Role of duplex color Doppler ultrasound, computed tomography, and MR angiography in the diagnosis of septic puerperal ovarian vein thrombosis

Idiopathic left-sided ovarian vein thrombosis in a post-menopausal woman

Ovarian vein thrombosis (OVT) is a rare thromboembolic condition largely involving the right ovarian vein. Risk factors include pregnancy/ peripartum period, oestrogen therapy, recent surgery or hospitalisation, malignancy, pelvic inflammatory diseases, and thrombophilia; OVT without risk factors is considered idiopathic. We present a rare case of idiopathic left-sided OVT in a post-menopausal woman in her 60s with insignificant past medical history and no identifiable risk factors. She presented with isolated left -lower -quadrant abdominal pain ultimately found to have OVT on computed tomography (CT) scan and confirmed with magnetic resonance imaging (MRI). The patient was initially treated with low-molecular-weight heparin and then transitioned to apixaban. She remained symptom-free at 3-month follow-up. Five previous cases of idiopathic left-sided OVT have been reported to-date, but this is the first case in a postmenopausal woman that has not been associated with hypercoagulable risk factors nor further thromboembolic complications.

Rectus Sheath Hematoma Triggered by Post-cesarean Anticoagulant Therapy for Intraoperative Acute Pulmonary Thromboembolism: A Case Report

Anticoagulant therapy is essential for the prevention or treatment of peripartum venous thromboembolism (VTE). Administration of a therapeutic dose of anticoagulant immediately after cesarean section may result in the formation of a rectus sheath hematoma. A 32-year-old Japanese woman delivered twin neonates by cesarean section at 37+5 weeks of gestation. After the removal of the placenta, the patient suddenly complained of left anterior chest pain and dyspnea with hypotension and desaturation, requiring the administration of oxygen and vasopressors. Postoperative contrast-enhanced computed tomography (CT) revealed pulmonary embolism and massive right ovarian vein thrombosis (OVT). An inferior vena cava filter was placed and continuous intravenous heparin was started. A rectus sheath hematoma was noted on postoperative day 2 (POD 2). On POD 5, heparin administration was temporarily discontinued because of an enlarged rectus sheath hematoma. Approximately 24 hours later, the hemoglobin level recovered, and heparin administration was resumed. No further expansion of the hematoma was observed. When a rectus sheath hematoma is formed due to treatment with a therapeutic dose of anticoagulant immediately after cesarean section for peripartum VTE, temporary suspension of anticoagulant administration is reasonable to prevent further expansion of the hematoma without fatal complication.

Ovarian Vein Thrombosis: An Unusual Cause of Abdominal Pain in Breast Cancer

Ovarian vein thrombosis (OVT) is a rare but potentially life-threatening complication that is usually seen in the intrapartum or postpartum period but can also be seen in patients with risk factors for venous thromboembolism. When symptomatic, it usually presents with abdominal pain and other vague constitutional symptoms, hence it is important for healthcare professionals to be aware of this condition when evaluating patients with risk factors. We present a rare case of OVT in a patient with breast cancer. Due to a lack of clear guidelines regarding the treatment and duration of treatment in non-pregnancy-related OVT, we followed the guidelines for the treatment of venous thromboembolism and started the patient on rivaroxaban for a three-month duration with close outpatient follow-up.

Postpartum Ovarian Vein Thrombosis Due to COVID-19 in Pregnancy: A Case Report

Ovarian vein thrombosis is a clinic condition that is generally seen in the postpartum period and can mimic acute appendicitis with acute abdomen. The incidence of occurrence has increased further in cases predisposing to thrombosis. Coronavirus disease 2019 (COVID-19) during pregnancy causes increased thromboembolic events. Here we examined a case of ovarian vein thrombosis after stopping enoxoparin in a postpartum patient who had COVID-19 during pregnancy.

Diagnosis and management of ovarian vein thrombosis after laparoscopic -assisted vaginal hysterectomy with bilateral salpingectomy: A case report and literature review

OBJECTIVE

We present a case who developed ovarian vein thrombosis (OVT) after laparoscopic-assisted vaginal hysterectomy with bilateral salpingectomy to share our experience.

