Right ovarian vein thrombophlebitis complicated by an inferior
endocaval floating thrombus revealed by postpartum pyrexia: a case
report
Clément Faidherbe, Robert Leach
Centre Hospitalier de Wallonie
Picarde (CHwapi), Service des Urgences, Tournai, Belgique
Correspondence:
Dr Clément Faidherbe
Centre Hospitalier de Wallonie Picarde (CHwapi), site Union
Service des Urgences
Rue des Sports 51
7500 Tournai
Belgium
Telephone: 0032460949681
E-mail: cfaidherbe@yahoo.fr
ABSTRACT
The clinical course of our patient highlights an atypical presentation
of thromboembolic disease related to pregnancy, a thrombophlebitis of
the right ovarian vein with endocaval floating thrombus. The diagnosis
remains difficult since it is a rare entity with an atypical
presentation but with serious medical consequences.
KEYWORDS
Thrombosis
Ovarian vein
Postpartum
Pyrexia
Coagulation
KEY CLINICAL MESSAGE
Thrombophlebitis of the right ovarian vein is a rare presentation of
thromboembolic disease in postpartum period. Diagnostic is
challenging.This case report reminds clinicians the importance of not
forgetting this entity.
INTRODUCTION
Pregnancy-associated thromboembolic disease, and in particular pulmonary
embolism, is a major cause of maternal morbidity and mortality in
Western countries. The pathology is due in part to the natural shift of
the coagulation and fibrinolysis system to a state of hypercoagulability
during pregnancy, which minimizes the risk of bleeding during delivery.
Other predisposing factors include maternal age, immobilization,
thrombophilia, personal and family history of thrombosis, pre-eclampsia,
obesity, smoking, and the mode of delivery. The immediate postpartum
period is also a major risk factor. Pelvic vein thrombosis represents
less than 1% of thromboses outside of pregnancy or pelvic surgery, but
accounts for 10% of thromboses during pregnancy and postpartum (1). The
diagnosis remains difficult because it is a rare entity with a mostly
atypical presentation. We report the clinical management and
anticoagulation therapy of a patient with a postpartum thromboembolic
complication with an uncommon clinical presentation.
CASE REPORT
A 36-year-old woman, gravida 3, para 2, without any health problems
presented to the emergency room 11 days postpartum for chills, sweating,
myalgias, headache, and back pain radiating to the cervical region
associated with a stiff neck. She had no associated abdominal pain but
reported of strong-smelling, menstruation-type vaginal discharge. The
pregnancy was unremarkable with a post-term eutocic delivery with
induction of labor and birth of a healthy female child weighing 2,920 g.
There was, however, a difficult epidural catheter placement.
Pathological analysis of her past miscariage did not reveal any
chromosomal abnormalities in the fetus. In addition, she previously
underwent a conization for grade III dysplasia and human papilloma virus
infection. The patient did not have a general history of
thromboembolism. However, she previously smoked one pack of 20
cigarettes a day and took contraceptive pills. The patient also had a
body mass index (BMI) of 30.
On clinical examination, the patient was pyretic with a 38.6°C
temperature. Otorhinolaryngology was normal, except for pain on cervical
mobilization without neck stiffness. Cardiopulmonary auscultation was
normal. Abdominal examination revealed suprapubic pain and left iliac
fossa pain on deep palpation. The neurological examination was
unremarkable. A gynecologic ultrasound revealed only minimal fluid in
the pouch of Douglas.
Blood tests revealed anemia with a hemoglobin level of 9.7 mg/dL, no
hyperleukocytosis, but a C-reactive protein level of 224 mg/L and a
D-Dimer level of 3,543 μg/L. The remaining hematology results were
within normal limits. The urinalysis and blood cultures were negative. A
brain scan was within normal limits. An abdominopelvic computed
tomography (CT) scan with portal phase contrast revealed
thrombophlebitis of the right ovarian vein over its entire length,
extending to the inferior vena cava in the form of a floating thrombus
with a diameter of 15 mm. (Fig. 1)
Given the context and the patient’s age, we presented our patient’s case
to the cardiothoracic surgeon of our hospital, who indicated an
emergency vena cava filter placement via the right jugular approach
under local anesthesia. The filter was deployed to the right renal vein
without any incident.
