A Snowball Effect; From an Uncomplicated Delivery to a Rare Case of Septic Ovarian Vein Thrombophelbitis Complicated by Ureteral Obstruction and Septic Pulmonary Emboli
Hejab A, and Hurst G. A snowball effect; From an uncomplicated delivery to a rare case of septic ovarian vein thrombophelbitis complicated by ureteral obstruction and septic pulmonary emboli. J Gen Intern Med 2018; 33(2):441-442.
J Gen Intern Med
Learning Objective #1: Recognize septic ovarian vein thrombophelbitis SVOT as an important cause of abdominal pain in peripartum females. Learning Objective #2: Know potential complications of SVOT that may occur beyond the pelvis. CASE: A 23 years old female, G2P2 presented 11 days post normal vaginal delivery with acute onset severe lower abdominal pain and substernal chest pain. She denied any change in the postpartum vaginal discharge and physical exam was only remarkable for diffuse abdominal tenderness. Computed Tomography CT of the abdomen/Pelvis and Chest were performed. CT abdomen revealed a thrombus in the inferior vena cava extending to the right adnexa suggestive of ovarian vein thrombus, and suspicious for thrombophlebitis, in addition to severe right hydroureter secondary to external obstruction. CT chest revealed lobar segmental pulmonary embolus as well as multiple patchy nodules suspicious for septic emboli. She was initially started on Ampicillin + Sulbactam, covering against common endometritis pathogens including streptococci, gram negatives and anaerobes, despite no growth of the blood cultures. She was also anti-coagulated with unfractionated heparin. She underwent placement of percutaneous nephrostomy tube for the un-resolving unilateral hydroureter. Subsequent workup for thrombophilia was negative and the patient was discharged home on warfarin, Clindamycin and Ceftriaxone for total 6 weeks. The percutaneous nephrostomy tube was removed 8 weeks later. The patient achieved a full recovery.
IMPACT: This case of complicated septic ovarian vein thrombophelbitis SVOT made me realize that high index of suspicion of the diagnosis in peripartum patients with abdominal pain. Thoughtful consideration is needed to obtain the appropriate imaging modality (CT, US with dopplers or MRI of the abdomen), as well as the appropriate anatomical site imaged (lungs or the urinary system) to diagnose complications.
DISCUSSION: Septic Ovarian vein thrombophlebitis SOVT complicated by septic pulmonary emboli and ureteral obstruction is very rare with few cases reported in the literature. SOVT mostly happens in the first 10 days postpartum with an incidence of 1 in 9000 of vaginal deliveries and 1 in 800 of caesarian deliveries. Other rare causes of SOVT include pelvic inflammatory disease and endometritis, malignancy and following pelvic surgery. The etiology for developing SOVT in the peripartum is proposed to be the general hypercoagulable state of pregnancy in addition to the stasis of ovarian venous drainage postpartum. Few studies suggested prothrombotic predisposition in up to 50% of SOVT cases. The diagnosis of SOVT is achieved radiologically utilizing ultrasound with doppler, CT or MRI of the abdomen. The current management of SVOT include anticoagulation and antibiotic therapy. Complications of SOVT include extension into the renal veins and the inferior vena cava, pulmonary emboli and sepsis. Few cases of SOVT complicated by ureteral obstruction are reported.