CASE REPORT

A 46-year-old woman came to our hospital due to severe dysmenorrhea induced by adenomyosis. Medical treatments were given but with unsatisfactory effect. As the patient had completed family planning, a hysterectomy was scheduled. However, on the sixth postoperative day, the patient complained of low abdominal pain with fever on and off. After a series of examinations, right OVT was diagnosed. The patient was treated with antibiotics only. Under close surveillance, the OVT resolved spontaneously, and the patient was discharged.

CONCLUSION

Diagnosis of OVT requires highly suspicion owing to its rarity and non-specific presentation. OVT is a potentially serious venous thromboembolism that sometimes can be life threatening. Anticoagulant treatment is still controversial. Conventional Tomography with contrast medium could detect early OVT with high sensitivity and specificity.

Ovarian vein thrombosis: A rare cause of abdominal pain as a complication of an elective abortion

Ovarian vein thrombosis (OVT) is a rare diagnosis. Patients can appear to be very uncomfortable on presentation with a physical examination that can mimic an acute abdomen. OVT is most often diagnosed during the postpartum period [Jenayah et al., 2015] and not typically seen during pregnancy or after procedures such as dilation and curettage (D&C). The complications from an OVT are significant and include sepsis, thrombophlebitis and pulmonary embolism [Harris et al., 2012]. Here we describe a case of OVT with an atypical presentation, diagnosed twenty-four hours after an elective D&C for a second trimester abortion.

Clinical Characteristics and Management of Ovarian Vein Thrombosis: A Case Series

Background

Ovarian vein thrombosis (OVT) is an uncommon condition, occurring in ~1 in every 600–2,000 pregnancies. It is associated with various conditions, including thrombophilia, malignancy, sepsis, intra-abdominal and pelvic inflammatory conditions, pregnancy, and the postpartum period, and specific surgical interventions, particularly gynecological surgeries. Thus, this study aims to identify the associated factors for OVT and elaborate on the standard treatment strategies for its management.

Methods

Retrospective data collection was used. Our study consists of 18 patients diagnosed with OVT between 2005 and 2016; the data was collected from the Health Information Management system at King Fahad Medical City, Riyadh, Saudi Arabia using a standard format.

Results

Our study found that OVT involves the right ovarian vein more often than the left and mainly occurs in women during their postpartum period. These patients other associated factor included hypertension, diabetes, and a higher body mass index (BMI) of above 25 kg/m². The most frequently presenting complaints were abdominal pain and fever. The most common treatment was the administration of enoxaparin (a low molecular weight heparin) for an average duration of one to three months, which resulted in a low recurrence rate of OVT.

Conclusions

Physicians should be vigilant for suspicion of OVT in female patients presenting with lower abdominal pain and fever in their postpartum period. Additionally, it is suggested to use low molecular weight heparin as initial therapy for OVT for one to three months, resulting in a high remission rate.

Ovarian Vein Thrombosis as an Uncommon Cause of Postpartum Fever: A Case Report

Postpartum ovarian vein thrombosis (POVT) is an uncommon cause of postpartum fever. Because POVT is sometimes complicated by pulmonary embolism, preventing diagnostic delay is critical. Nonetheless, the diagnostic delay of POVT is common due to its rarity. Antibiotics along with anticoagulants are recommended as the standard therapy for POVT, but this recommendation is based on older, low-quality literature. Here, we present a case of POVT, presenting with a persistent postpartum fever, which was treated by anticoagulants without antibiotics. Our case highlights the importance of awareness of POVT as a differential diagnosis and the need for studies to investigate the role of antibiotics in POVT.

