Postpartum ovarian vein thrombosis

Abstract

Key content Postpartum ovarian vein thrombosis (POVT) is a rare but potentially fatal condition. Symptoms up to 4 weeks postpartum often include vague abdominal pain and pyrexia. A high index of suspicion is required to make the diagnosis. As there is no consensus regarding management, a multidisciplinary approach is advised. Learning objectives Recognise the symptoms and signs of POVT and formulate a differential diagnosis. Recognise the importance of imaging in confirming the diagnosis and involvement of the multidisciplinary team to plan management. Understand that conservative management with low‐molecular‐weight heparin is the first‐line treatment, and understand the situations that may require vena caval filter insertion or surgical intervention. Ethical issues How can we counsel women about risks of conservative and surgical management of this condition when there is no consensus for this management? Should women who have had an ovarian vein thrombosis in a previous pregnancy be counselled toward avoiding future pregnancy?

Postpartum ovarian vein thrombosis and venous anatomical variation

“…OVT occurs in 0.02%–0.18% of pregnancies 1. The risk is higher in caesarean delivery (1%–2%) compared with vaginal delivery (0.05%) 2 3. Eighty per cent to 90% occur in the right side and multiple factors can contribute to this lateral predisposition, which can be explained by the increased length of the right ovarian vein, lack of retrograde flow and the presence of multiple incompetent valves.…”

“…This condition presents usually in the puerperal stage, due to the increased risk of intrapartum endothelial trauma, in addition to a relatively hypercoagulable state and blood flow stasis that occur during pregnancy, which predispose women to postpartum ovarian vein thrombosis 1 3. It may also occur in the prepartum period, after ruptured ectopic pregnancy, abortion and in patients with hydatidiform mole.…”

“…The preferable route of administration is the intravenous and agents such as clindamycin, gentamicin, imipenem, cilastatin, ampicillin, sulbactam or the use of second or third-generation cephalosporin in a single-agent therapy or in combination with metronidazole (if concomitant anaerobic infection is suspected), are appropriate to treat this process 8 24. The current consensus states that antibiotic therapy should be continued until the patient has clinically improved (lack of fever for at least 48 hours, resolution of leukocytosis), which usually takes several days to a week 3…”

“…Currently, there are no generally accepted guidelines about the need of routine thrombophilia testing after ovarian vein thrombosis in postpartum patients 2 3. However some authors recommend that it is usually unnecessary when the thrombosis is located only in the ovarian vein 3 23…”

“…The recurrence rate of OVT is unknown, but apparently is similar to that of deep venous thrombosis, thus antenatal prophylactic doses of anticoagulants, continued until 6 weeks postpartum, are recommended in future pregnancies 2 3…”