Abdom Imaging 27:93–95 (2002) DOI: 10.1007/s00261-001-0034-7


Postpartum ovarian vein thrombophlebitis: sonographic diagnosis
I. Hadas-Halpern, M. Patlas, D. Fisher
Department of Radiology, Shaare Zedek Medical Center, POB 3235, Jerusalem 91031, Israel Received: 23 February 2001/Accepted: 21 March 2001

Abstract Background: We describe our experience with sonographic diagnosis of ovarian vein thrombosis, an uncommon but dangerous postpartum complication. Methods: We retrospectively reviewed the medical records of seven patients in our institution who developed postpartum ovarian vein thrombophlebitis within the past 5 years. Results: In all cases the diagnosis was made by ultrasound, which showed tubular hypoechoic masses lateral to the great abdominal vessels. The postpartum ovarian vein thrombophlebitis was on the right side in six cases and on the left side in one. In five cases, it protruded into the inferior vena cava. The first three cases were referred to computed tomography after the sonographic diagnosis. In the last four cases, the diagnosis relied solely on sonography and no further evaluation was necessary. Conclusion: Sonographic examination can be diagnostic for ovarian vein thrombosis if performed very carefully in symptomatic postpartum patients. Key words: Thrombophlebitis—Ovarian vein—Postpartum— Ultrasonography.

ministration. False-positive CT results have beenreported [6]. We present our experience in diagnosing PPOVT by ultrasound (US) and stress the importance of recognizing the sonographic signs, as most postpartum patients with abdominal symptoms are referred primarily to US.

Patients and methods During the past 5 years, seven patients in our institution were diagnosed as having PPOVT. The age range was 22–36 years. Three patients had had vaginal delivery, and four patients had undergone cesarean section. The patients were referred to abdominal US for flank pain (n 2), flank pain and fever (n 2), fever (n 1), shortness of breath (n 1), and increased white blood cell count (n 1). The clinial diagnoses were ureteral obstruction (n 2), appendicitis (n 1), pyelonephritis (n 3), and deep vein thrombosis in one patient with pulmonary embolism. The US examinations were performed with an ATL Ultramark 9 (Advanced Technology Laboratories, Bothell, WA, USA) using 3.5- and 7-MHz probes. Three patients also had CT (HeliCAT II, Marconi Medical Systems, Cleveland, OH, USA) examinations.

Postpartum ovarian vein thrombophlebitis (PPOVT) is an uncommon but potentially fatal situation. The incidences are 0.02– 0.15% of vaginal deliveries and 1–2% of cesarian sections [1]. It is difficult to diagnose clinically because the signs and symptoms are not specific and can mimic other, more common conditions such as ureteral obstruction, pyelonephritis, appendicitis, endometritis, or tuboovarian abscess [2, 3]. Computerizedtomography (CT) is considered highly accurate in diagnosing ovarian vein thrombosis [4, 5], but it requires radiation exposure and contrast medium adCorrespondence to: I. Hadas-Halpern

Results In all cases abdominal US showed a longitudinal tubular structure alongside the great vessels containing heterogeneous echoic material (Fig. 1). The thrombus was on the right size in six patients and in the left ovarian vein in one. In five patients the thrombus projected into the inferior vena cava in the infrarenal vein region (Fig. 2). No blood flow was seen within the thrombosed veins (Fig. 3). In the three patients who also had CT, the diagnosis of PPOVT was confirmed (Fig. 4). Six patients were followed up by US and showed disappearance of the


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I. Hadas-Halpern et al.: Ovarian vein thrombophlebitis

Fig. 1. Oblique sagittal sonogram shows the thrombosed right ovarian vein (arrow). Fig. 2. Sagittal (A) and transverse (B) images of the inferior vena cava show a clot extending from the right ovarian vein (OV) into the inferior vena cava (IVC). Fig. 3. Oblique sagittal color Doppler sonography, depicted in gray scale, shows lack of blood flow in the right ovarian vein (RT OV). Fig. 4. CT after administration of intravenous and oral contrast shows enlarged right ovarian vein with low-density contents and enhancing wall, representing ovarian vein thrombosis. The low-density area around the thrombosed vein represents edema.