A Rare Case of Idiopathic Gonadal Vein Thrombosis

Gonadal vein thrombosis, also known as ovarian vein thrombosis, is a rare medical condition presenting mostly in the postpartum period. Gonadal vein thrombosis is associated with conditions such as inferior vena cava thrombosis, sepsis, and pulmonary emboli which can lead to high morbidity and mortality. This report illustrates the case of a 25-year-old female patient who presented to the emergency department with a history of abdominal pain for over three days. The pain initially started centrally for a day, gradually, without radiation, and then became more localized in the right lower area and radiated to the genital area. The patient had a history of a cesarean section two years ago. Based on the presentation, an abdominal computed tomography scan demonstrated thickened tortuous right gonadal vein with the possibility of right gonadal vein thrombophlebitis and thrombosis. Having been examined by the general surgery and gynecology teams, a treatment plan was drawn involving thrombophilia workup and therapeutic anticoagulation. Although a rare entity, idiopathic gonadal vein thrombosis can present in the emergency department with vague abdominal pain and unclear diagnosis with a lack of risk factors. A high index of suspicion and imaging might be helpful to make this unique diagnosis.

Ovarian Vein Thrombosis Can Be a Complication of Hysteroscopy

Ovarian vein thrombosis is not well understood, and there is no consensus regarding treatment. It can present with subtle symptoms and is not usually high on the list of differentials. Traditionally, most cases are linked to pregnancy and postpartum state, but our case adds to the growing list of non-puerperal patients diagnosed with ovarian vein thrombosis after an outpatient procedure. In an era where there is a drive for minimally invasive procedures and shorter hospital stays, there is a need to have specific guidelines to direct the diagnosis and treatment of this rare form of thromboembolism.

Idiopathic Ovarian Vein Thrombosis: A Rare Cause of Abdominal Pain

Ovarian vein thrombosis (OVT) is a rare entity. It is usually seen in hypercoagulable states such as pregnancy, peripartum period, active malignancy, recent pelvic surgeries, pelvic infections, and inherited or acquired thrombophilias. Idiopathic OVT is exceedingly rare. We report a case of OVT in a healthy 42-year-old post-menopausal female presenting with right lower quadrant abdominal pain for four days. The patient denied any recent pelvic surgery, pelvic infection, or any family history of thrombophilia. Right ovarian vein thrombosis was found on a computed tomography scan of the abdomen and pelvis. Laboratory workup including hypercoagulability studies was normal. The patient was treated with a therapeutic dose of lower molecular weight heparin and later transitioned to rivaroxaban for three to six months. This case emphasizes OVT as a differential diagnosis of lower abdominal pain in healthy females. Currently, there are no standard guidelines for the duration of anticoagulation in OVT, however based on literature review, deep venous thrombosis treatment guidelines can be followed.

Non-pregnancy-related ovarian vein thrombosis: A rare cause of chronic abdominal pain

Background: Ovarian vein thrombosis (OVT) commonly occurs during the peripartum and postpartum period. However, few cases of idiopathic OVT unrelated to pregnancy have been described.

Case report: We report a case of a previously healthy, 32-year-old female who presented with chronic right-sided abdominal pain. Abdominal and pelvic gadolinium-enhanced MRI showed a right OVT. The patient was not in the peripartum or postpartum period. Thrombophilia test results were negative, and no risk factors for thrombosis were noted. The patient received warfarin for 6 months, with resolution of her symptoms.

Conclusion: The presented case emphasizes the significance of considering OVT as a cause of unexplained abdominal pain in a young female. We describe a rare case of idiopathic OVT with a unique presentation.

Postpartum ovarian vein thrombophlebitis presenting as vaginal bleeding: A case report

RATIONALE

Postpartum ovarian vein thrombophlebitis (POVT) is a rare condition, and it can lead to severe complications and mortality. Here we report a patient who presented with vaginal bleeding and the diagnosis of POVT was confirmed by imaging.

PATIENT CONCERNS

A 38-year-old postpartum woman without remarkable medical history presented with vaginal bleeding and lower abdominal pain.

DIAGNOSES

The diagnosis was confirmed by computed tomography scan marked by a thrombus mass involving the right ovarian vein and inferior vena cava.

INTERVENTIONS

The patient was treated with intravenous antibiotics and low-molecular-weight heparin.

OUTCOMES

The patient recovered smoothly without complications.

LESSONS

We should pay high attention to the recognition and management of POVT to prevent morbidity and mortality.

