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Ovarian vein thrombosis in pregnancy and the puerperium – A case series ARTICLE in JOURNAL OF OBSTETRICS AND GYNAECOLOGY · MAY 2015 Impact Factor: 0.6 · DOI: 10.3109/01443615.2015.1009420 · Source: PubMed

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Available from: Fionnuala Mone Retrieved on: 17 June 2015

Journal of Obstetrics and Gynaecology, 2015; Early Online: 1–2 © 2015 Informa UK, Ltd. ISSN 0144-3615 print/ISSN 1364-6893 online

CASE REPORT

Ovarian vein thrombosis in pregnancy and the puerperium – A case series F. Mone, G. McKeown, & B. Adams Department of Obstetrics and Gynaecology, Craigavon Area Hospital, Northern Ireland, UK

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DOI: 10.3109/01443615.2015.1009420 Correspondence: Dr. Beverley Adams, Department of Obstetrics and Gynaecology, Craigavon Area Hospital, 68 Lurgan Rd, Portadown, BT63 5QQ. UK. Tel: ⫹ 44 (0)28 3861 2359. E-mail: [email protected]

Case reports Case one A 24-year-old low-risk primigravida presented with severe acute right-sided colicky abdominal pain at 26 weeks’ gestation. A finding of bilateral hydronephrosis on ultrasound of the renal tracts suggested renal calculi, following which the patient underwent bilateral ureteric stenting. Symptoms persisted and an investigative laparotomy and emergency caesarean section (EMCS) were performed, with negative findings. Subsequent computerised tomography (CT) scan of the abdomen and pelvis (CTAP) revealed a diagnosis of a right-sided ovarian vein thrombus (OVT). The patient was treated with therapeutic low-molecular weight heparin (LMWH) and subsequently warfarin, antibiotics and analgesia with the input of a haematologist. A transient thrombocytopenia and neutropenia developed within 3 days of treatment. Maternal testing for inherited thrombophilia and lupus anti-coagulant were negative. Follow-up CT imaging 4 months later revealed resolution of the OVT and warfarin was stopped. In a subsequent pregnancy the patient was commenced on prophylactic LMWH from booking. Case two A 31-year-old low-risk primigravida presented at 19 weeks’ gestation with non-specific lower abdominal pain. The patient underwent an EMCS at term for the indication of dystocia in labour and had an uneventful recovery. She subsequently presented one month later with right-sided abdominal pain and pyrexia and was initially treated for suspected endometritis. Following re-presentation one week later a CTAP was performed. This demonstrated that the right ovarian vein was partially attenuated in keeping with an OVT. Management involved therapeutic LMWH and antibiotic therapy for 10 days with follow-up imaging demonstrating thrombus resolution.

fossa pain worse on movement. Clinical suspicion was that endometritis and treatment was commenced. Despite five days of treatment, symptoms persisted and a CTAP demonstrated a filling defect in the right ovarian vein, and subsequent imaging two-weeks later confirmed a diagnosis of OVT (Figure 1). She was commenced on warfarin and symptoms resolved, with follow-up imaging reported as normal.