Despite administration of cefazolin, the patient subsequently developed
several episodes of pyrexia without an infectious focus, and several
negative blood cultures. These episodes required the patient to stay in
intensive care for 24 hours two days after placing the intracaval
filter, and cefazolin was changed to amoxicillin-clavulanate. She then
returned to the general ward and was discharged home eight days after
admission. The clinical outcome was favorable. At four-month follow-up,
a phleboscan and thrombophilia assessment were performed. The patient
was found to be a carrier of Factor V Leiden, and therefore prone to
thromboembolic disease. The phleboscan was normal.
Subsequently, a multidisciplinary team including intensivists, surgeons,
pulmonologists, and hematologists determined to treat the patient with
rivaroxaban (Xarelto®, Janssen Pharmaceuticals, Inc., Titusville, NJ,
USA) 15 mg twice daily for 21 days followed by 20 mg once daily for six
months.
DISCUSSION
Although perinatal thromboembolic management has improved in the past
20 years, each case is critical because it concerns both, a mother and a
child. This case demonstrates the difficulty of diagnosing postpartum
thromboembolic diseases and the importance of considering these
diagnoses given the seriousness of the complications (1). While
thromboembolic diseases are common during pregnancy and postpartum,
thrombophlebitis of the ovarian vein remains a rare complication (2).
Manifestations are most often associated with pyrexia with abdominal
pain. Differential diagnoses include acute appendicitis, urinary tract
infection, or other pelvic conditions (1). Furthermore, the majority of
ovarian vein thromboses affect the right ovarian vein for anatomical
reasons; the right ovarian vein is compressed at the level of the sacral
promontory by a large dextroverted uterus with an anterograde ovarian
vein flow. Finally, normal pregnancy includes changes in venous stasis,
hypercoagulability, and potential venous injury, which promotes these
thromboses (3), this is named Virchow’s triad.
The basic treatment for thrombosis consists of antibiotic and
anticoagulation therapy (4). One of the major complications is extension
to the vena cava, which was present in our patient, with the risk of
pulmonary embolism. Our patient had pyrexia, but abdominal complaints
were not in the foreground, which did not facilitate the diagnosis.
However, the postpartum context was a reminder of this diagnostic
possibility. D-dimer testing can help in the diagnosis, but the usual
presence of D-dimers in the immediate postpartum can be misleading( 5).
According to a well-known paper ( 6), in addition to the
hypercoagulable state associated with pregnancy, there are various
predisposing factors for postpartum thromboembolism: thrombophilia,
thrombotic history in the patient and family, maternal age,
pre-eclampsia, cesarean section, high BMI, (above normal for the
patient), immobilization, and placental abruption. Therefore, it would
be interesting to include a calculation of thromboembolic disease risk
in the pre-conception gynecology or pregnancy follow-up consultations to
determine which patients would benefit from preventive treatment.
Unfortunately, the usual scores (Wells, Geneva) are not validated for
specific populations, such as pregnancy or postpartum (7).
Considering the various reports in the literature and our own
experience, we can reasonably assert that each woman presenting with
fever in the postpartum period must be checked for thromboembolic
disease. Unfortunately, the lack of references concerning the safety and
efficacy of treatment for perinatal thromboembolic disease, and the lack
of validated diagnostic scores, does not allow a comprehensive
recommendation at present. Finally, all emergency professionals should
keep in mind that the postpartum period may have a very high risk of
thromboembolic disease, which may have an unusual presentation. This is
even more critical in this particular period of COVID-19, which seems to
give a state of hypercoagulability (8) whose origin is not yet known at
the time of writing this paper.
CONCLUSION
In Western countries, thromboembolic disease is the leading cause of
pregnancy-related morbidity and mortality up to six weeks postpartum
(2). It is linked to the state of hypercoagulability associated with
pregnancy as well as other predisposing factors. Thrombophlebitis of the
ovarian vein is rare, and difficult to diagnose in view of its
nonspecific presentation. However, it is important to highlight this
possible diagnosis in view of the risks of extension to the inferior
vena cava and pulmonary embolism.
AUTHOR CONTRIBUTION
Author 1: Main work in patient care, data collection, and manuscript
writing
Author 2: Emergency physician and final manuscript revision
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FIGURES
Figure 1