Ovarian Vein Thrombosis: A Narrative Review

Ovarian vein thrombosis (OVT) is a rare type of venous thromboembolism. The most common risk factors for OVT include pregnancy, oral contraceptives, malignancies, recent surgery, and pelvic infections; however, in 4 to 16% of cases, it can be classified as idiopathic. Most of the available information regards pregnancy-related OVT, which has been reported to complicate 0.01 to 0.18% of pregnancies and to peak around 2 to 6 days after delivery or miscarriage/abortion. The right ovarian vein is more frequently involved (70-80% of cases). Clinical features of OVT include abdominal pain and tenderness, fever, and gastrointestinal symptoms. The most typical finding is the presence of a palpable abdominal mass, although reported in only 46% of cases. OVT can be the cause of puerperal fever in approximately a third of women. Ultrasound Doppler is the first-line imaging, because of its safety, low cost, and wide availability. However, the ovarian veins are difficult to visualize in the presence of bowel meteorism or obesity. Thus, computed tomography or magnetic resonance imaging is often required to confirm the presence and extension of the thrombosis. In oncological patients, OVT is often an incidental finding at abdominal imaging. Mortality related to OVT is nowadays low due to the combination treatment of parenteral broad-spectrum antibiotics (until at least 48 hours after fever resolution) and anticoagulation (low-molecular-weight heparin, vitamin K antagonists, or direct oral anticoagulants). Anticoagulant treatment duration of 3 to 6 months has been recommended for postpartum OVT, while no anticoagulation has been suggested for incidentally detected cancer-associated OVT.

A Case of Postpartum Thrombophlebitis of a Retroperitoneal Varix Mimicking Acute Appendicitis

A case of thrombophlebitis of a retroperitoneal varix in a postpartum patient with right lower quadrant pain is presented. The sonographic examination was falsely positive for appendicitis, but the correct diagnosis was made with a subsequent computed tomogram. The thrombosed varix was likely a collateral of the right ovarian vein, analogous to postpartum ovarian vein thrombophlebitis (POVT), an uncommon potentially fatal disorder. POVT is reviewed, emphasizing features useful for distinguishing it from appendicitis at sonography. Sonographers should be aware of the possibility of thrombophlebitis when examining postpartum patients with right lower quadrant pain.

Postpartum ovarian vein thrombosis and venous anatomical variation

A 34-year-old multipara presented 72 hours postpartum with acute right-sided abdominal pain. The investigation revealed mild leucocytosis with positive D-dimer and elevated C reactive protein. Abdominal ultrasound and abdominopelvic CT demonstrated an enlarged right ovarian vein with endoluminal thrombus, representing postpartum ovarian vein thrombosis. The patient became asymptomatic 48 hours after starting broad-spectrum antibiotic treatment and anticoagulant therapy. She completed the treatment in ambulatory regimen and control abdominopelvic CT imaging was performed and revealed a duplicated right ovarian vein and a small residual subacute thrombus in the lumen of the distal right ovarian vein. The patient remained asymptomatic in the clinical follow-up.

A rare case of ovarian vein thrombosis in a gestational trophoblastic neoplasia patient

Ovarian vein thrombosis (OVT) is a rare disease with complications that can be life-threatening. An ovarian vein thrombus in a gestational trophoblastic neoplasia (GTN) is an extremely rare condition that has not been previously reported in the literature. We report the case of a 23-year-old woman who presented with symptoms of amenorrhea for 15 weeks and 6 days along with intermittent lower abdominal pain. She was diagnosed with a hydatidiform mole, and a metastatic workup was scheduled. Abdominal computed tomography showed a right ovarian vein thrombus. She received methotrexate chemotherapy combined with oral anticoagulants. Complete radiological remission was obtained. During the 12-month follow-up period, no disease progression or recurrence was noted. Early recognition and detection of the condition are of the utmost importance. The differential diagnosis of OVT must be considered when there is unexplained abdominal pain, fever, and leukocytosis during the diagnosis and treatment of GTN. A high level of suspicion is required for prompt diagnosis of OVT.

