You are in: eMedicine Specialties > Radiology > OBSTETRICS/GYNECOLOGY Ovarian Vein ThrombosisArticle Last Updated: Jul 3, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Melanie R Chellman-Jeffers, MD, Consulting Staff Radiologist, Section of Breast Imaging, Division of Radiology, Cleveland Clinic Foundation Melanie R Chellman-Jeffers is a member of the following medical societies: American Association for Women Radiologists, American Roentgen Ray Society, Radiological Society of North America, and Society of Breast Imaging Editors: Harris L Cohen, MD, FACR, Vice Chairman/Associate Chairman (Research Activities), Director, Division of Body Imaging, Professor of Radiology, Stony Brook School of Medicine; Visiting Professor of Radiology, Johns Hopkins School of Medicine; Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand; Karen L Reuter, MD, FACR, Professor, Department of Radiology, Lahey Clinic Medical Center; Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute; Eugene C Lin, MD, Consulting Staff, Department of Radiology, Virginia Mason Medical Center Author and Editor Disclosure Synonyms and related keywords: childbirth, recent childbirth, pregnancy-related thrombosis, thrombophlebitis, ovarian vein thrombophlebitis, pregnancy-related thrombophlebitis, septic pelvic thrombophlebitis INTRODUCTIONSection 2 of 11
  BackgroundOvarian 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. PathophysiologyOvarian 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,1 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.2 FrequencyUnited StatesOvarian 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. InternationalInternational frequency figures are not available for ovarian vein thrombosis. Mortality/MorbidityComplications 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). RaceOvarian vein thrombosis has no racial predilection. SexOvarian 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. AgeOvarian vein thrombosis can occur in females of any age, but postpartum ovarian vein thrombosis occurs in women of childbearing age. AnatomyThe 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. Clinical DetailsThe typical patient with ovarian vein thrombosis (ie, thrombophlebitis) presents with pelvic pain, fever, and a right-sided abdominal mass.3 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.4) Preferred ExaminationUltrasound (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. Limitations of TechniquesUS 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. DIFFERENTIALSSection 3 of 11
Appendicitis Leiomyoma, Uterus (Fibroid) Nephrolithiasis/Urolithiasis Ovarian Torsion Other Problems to Be ConsideredBroad ligament phlegmon or hematoma CT SCANSection 4 of 11
FindingsCT scanning demonstrates an enlarged ovarian vein with central hypodensity—representing thrombosis—a sharply defined vessel wall, and perivascular inflammatory stranding. Degree of ConfidenceOvarian vein thrombosis can be diagnosed only with IV contrast. Spiral CT scanning is the preferred technique. When the classic image is present, the degree of confidence in the diagnosis is high. CT scanning can also exclude other conditions, although US is preferred for many of the gynecologic differential diagnostic possibilities. False Positives/NegativesThe primary limitation is achieving sufficient contrast enhancement. The timing of the contrast administration must be such that the contrast is in the venous phase. If contraindications to IV contrast exist (eg, allergy), CT scanning becomes a more limited and perhaps inadequate modality. MRISection 5 of 11
FindingsFor optimal MRI imaging, obtain axial T1-weighted, spin-echo images and axial fat-saturated, T2-weighted, fast spin-echo images with a body coil. MR angiography (MRA) is performed with patient breath holding and 2-dimensional time-of-flight techniques, with flow compensation (gradient moment nulling). A spatial saturation pulse is placed superiorly to obtain selective venograms. Maximum intensity projections can be created from MRA acquisitions in different angles. Findings demonstrate a flow void where thrombosis is present. Degree of ConfidenceMRI sensitivity and specificity are high. A positive finding virtually always means that ovarian vein thrombosis is present. ULTRASOUNDSection 6 of 11
FindingsUS findings include a tubular anechoic-to-hypoechoic structure that extends superiorly from the adnexa, with absence of flow on Doppler US interrogation.6 Degree of ConfidenceUS may be limited by the presence of overlying bowel gas. If clinical suspicion of ovarian vein thrombosis persists after a negative or equivocal US, CT scanning or MRI is recommended as the next examination. False Positives/NegativesOvarian vein thrombosis can be confused with appendicitis, hydroureter, lymphadenopathy, a dilated fallopian tube, and a thrombosed inferior mesenteric vein. US can readily image many of the other differential diagnostic possibilities. NUCLEAR MEDICINESection 7 of 11
FindingsNuclear medicine is not commonly performed to evaluate a patient for ovarian vein thrombosis. A variety of approaches have been attempted that have provided only limited results. ANGIOGRAPHYSection 8 of 11
FindingsA positive finding on venography is the presence of a filling defect that is consistent with a clot within the ovarian vein. Degree of ConfidenceAngiography can help to make the diagnosis of ovarian vein thrombosis, but this technique is not usually performed because of the availability of noninvasive, cross-sectional imaging methods. INTERVENTIONSection 9 of 11
Medical/Legal PitfallsFailure of the clinician to consider ovarian vein thrombosis in the appropriate clinical setting delays investigation of this condition, resulting in an unnecessary delay in diagnosis, as well as the possibility of morbidity and mortality that are related both to the thrombosis and to any associated infection/sepsis. MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
Ovarian Vein Thrombosis excerpt Article Last Updated: Jul 3, 2007 | |||||||||||||||||||||
