Teaching file series

ULTRA SONOGRAPHY FILE 

 Rt. Ovarian vein thrombosis 

 LS section of ovarian vein: Lumen is hypo to iso echoic                      LS section of ovarian vein (Color Doppler): No E/o flow.

US scan at mid renal level (Transverse section): Thrombosis in Rt. ovarian vein noted between Kidney & IVC. No thrombus in IVC at this level.	US scan Transverse section at the level of Rt.ovarin vein entering in the IVC: Partial thrombus in IVC with flow in the rest of lumen on color doppler
Plain CT Scan abdomen TS section at level of kidney: Enlarged Rt.ovarian vein(Arrow) with hypodense lumen. Plain CT Scan abdomen TS section at level of kidney: Rt.Ovarian vein joining into IVC. IV contrast study of CT Scan abdomen TS section at level of kidney: Pheripheral enhancement of Rt. ovarian vein with central non enhanceing hypodensity (Thrombus). IV contrast study of CT Scan abdomen TS section at level of kidney: Filling defect in the IVC at the level of joining of Rt. ovarian vein.

Clinical History : 28 years female with severe back pain from 10 days.

                          H/O normal delivery 1 month back.

Ultrasound Findings : 

Enlarged Rt. ovarian vein filled with hypo echoic thrombus extending into IVC. On color Doppler no E/o color uptake in the ovarian vein. Filling defect noted in the IVC. Minimal free fluid noted in the pelvis.

CT Scan findings:

Enlarged Rt. ovarian vein on contrast showing peripheral wall enhancement with central non enhancing area. Thrombus extending into the IVC.

Diagnosis : Rt.Ovarian vein thrombosis.  

Discussion :

Introduction

The impact of ovarian vein thrombosis and potential embolism on the postpartum patient is significant. The incidence of pulmonary embolism in women with postpartum ovarian vein thrombosis has been reported to be from 13% to 33%. The thrombus may extend into the renal veins and the IVC.

Incidence :

1:600 - 1:2000 deliveries 80% Rt. ovarian vein, 14% bilateral, 6% Lt. ovarian vein

Etiology :

Puerperal ovarian vein thrombophlebitis

Pelvic inflammatory disease

Gynecologic surgery

Malignant tumors

Chemotherapy.

PATHOPHYSIOLOGY

The ovarian veins arise from venules draining the ovaries, the broad ligament, and the infundibulopelvic brim. The right ovarian vein usually enters the anterolateral IVC at the L2 level, and the left ovarian vein usually enters the left renal vein. Both vessels are long and unbranched, and have incompetent valves.

During pregnancy, the ovarian vein diameters increase 3-fold, flow capacity becomes 60 times greater, and valvular incompetence is exacerbated.

After childbirth, blood flow in the ovarian veins immediately decreases, leading to venous collapse and stasis . Altered coagulation   is usual after pregnancy. Hypercoagulability is present for 6 weeks postpartum, caused by increased production of coagulation factors 1, 2, 7, 10, and 11 and an increase in platelet adhesiveness. These changes usually peak on the 4th postpartum day.     

CLINICAL FEATURES:

Symptoms typically have an abrupt onset and include chills, fever, and lower abdominal / flank pain. Palpable ropelike tender abdominal mass. Thrombosis has been most frequently identified in the right ovarian vein and is associated with RLQ pain. The right-sided prevalence is due to the physiologic dextrorotation of the uterus during pregnancy, which may compress the ovarian vein on that side, and also to the direction of postpartum blood flow, which is antegrade in the right ovarian vein and retrograde in the left ovarian vein.

CT Scan Findings :

Tublar structure in location of ovarian vein with low density center + peripheral enhancement.

D.D

Endometritis, Acute appendicitis, Hydronephrosis, Urolithiasis, Torsion of ovarian cyst, Pelvic / Abdominal abscess or Pyelonephritis.

 

 Reference :   5th Edition Radiology revew manual & Internet.

Submitted by: Dr.M.Adinarayana Rao, MD.,RD.

                           Dr. D.Prasada Reddy, DMRD.

                           Dr.G.Gowri Sekhar, DMRD., DNB.

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