Discussion OVT affects between 0.05% and 0.18% of pregnancies (Basili et al. 2011). In our unit, where these four cases were managed, the incidence of OVT was 0.07%. OVT is caused by the hypercoaguable state of pregnancy combined with uterine compression of the pelvic vessels. It usually presents in the post-partum period and is right-sided, due to dextrotorsion of the enlarging uterus compressing the right ovarian vein (Arkadopoulos et al. 2011). It is associated with high maternal morbidity and mortality with sequelae including septic shock and pulmonary embolus (Virmani et al. 2012). Additionally, ureteric obstruction and hydronephrosis may develop at the level where the ovarian vein crosses anterior to the ureter (L4). Diagnosis can be confirmed using CT or magnetic resonance imaging (MRI) imaging (Sharma and Abdi 2012). Contrast CT imaging permits direct visualisation of the OVT, demonstrating a low attenuating central thrombus surrounded by contrast enhancement while MRI typically demonstrates an enhanced signal on T1- and T2-weighted images. Duplex colour Doppler ultrasound (CDUS) may demonstrate a dilated tubular structure, extending from the adnexa to the para-aortic region adjacent to the hilum (Forstner and Schneider 2007) and has sensitivity and specificity rates of 55.6% and 41.2%, respectively (Kubik-Huch et al. 1999). Sensitivity and specificity rates for OVT detection are approximately 100% for MRI and 77.8% and 62.5% for CT, respectively (Kubik-Huck et al. 1999). Compared with CT, MRI limits exposure of the foetus to radiation or contrast, and hence may be regarded as being safer as an imaging modality antenatally (Bilgin et al. 2012). Treatment includes multi-disciplinary input, antibiotics and anti-coagulation with LMWH in the first instance followed by warfarin for a three-month period with follow-up imaging reported after two months from diagnosis (Warde et al. 2001; Wiggermann and Stroszczynski 2011). OVT is rare and pregnancy poses challenges in terms of recognition, investigation and management. Despite the rarity of the condition it is important to consider OVT in the list of differentials for

Case three A 30-year-old woman in her second pregnancy presented four days following a spontaneous vaginal delivery (SVD) with right-sided loin-to-groin pain, malaise and reduced mobility of the right leg. Observations revealed pyrexia and tachycardia, and pyelonephritis was suspected. Pyrexia persisted despite treatment and CTAP revealed a right-sided OVT. The patient was managed with LMWH and subsequently warfarin. A CT one month later (for another indication) revealed re-canalisation of the right ovarian vein. The patient was anti-coagulated for a further three months and advised to avoid the oral contraceptive pill and start prophylactic LMWH when pregnant again. Case four A 31-year-old low-risk woman in her second pregnancy presented five days post-SVD with tachycardia, pyrexia, malaise and right iliac

Figure 1. CT abdomen and pelvis axial image demonstrating right-sided ovarian vein thrombosis.

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abdominal pain in the puerperium. It is important that clinicians have an understanding of symptoms and subsequent management.

Acknowledgements None. Declaration of interests: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper.

References

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Arkadopoulos N, Dellaportas D, Yiallourou A et al. 2011. Ovarian vein thrombosis mimicking acute abdomen: a case report and literature review. World Journal of Emergency Surgery 6:45. Basili G, Romano N, Bimbi M et al. 2011. Postpartum ovarian vein thrombosis. Journal of the Society of Laparoendoscopic Suregons 15:268–271.

Bilgin M, Sevket O, Yildiz S et al. 2012. Imaging of postpartum ovarian vein thrombosis. Case Reports in Obstetrics and Gynecology 2012:134603. Published online Oct 2012 doi:10.1155/2012/134603 Forstner R, Schneider A. 2007. Acute and Chronic Pain Disorders. In: Hamm B, Forstner A, editors. MRI and CT of the female pelvis. Berlin: Spinger. p 355–375. Kubik-Huch RA, Hebisch G, Huch R et al. 1999. Role of duplex colour Doppler ultrasonography, and MR angiography in the diagnosis of septic puerperal ovarian vein thrombosis. Abdominal Imaging 24:85–91. Sharma P, Abdi S. 2012. Ovarian vein thrombosis. Clinical Radiology 67: 893–898. Virmani V, Kaza R, Sadaf A et al. 2012. Ultrasound, computed tomography, and magnetic resonance imaging of ovarian vein thrombosis in obstetrical and non-obstetrical patients. Canadian Association of Radiologists’ Journal 63:109–118. Warde L, McDermott EW, Hill ADK et al. 2001. Post partum ovarian vein thrombosis. Journal of the Royal College of Surgeons of Edinburgh 46:246–248. Wiggermann P, Stroszczynski C. 2011. Images in clinical medicine. Ovarian-vein thrombosis. New England Journal of Medicine 364:1544.

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