Diagnosis and management of postpartum ovarian vein thrombosis

A 26-year-old woman experienced persistent fever (39.5°C), chills, and right-lower-quadrant tenderness 3 days after caesarean delivery. A computed tomography (CT) scan of the abdomen and pelvis with contrast revealed enlargement of her right ovarian vein with an associated intraluminal filling defect. What is the best treatment of this patient?

Puerperal sepsis and maternal mortality: what role can new technologies play?

OBJECTIVE

To identify new and underutilized technologies to reduce maternal mortality related to puerperal sepsis in developing countries.

METHOD

Review of current medical literature.

RESULT

The literature indicates that infection-control protocols and evidence-based procedures--including prophylactic antibiotics for cesarean section or preterm rupture of membranes, and updated antibiotic regimens--should be widely adopted. Devices such as hand rubs, needle-disposal systems, and rapid microbiological diagnostic tests can improve compliance and efficiency. Operational research on promising developments like vaginal cleansing with antiseptics, vitamin A supplementation, and prophylactic antibiotics in high-risk women is needed.

CONCLUSION

Sepsis management continues to depend on good implementation of established technologies. Program-based approaches are required to improve uptake.

Ovarian and Renal Vein Thrombosis: A Rare Cause of Fever Outer the Postpartum Period

Although there is no other underlying disease, women can sometimes experience rare and serious diseases such as ovarian vein thrombosis (OVT) and renal vein thrombosis (RVT) after giving birth. The widespread development of thrombosis is treated for the first time in this study. Stasis, coagulation factor abnormalities, and intimal damage to the venous thrombosis risk can increase during pregnancy. It was mentioned that it diagnoses an abnormality in the hypercoagulability half of women with OVT. Despite the hypercoagulant abnormality observed in pregnant women, it was very unusual that the renal vein thrombosis led to this complication. It can lead to severe complication of OVT which can even cause death. It was the first time that the renal vein and ovarian vein thrombosis were observed in the postpartum period, and there was no coagulation abnormality. It is known that the thrombus in the postpartum period can be observed with the fever of unknown origin. The problematic, but rarely observed, postpartum disease such as ovarian venous thrombosis (OVT) is generally observed in the right ovarian vein. In this disease, avoiding the resulting laparotomy heparin and intravenous antibiotics is best solution for the patient. If it is to be noted a fever for unknown reasons, that it be thrombosis.

CT and MR imaging findings of systemic complications occurring during pregnancy and puerperal period, adversely affected by natural changes

Dynamic physiological and anatomical changes for delivery may adversely induce various specific non-obstetric complications during pregnancy and puerperal period. These complications can be fatal to both the mother and the fetus, thus a precise and early diagnosis ensued by an early treatment is essential. Along with ultrasonography, computed tomography (CT) and magnetic resonance imaging (MRI) have assumed an increasing role in the diagnosis.

This article aims to discuss the pathophysiology of these complications, the indications for CT and MRI, and the imaging findings.

Septic pelvic thrombophlebitis of unknown origin: an ever threatening entity

Septic pelvic thrombophlebitis (SPT) is a rare and severe entity, which may occur after abortion, delivery, gynecological diseases, or surgeries. Diagnosis is challenging when no risk factor is clearly present, since clinically, symptoms are non-specific. Nowadays, with the aid of imaging methods, diagnosis has become more achievable, but the treatment still bears some uncertainties. The authors present a fatal case of SPT in a young woman who sought medical care already presenting signs of septic shock, referring fever and non-characteristic abdominal pain. The patient evolved rapidly to multiple organ failure and respiratory distress, which was also due to septic pulmonary embolism. The autopsy confirmed the computed tomographic findings of a right ovarian vein septic thrombophlebitis and multiple septic pulmonary embolization foci. The patient did not present any of the recognized risk factors; neither did she present signs of pelvic inflammatory disease on admission or at autopsy. However, an intrauterine device was present. The authors call attention to this entity in the differential diagnosis of a woman with fever and abdominal pain, as well as for an empiric broad-spectrum antibiotic regimen in these cases.

