One Month After Given Birth to a Stillbirth Baby Small Sharp Pain on Left Pelvic Side

JSLS. 2011 Apr-Jun; 15(2): 268–271.

Postpartum Ovarian Vein Thrombosis

Giancarlo Basili, Dr., Nicola Romano, MD, Marco Bimbi, Doc, Luca Lorenzetti, MD, Dario Pietrasanta, MD, and Orlando Goletti, MD

Giancarlo Basili

Health Unit of measurement 5 Pisa, Pontedera Hospital, General Surgery Unit, Pontedera, Italy.

Nicola Romano

Health Unit of measurement 5 Pisa, Pontedera Hospital, General Surgery Unit, Pontedera, Italia.

Marco Bimbi

Wellness Unit 5 Pisa, Pontedera Hospital, Department of Emergency Radiology, Pontedera, Italy.

Luca Lorenzetti

Health Unit of measurement v Pisa, Pontedera Hospital, Full general Surgery Unit, Pontedera, Italy.

Dario Pietrasanta

Health Unit 5 Pisa, Pontedera Hospital, General Surgery Unit, Pontedera, Italy.

Orlando Goletti

Health Unit 5 Pisa, Pontedera Hospital, General Surgery Unit, Pontedera, Italy.

Abstract

Background:

Ovarian vein thrombosis (OVT) is a rare but potentially serious postpartum complexity, which occurs in 0.05% to 0.18% of pregnancies and is diagnosed on the right side in eighty% to 90% of the cases.

Case Report:

A 32-twelvemonth-old woman presented at fifteen days postpartum to our emergency department with severe abdominal pain, fever, and intestinal distension. Abdominal examination revealed right lower quadrant hurting with rebound tenderness. The plain abdominal radiography evidenced a diffuse fecal stasis; abdominal ultrasound showed the presence of costless fluid in the Douglas' pouch and between small bowel loops. Diagnosis of acute appendicitis was made. The patient immediately underwent explorative laparoscopy; at surgery, a woody tumoration consequent with right ovarian vein thrombosis was found. Laparoscopic ultrasound confirmed the diagnosis. Anticoagulation therapy and antibiotics were instituted. CT-scan confirmed the presence of thrombosis up to the vena cava. The patient was discharged on postoperative mean solar day 4. At 1-calendar month follow-upwardly, she remained stable and symptom free.

Discussion:

Even though postpartum ovarian vein thrombosis is rare, recognition and treatment is needed to found adequate therapy and avert potential serious sequelae. The diagnosis can exist established past ultrasound, CT scan, and MRI examinations, although, as in the case described, the limitation of ultrasound includes obscuration of the gonadic vein by overlying bowel gas.

Conclusion:

OVT should be considered in any woman in the postpartum period with lower intestinal pain, fever, and leucocytosis.

Keywords: Ovarian vein, Thrombosis, Puerperium

INTRODUCTION

Ovarian vein thrombosis is a rare merely potentially serious disorder associated with a variety of pelvic conditions, most notably, recent childbirth, but also pelvic inflammatory disease, gynecological surgery, and malignancies.¹ Recognition and treatment of this status is needed to avoid the morbidity and the mortality related both to the thrombosis and to any associated infection or sepsis. Ovarian vein thrombosis occurs in 0.02% to 0.18% of pregnancies. Eighty percentage to xc% occur in the correct side. This is believed to be due, in office, to the dextrotorsion of the enlarging uterus that commonly occurs during pregnancy, which causes pinch of the right ovarian vein and right ureter as they cross the pelvic rim.ⁱⁱ The usual clinical features of postpartum ovarian vein thrombosis (POVT) includes pelvic or flank pain, or both, fever during the 15 days after delivery, and right-sided palpable mass.³ Ultrasound can provide a quick and inexpensive initial examination. Color Doppler evaluation is a helpful tool for the assessment of blood flow in the imaged vessels.^four Hence, correct identification is of crucial importance when we are faced with a postpartum patient with lower quadrant pain and fever.

Instance REPORT

A 32-year-quondam adult female presented at 15 days postpartum to our emergency department with severe, stabbing abdominal hurting, fever (up to 39°C) and intestinal amplification. There was no associated vaginal bleeding, nausea, or vomiting. She had a spontaneous vaginal commitment of a live full-term male; the immediate postpartum flow was unremarkable. Her past clinical history was negative. Intestinal exam revealed right lower quadrant hurting associated with rebound tenderness. Apparently abdominal X-ray evidenced a diffuse fecal stasis; ultrasonography showed the presence of gratuitous fluid into Douglas' pouch and between small bowel loops. Investigations showed a white blood cell count of xiv.4×ten⁹/L and hemoglobin of 12g/dL. The rest of the laboratory investigations were inside normal values. A diagnosis of acute appendicitis was suspected. The patient underwent exploratory laparoscopy; three port sites were used. A pseudotumor aspect of the right ovarian vein was discovered (Effigy 1). The appendix and the left ovary and gonadic vein were absolutely normal. Suspecting a POVT, laparoscopic ultrasound was immediately performed. A complete correct ovarian vein thrombosis extending upwards to the vena cava was discovered; Doppler interrogation demonstrated the absence of period (Effigy 2). Later that, intestinal CT scan demonstrated an enlarged right ovarian vein with key hypodensity, representing a complete thrombosis, extending upward to the vena cava, 3cm beneath the right renal vein (Figure three, ​ 4). The patient was treated with intravenous heparin for 5 days, combining oral anticoagulants in the form of warfarin. Antibiotic therapy with ceftriaxone (2g/24-hour interval) was besides administered. She fabricated a skilful recovery and was discharged from the infirmary after 15 days. At 2-month follow-up, the patient remained stable and symptom free.