I. Hadas-Halpern et al.:Ovarian vein thrombophlebitis

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thrombus, with resolution of the symptoms. One patient left the hospital and was lost to follow-up.

Discussion PPOVT is a serious postpartum complication that can lead to sepsis, pulmonary embolism, and thrombosis of the inferior vena cava. However, it is difficult to diagnose clinically because the presenting signs and symptoms are usually nonspecific and can be seen in other, more common postpartum entities such as pyelonephritis, ureteral calculi, ureteral ligation, endometritis, acute appendicitis, tuboovarian abscess, and acute cholecystitis [7]. Postpartum patients with such symptoms are usually referred for US examination. A characteristic US finding is a hypoechoic tubular mass extending superiorly from the adnexa lateral to the great vessels. On Doppler, there is absence of flow. However, US is considered limited for diagnosing this entity. Because of their retroperitoneal location, the ovarian veins are usually obscured by overlying bowel gas, thereby compromising US identification of thrombosis [3]. The reported cases of sonographically diagnosed ovarian vein thrombosis have relied largely on the identification of thrombus extending into the inferior vena cava, a region that is more accessible to US examination [3, 8, 9, ]. Our experience demonstrates the efficiency of US in such cases. In most cases, it was quite a simple examination and the diagnosis was made in almost all cases by gray-scale imaging.Doppler confirmed those findings. CT has high diagnostic accuracy in identifying thrombosed ovarian veins and is considered the definitive study [4]. However, CT has some drawbacks, especially radiation exposure and the need to administer intravenous contrast material. Moreover, false-positive CT results of PPOVT have been reported. Therefore, an alternative means of diagnosing PPOVT is desirable. Although our group was small, it showed that US can be the definitive diagnostic examination for PPOVT. In all our cases the diagnosis was

made by US. The examination is made very carefully; we always look for the ovarian veins in postpartum patients and examine the blood flow within those veins. US also is a means to document the response to therapy. Because most postpartum patients with abdominal symptoms are referred to US examination, it is extremely important that the sonographer be familiar with the US signs of ovarian vein thrombosis. These signs should be carefully looked for, when no other pathology is recognized. Once demonstrated sonographically, there is no need for further imaging work-up. When the US examination is negative, the patient may be referred for further evaluation with CT. References
1. Giraud R, Poulain P, Renaud-Giono A, et al. Diagnosis of postpartum ovarian vein thrombophlebitis by color Doppler ultrasonography: about 10 cases. Acta Obstet Gynecol Scand 1997 – 778 2. Toland KC, Pelander WM, Mohr SJ. Postpartum ovarian veinthrombosis presenting as ureteral obstruction: a case report and review of the literature. J Urol 1993 3. Johnson SC, Esclapes M. Sonography of postpartum ovarian vein thrombophlebitis. J Clin Ultrasound 1998 –148 4. Twickler DM, Setiawan AT, Evans RS, et al. Imaging of puerperal septic thrombophlebitis: prospective comparison of MR imaging, CT, and sonography. AJR 1997 –1043 5. Brown CE, Lowe TW, Cunningham FG, et al. Puerperal pelvic thrombophlebitis: impact on diagnosis and treatment using x-ray computed tomography and magnetic resonance imaging. Obstet Gynecol 1986 –794 6. Cranston PE, Hamrick-Turner J, Morano JU. Pseudothrombosis of the right ovarian vein: pitfall of abdominal spiral CT. Clin Imaging 1995 –179 7. Munsick R, Gillanders LA. A review of the syndrome of puerperal ovarian vein thrombophlebitis. Obstet Gynecol Surv 1981 – 66 8. Dale RD, Gallaspy JW, Wise RB, et al. Postpartum ovarian vein thrombophlebitis: a review. Obstet Gynecol Surv 1991 9. Baka JJ, Lev-Toaff AS, Friedman AC, et al. Ovarian vein thrombosis with atypical presentation: role of sonography and duplex Doppler. Obstet Gynecol 1989 – 889 10. Grant TH, Schoettle BW, Buchsbaum MS. Postpartum ovarian vein thrombosis: diagnosis by clot protrusion into the inferior vena cava at sonography. AJR 1993 –552


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