Idiopathic Ovarian Vein Thrombosis: A Rare Cause of Abdominal Pain

Idiopathic left-sided ovarian vein thrombosis in a post-menopausal woman

Ovarian vein thrombosis (OVT) is a rare thromboembolic condition largely involving the right ovarian vein. Risk factors include pregnancy/ peripartum period, oestrogen therapy, recent surgery or hospitalisation, malignancy, pelvic inflammatory diseases, and thrombophilia; OVT without risk factors is considered idiopathic. We present a rare case of idiopathic left-sided OVT in a post-menopausal woman in her 60s with insignificant past medical history and no identifiable risk factors. She presented with isolated left -lower -quadrant abdominal pain ultimately found to have OVT on computed tomography (CT) scan and confirmed with magnetic resonance imaging (MRI). The patient was initially treated with low-molecular-weight heparin and then transitioned to apixaban. She remained symptom-free at 3-month follow-up. Five previous cases of idiopathic left-sided OVT have been reported to-date, but this is the first case in a postmenopausal woman that has not been associated with hypercoagulable risk factors nor further thromboembolic complications.

Choosing safe and effective anticoagulation to treat idiopathic ovarian vein thrombosis: using first principles of deep vein thrombosis management to treat a rare diagnosis: a case report and review of the literature

BACKGROUND

Ovarian vein thrombosis (OVT) often presents in the post-partum period and is associated with significant complications including inferior vena cava extension, pulmonary embolism, sepsis, and renal obstruction. Idiopathic OVT is rare, and no consensus has been agreed upon regarding its diagnosis and management. This case presents a patient who was diagnosed with idiopathic OVT and was treated with apixaban. A literature review was performed collating reported cases of idiopathic OVT to form a recommendation regarding optimal management and follow up.

CASE PRESENTATION

A 42-year-old Chinese woman presenting with right lower quadrant pain underwent a CT abdomen after urinary tract obstruction was excluded on ultrasound. She was subsequently diagnosed with an idiopathic 35 mm ovarian vein thrombus (OVT) given no history of primary coagulopathy nor secondary aetiology. A literature review was performed collating 18 case reports with method of diagnosis and management summarized. Treatment alternatives included low molecular weight heparin, warfarin, rivaroxaban and apixaban. Most were diagnosed after work up for suspected renal calculus or appendicitis. Follow up imaging was performed from between 6 weeks to 6 months after initiation of anticoagulation.

CONCLUSIONS

Direct oral anticoagulants were an effective treatment for OVT, however warfarin should be commenced in those suspected of antiphospholipid syndrome awaiting confirmation or exclusion of the diagnosis.