Huge Trombus including Left Renal Vein, Ovarian Vein, and Inferior Vena Cava Mimicking Renal Colic

A 31-year-old female presented with acute left flank pain; she had a C/S at the postpartum day 24. Ureteral stone was suspected but ultrasound examination was normal. Then Doppler ultrasound revealed a trombus in left renal vein and inferior vena cava. Contrast enhanced MDCT scan showed swelled and nonfunctional left kidney, a trombus including distal part of left ovarian vein, left renal vein, and inferior vena cava. We started anticoagulation treatment. Further examination revealed diagnosis of chronic myeloproliferative disease. The trombus was completely recanalized at 3-month followup.

Ovarian vein thrombosis following total laparoscopic hysterectomy

Ovarian vein thrombosis usually occurs in pregnant patients, especially during the postpartum period. However, it is a rare complication following laparoscopic surgery in gynecology. The risk of a thromboembolic event is not well defined, and evidence-based guidelines regarding deep vein thrombosis prophylaxis in gynecological laparoscopic surgery are still lacking. Herein we report a rare case of ovarian vein thrombosis following total laparoscopic hysterectomy in a 35-year-old woman who developed a fever of unknown origin on postoperative day 3. A complete fever work-up was done. Her urine, vaginal stump and blood culture were all negative, and her white blood cell count was normal. CT revealed left ovarian vein thrombosis. The patient responded well to anticoagulation in conjunction with antibiotic therapy.

Imaging in infections of the left iliac fossa

The main organs in the left iliac fossa are the descending colon, sigmoid colon and, in women, internal reproductive organs. An infection of the left iliac fossa must lead the clinician firstly to suspect diverticulitis of the sigmoid colon in older patients and salpingitis in women of childbearing age. Other less common aetiologies are possible (inflammatory or infectious colitis, epiploic appendagitis, abscess of the psoas, pyelonephritis, renal abscess, etc.). Sonography as a first-line investigation may lead to diagnosis (especially in gynaecological disease), but a CT scan with intravenous injection of an iodine-containing contrast medium will allow for a full assessment of disease spread, and complications of sigmoid colitis or its differential diagnoses (abscess, fistula, perforation) to be investigated. It can also be used to guide percutaneous drainage or fine-needle aspiration for microbiology investigations.

Ovarian vein thrombosis

Ovarian vein thrombosis is a well-known but rare entity, which can occur during the post-partum period. This condition has also been associated with inflammatory and malignant processes within the pelvis. Untreated, complications of ovarian vein thrombosis can be significant due to the associated sepsis and risk of pulmonary embolism. Diagnosis can be made with confidence using ultrasound, computed tomography or magnetic resonance imaging. Treatment of ovarian vein thrombosis is particularly important in the post-partum patients, with anticoagulation therapy being the current recommendation.

Ovarian vein thrombosis mimicking acute abdomen: a case report and literature review

Background

Ovarian vein thrombosis (OVT) is a rare, but serious condition that affects mostly postpartum women. A high index of suspicion is required in order to diagnose this unusual cause of abdominal pain.

Case presentation

A 19-year-old woman at three days postpartum was admitted to our hospital because of severe right lower quandrant abdominal pain and fever 38.5'C. Physical examination revealed an acutely ill patient and right lower quadrant tenderness with positive rebound and Giordano signs. The patient underwent appendectomy which proved to be negative for acute appendicitis. Postoperatively fever and pain persisted and abdominal CT-scan with intravenous contrast agent demonstrated a thrombosed right ovarian vein. The patient was initiated on low-molecular weight heparin (LMWH) and antibiotic treatment and a month later a new abdominal CT-scan showed a patent right ovarian vein.

Discussion

Pathophysiologically, OVT is explained by Virchow's triad, because pregnancy is associated with a hypercoagulable state, venous stasis due to compression of the inferior vena cava by the uterus and endothelial trauma during delivery or from local inflammation. Common symptoms and signs of OVT include lower abdomen or flank pain, fever and leukocytosis usually within the first ten days after delivery. The reported incidence of OVT ranges 0,05-0,18% of pregnancies and in most cases the right ovarian vein is the one affected. Anticoagulation and antibiotics is the mainstay of treatment of OVT. Complications of OVT include sepsis, extension of the thrombus to the inferior vena cava and renal veins, and pulmonary embolism. The incidence of pulmonary embolism is reported to be 13.2% and represents the main source of mortality due to OVT.

