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Abdomen
Ovarian vein thrombophlebitis with a thrombus extending into the inferior vena cava
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Author(s) :
Taco Geertsma, MD
 
Presentation 31 year old female 2 weeks post Caesarian section.  Now presents with pain in the right lower abdomen, fever and slightly raised infection parameters.
 
 
 
Caption: Transverse image of the lower abdomen
Description: There is a thick walled non compressible hypoechoic structure that looks like a thickened appendix
 
 
 
Caption: Longitudinal image of the lower abdomen
Description: There is a tubular structure with a thickened wall in the caudal part. There is no relation with the cecum so it is not the appendix
 
 
 
Caption: Longutudinal image with color Doppler
Description: There is flow around, but not in the tubular structure
 
 
 
Caption: Longutudinal image with color Doppler cranial to image 3
Description: There is no flow in the tubular structure. The course resembles the course of the right ureter
 
 
 
Caption: Transverse image at the level of the lowerpole of the right kidney
Description: Transverse image of the noncompresible structure that has now a thinner wall
 
 
 
Caption: Longitudinal image of the uterus
Description: The uterus is large but normal considering the recent pregnancy
 
 
 
Caption: Transverse image at the level of the hilum of the right kidny
Description: The tubular structure has no relation with the renal pelvis so does not represent the right ureter. There is a thrombus in the inferior vena cava.
 
 
 
Caption: Axial CT image at the level of image 5
Description: The thrombus filled ovarian vein lies anterior to the vena cava (arrow)
 
 
 
Caption: Axial CT image at the level of image 7
Description: The thrombus in the inferior vena cava can be seen (arrow)
 
 
Caption: Transverse cineloop of the inferior vena cava
Description: The thrombus is seen moving in the inferior vena cava
 
 
Caption: Longitudinal color Doppler cineloop of the inferior vena cava
Description: The thrombus is seen as an intraluminal filling defect in the inferior vena cava
 
Differential Diagnosis Appendicitis. However the tubular structure showed no relation to the cecum

Pyelonephritis. Although the tubular structure could be held for a dilatated ureter, the structure showed no relation to the renal pelvis or the bladder.

PID Thrombophlebitis of the ovarian vein is sometimes associated with pelvic inflammatory disease. However in this case the thrombophlebitis of the ovarian vein was related to the post pregnant condition of the patient
 
Final Diagnosis Ovarian vein thrombophlebitis with a thrombus extending in the inferior vena cava
 
Discussion

Ovarian vein thrombosis or thrombophlebitis of the ovarian vein is a serious condition.

Ovarian vein thrombosis is the result of a number of conditions such as venous stasis and hypercoagulability, which are commonly present in the recently postpartum patient

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.

Complications include sepsis; and 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.

The treatment is usualy anticoagulant therapy and antibiotics, although in some cases a vena cava filter is placed to prevent pulmonary embolism.

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; the left ovarian vein terminates in the left renal vein.

For more cases see http://www.ultrasoundcases.info
 
Case References
  1. Al-toma A, Heggelman BG, Kramer MH. Postpartum ovarian vein thrombosis: report of a case and review of literature.Neth J Med. 2003 Oct;61(10):334-6. Review.
  2. Lee EH, Im CY, Kim JW.Ultrasound diagnosis of postpartum ovarian vein thrombosis: case report.Ultrasound Obstet Gynecol. 2001 Oct;18(4):384-6
  3. Brown DL.Pelvic ultrasound in the postabortion and postpartum patient.Ultrasound Q. 2005 Mar;21(1):27-37. Review
  4. Prieto-Nieto MI, Perez-Robledo JP, Rodriguez-Montes JA, Garci-Sancho-Martin L. Acute appendicitis-like symptoms as initial presentation of ovarian vein thrombosis.Ann Vasc Surg. 2004 Jul;18(4):481-3.

 
Follow Up A CT scan confirmed the diagnosis
Patient was treated with anticoagulant therapy and antibiotics
 
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