVT is non-specific and can be similar to that of acute pyelonephritis. Physicians should have a high index of suspicion in postpartum patients presenting with flank pain and imaging techniques such as MRI, CT scan and ultrasound should be used to help in making the diagnosis.

A Case of Postpartum Thrombophlebitis of a Retroperitoneal Varix Mimicking Acute Appendicitis

A case of thrombophlebitis of a retroperitoneal varix in a postpartum patient with right lower quadrant pain is presented. The sonographic examination was falsely positive for appendicitis, but the correct diagnosis was made with a subsequent computed tomogram. The thrombosed varix was likely a collateral of the right ovarian vein, analogous to postpartum ovarian vein thrombophlebitis (POVT), an uncommon potentially fatal disorder. POVT is reviewed, emphasizing features useful for distinguishing it from appendicitis at sonography. Sonographers should be aware of the possibility of thrombophlebitis when examining postpartum patients with right lower quadrant pain.

Rivaroxaban and Apixaban for Initial Treatment of Acute Venous Thromboembolism of Atypical Location

OBJECTIVES

To assess the outcome of direct oral anticoagulants (DOACs), specifically Xa inhibitors: rivaroxaban and apixaban, for the treatment of venous thromboembolism (VTE) of atypical location (VTE-AL), portal, mesenteric, hepatic, splenic, gonadal, renal, and cerebral veins, prospectively collected data of Mayo Thrombophilia Clinic Registry were used.

METHODS

Patients with acute VTE-AL treated with DOACs, enrolled between March 1, 2013, and February 1, 2017, were compared with patients with VTE of typical location (VTE-TL: deep vein thrombosis of extremities and/or pulmonary embolism) receiving DOACs and with patients with VTE-AL treated with enoxaparin.

RESULTS

Out of 623 patients with acute VTE receiving the study drug within 14 days of diagnosis, there were 63 with VTE-AL: 36 on DOAC, 23 on enoxaparin, and 4 on warfarin; 352 received DOAC for VTE-TL. The VTE-AL treated with DOAC/enoxaparin included the following: splanchnic (26/22), ovarian (8/2), renal (3/5), and cerebral veins (1/1), respectively. Recurrence rate (per 100 person-years) for the VTE-AL group receiving DOAC was 7.3, which was not different when compared with those for VTE-TL (2.4; P=.13) and VTE-AL groups receiving enoxaparin (23.7; P=.37). Major bleeding rate in the VTE-AL group receiving DOAC was not different compared with those for VTE-TL (7.2 vs 3.0; P=.26) and VTE-AL groups on enoxaparin (22.4; P=.31). Mortality was higher in the VTE-AL group on DOAC compared with the VTE-TL group (21.45 [95% CI, 7.87-46.69] vs 8.26 [95% CI, 5.35, 12.20]; P=.03). All patients with VTE-AL with events had cancer.

CONCLUSION

The VTE recurrence and bleeding rates for rivaroxaban and apixaban used in VTE-AL are not different from those in patients with VTE-TL and similar to that for enoxaparin.