Conclusions

OVT is a rare condition, usually in the postpartum period. A high index of suspicion is required for the prompt diagnosis and management especially in cases that mimic acute abdomen.

Ultrasound, computed tomography, and magnetic resonance imaging of ovarian vein thrombosis in obstetrical and nonobstetrical patients

Ovarian vein thrombosis is an uncommon clinical entity, most familiar to radiologists as a source of postpartum sepsis, which, if unrecognized and left untreated, has the potential for septic shock, pulmonary thromboembolism, and death. Ovarian vein thrombosis also occurs with other common inflammatory and malignant conditions in the nonobstetrical patient. This article reviews the pathophysiology, predisposing conditions, clinical findings, imaging features on ultrasonography, computed tomography, and magnetic resonance imaging of acute and chronic ovarian vein thrombosis and its appropriate clinical management.

Puerperal Pyrexia: A Review. Part II

Puerperal pyrexia and sepsis are among the leading causes of preventable maternal morbidity and mortality not only in developing countries but in developed countries as well. Most postpartum infections take place after hospital discharge, which is usually 24 hours after delivery. In the absence of postnatal follow-up, as is the case in many developing countries, many cases of puerperal infections can go undiagnosed and unreported. Besides endometritis (endomyometritis or endomyoparametritis), wound infection, mastitis, urinary tract infection, and septic thrombophlebitis are the chief causes of puerperal infections. The predisposing factors leading to the development of sepsis include home birth in unhygienic conditions, low socioeconomic status, poor nutrition, primiparity, anemia, prolonged rupture of membranes, prolonged labor, multiple vaginal examinations in labor, cesarean section, obstetrical maneuvers, retained secundines within the uterus and postpartum hemorrhage. Maternal complications include septicemia, endotoxic shock, peritonitis or abscess formation leading to surgery and compromised future fertility. The transmissions of infecting organisms are typically categorized into nosocomial, exogenous, and endogenous. Nosocomial infections are acquired in hospitals or other health facilities and may come from the hospital environment or from the patient's own flora. Exogenous infections come from external contamination, especially when deliveries take place under unhygienic conditions. Endogenous organisms, consisting of mixed flora colonizing the woman's own genital tract, are also a source of infection in puerperal sepsis. Aseptic precautions, advances in investigative tools and the use of antibiotics have played a major role in reducing the incidence of puerperal infections. Part II of this review describes the best management of wound infection, pelvic abscess, episiotomy infection, thrombophlebitis, mastitis, urinary tract infection, and miscellaneous infections.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to recall that world wide puerperal sepsis is a leading cause of maternal mortality, state that many of the predisposing factors are preventable, explain that both nosocomial infections as well as exogenous infections are serious factors, and relate that septic techniques and antibiotics can play a major role in reducing the incidence of puerperal infections.

Postpartum Ovarian Vein Thrombosis: An Update

Ovarian vein thrombosis (OVT) is a rare complication of pregnancy. However, recognition and treatment is critical because a delay in diagnosis could lead to significant maternal morbidity. The diagnosis of OVT remains a challenge because there is no known profile of risk factors. Current controversies concern radiologic diagnosis, appropriate treatment strategies including antibiotics and anticoagulation, treatment duration, and testing for thrombophilias.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to explain that even though the occurrence of postpartum ovarian vein thrombosis (OVT) is rare the physician must consider it in a differential diagnosis in a patient with postdelivery fever unresponsive to antibiotics, state that missing the diagnosis can have devastating consequences, and recall that at times it is difficult to differentiate from septic thrombophlebitis.

Acute non-traumatic maternal illnesses in pregnancy: imaging approaches

The imaging methods used to obtain diagnostic information for pregnant patients presenting with acute non-traumatic maternal illnesses have been reviewed. Conditions affecting the gastrointestinal tract, urinary tract, uterus, adnexae, central nervous system and chest have been investigated via a variety of imaging methods, which include ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), intravenous pyelography (IVP), angiography and fluoroscopy. The method of choice, application, and safety to the mother and fetus are considered for investigation of each condition.