Laparoscopic exploration highlights the presence of a woody tumoration at the level of right ovarian vein.

Laparoscopic cross-section ultrasound prototype shows the presence of a tubular anechoic-to-hypoechoic structure, with absence of menses on Doppler U.s.a. interrogation.

CT coronal demonstrates an enlarged ovarian vein with central hypodensity, representing thrombosis (pointer).

CT coronal shows the extension of the thrombus up to the vena cava (pointer).

DISCUSSION

Postpartum ovarian vein thrombosis is an uncommon disease, with a reported incidence from ane:600 to 1:2000 deliveries. POVT is characterized by lower intestinal or flank pain, fever, and leucocytosis. A total of fourscore% to 90% of cases involve the right ovarian vein. The pathophysiology of ovarian vein thrombosis and septic pelvic thrombophlebitis are ascribed to Virchow's triad of vessel wall injury, venous stasis, and hypercoagulability. An increased risk of thrombosis in pregnancy and puerperium is known. Women are 5 times more probable to suffer from a thromboembolic event when they are significant. Compression of the inferior vena cava by the uterus and hormonal changes underlie the thrombus formation in the deep veins of the lower limbs and pelvis.⁵ However, changes in fibinolysis and coagulation during pregnancy are possibly the most of import factors. There is a decrease in blood period velocity immediately afterward delivery. Simons et al⁶ reported an anterograde flow in the right ovarian vein along with a retrograde menstruum in the left ovarian vein immediately after commitment. In improver, the correct ovarian vein is as well longer than the left ovarian vein and has many valves within its length, which could increase the risk of thrombosis considering these valves might deed as a nidus for thrombus formation.⁷ Other weather condition that are associated with hypercoagulability, such as recent surgery, Crohn's disease, or malignancy, could increase the patient'south risk for ovarian vein thrombosis.⁸ Salomon et al^ix performed a prospective study on the incidence and risk factors for POVT in 13 women over 4 years. The authors noted that the adventure for maternal POVT is increased by cesarean delivery of twins.

POVT typically presents with symptoms suggestive of acute appendicitis, and in most cases, patients undergo exploratory laparoscopy.¹⁰ 80 percent of patients present with pyrexia. Lower quadrant pain and flank pain with associated nausea are mutual. A mass may exist palpable in the right iliac fossa. The differential diagnosis of POVT includes septic pelvic thrombophlebitis, pyelonephritis, urinary tract infection, adnexal torsion, intestinal volvulus, puerperal endometritis, and tubo-ovarian abscess. The diagnosis is made on the clinical features described to a higher place. When POVT is suspected, the initial investigation should be an ultrasound examination, which may ostend the diagnosis. Withal, ultrasound examination is operator-dependent and, as in the case described, is frequently limited by overlying bowel gas. CT scan or MRI can provide amend and more than reliable visualization of the vascular organisation. Coronal images are useful in evaluating the extent of a thrombus. Indeed, the severity of POVT is related to the extension of thrombus to the vena cava with an increased risk of pulmonary embolism, which occurs in 13% of cases. A thick-walled, enlarged ovarian vein with rim enhancement and central hypodensity are considered the main CT imaging findings of POVT.^xi Hence, in cases of suspected POVT, a screw CT browse or MRI should be requested even in the presence of a negative ultrasound.¹² This careful approach should avoid what happened in the case described, in which a clinical diagnosis of acute appendicitis was suspected, only laparoscopic diagnosis revealed an unexpected ovarian vein thrombosis. Diagnosis and treatment should both be noninvasive. Once the diagnosis is considered, the appropriate investigations can exist ordered, and other surgical procedures avoided. Anticoagulants and antibiotics are the mainstay of treatment. Broad-spectrum antibiotic treatment should be initiated immediately, as should intravenous heparin; once thrombolysis has begun, warfarin is introduced and continued for 3 months to 4 months.¹³ Some authors suggest the employ of depression molecular weight heparin in uncomplicated cases of POVT; however, there is no uniform understanding regarding the type, dosage, or length of anticoagulation.¹⁴

CONCLUSION

Our feel proves that early recognition of this condition is of paramount importance, and fifty-fifty though postpartum ovarian vein thrombosis is infrequently reported, this entity carries a risk of significant morbidity and mortality if inadequately treated. Early on recognition is of paramount importance, and whatever woman who presents in the postpartum menstruation with unexplained lower abdominal pain, fever, and leucocytosis should be evaluated by ultrasound or CT scan to make the right diagnosis and avoid potential serious complications.

Contributor Information

Giancarlo Basili, Wellness Unit 5 Pisa, Pontedera Hospital, General Surgery Unit, Pontedera, Italian republic.

Nicola Romano, Wellness Unit 5 Pisa, Pontedera Hospital, General Surgery Unit, Pontedera, Italian republic.

Marco Bimbi, Wellness Unit 5 Pisa, Pontedera Hospital, Section of Emergency Radiology, Pontedera, Italia.

Luca Lorenzetti, Health Unit five Pisa, Pontedera Hospital, Full general Surgery Unit, Pontedera, Italy.

Dario Pietrasanta, Health Unit of measurement 5 Pisa, Pontedera Hospital, Full general Surgery Unit, Pontedera, Italian republic.

Orlando Goletti, Health Unit 5 Pisa, Pontedera Infirmary, General Surgery Unit, Pontedera, Italian republic.

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One Month After Given Birth to a Stillbirth Baby Small Sharp Pain on Left Pelvic Side

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3148888/

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