Magnetic Resonance Imaging of Maternal Diseases Causing Acute Abdominal Pain During Pregnancy

Evaluation of acute abdominal pain in a pregnant patient is a clinical challenge. In these patients, magnetic resonance imaging (MRI) can allow a systematic cross-sectional evaluation of the entire abdomen and can provide clinically useful information in a short enough time for emergent diagnosis. This pictorial essay demonstrates MRI findings of various maternal diseases that can present as acute abdominal pain in pregnant patients. Familiarity with these findings is important for the radiologist to make an accurate and prompt diagnosis.

Acute appendicitis-like symptoms as initial presentation of ovarian vein thrombosis

Postpartum ovarian vein thrombosis is a rare condition, with an incidence rate being 1/600 deliveries. It most often arises in the right ovarian vein. A 33-year-old patient who had had normal vaginal delivery presented with fever, pain in the right iliac fossa, and leukocytosis on the sixth day after delivery. An antibiotic course was instituted but 3 days later symptoms reappeared. Diagnosis of acute appendicitis was made. At surgery through a McBurney incision, a woody tumoration consistent with ovarian vein thrombosis was found. Anticoagulation therapy with heparin and antibiotics were instituted. Phlebography and color Doppler sonography confirmed the presence of thrombosis of both the common femoral iliac and inferior vena cava. Fribrolysis with urokinase was performed. The patient has remained stable and symptom-free over a 4-year follow-up. Ovarian vein thrombosis typically presents with symptoms suggestive of acute appendicitis, as was the case in our patient. Color Doppler sonography is the favored diagnostic procedure, with CT being a supplementary tool. Surgery is not necessary and treatment consists of anticoagulants and antibiotics. Even though postpartum ovarian vein thrombosis is rare, early recognition of the condition is of paramount importance to institute the adequate treatment and avoid potential serious sequelae.

MR Imaging of Maternal Diseases of the Abdomen and Pelvis during Pregnancy and the Immediate Postpartum Period

Magnetic resonance (MR) imaging provides multiplanar large field-of-view images of the body with excellent soft-tissue contrast and without ionizing radiation. As a result, MR imaging is increasingly being used to image the maternal abdomen and pelvis during and immediately after pregnancy. Results of rapid T1- and T2-weighted imaging are often diagnostic, and blood vessels, ductal structures, and the urinary tract can frequently be visualized without intravenous administration of contrast material. Until more conclusive safety data become available, MR imaging should be reserved for cases in which results of ultrasonography are inconclusive and patient care depends on further imaging. In the setting of acute abdomen during pregnancy, MR imaging allows identification of areas of inflammation, abscess formation, hemorrhage, and bowel obstruction. MR imaging also helps determine the organ of origin, extent, and composition of maternal neoplasms and is useful in evaluation of müllerian duct anomalies and abnormalities of placental formation, position, and implantation. Many postpartum complications such as retained products of conception and uterine dehiscence may be diagnosed with MR imaging when results of other modalities are indeterminate.

Diagnosis of pregnancy-associated uterine venous plexus thrombosis on the basis of transvaginal sonography

OBJECTIVE

To describe the sonographic signs of uterine venous plexus thrombosis.

METHODS

Four pregnant patients had a diagnosis of uterine venous plexus thrombosis in the first half of gestation. The diagnosis was based on transvaginal sonography only in 3 cases, and the fourth had magnetic resonance imaging corroboration.

RESULTS

All 4 patients had similar sonographic features of uterine venous plexus thrombosis on transvaginal sonographic examination. The thrombi within the dilated veins were shown as elongated echogenic structures along the lumen that appeared round on transverse views of the affected veins. They showed swinging movements provoked by gentle transducer pressure. Power and color Doppler sonography enhanced the uterine venous plexus thrombosis diagnosis by showing blood flow around the thrombi. There were no signs of thromboembolic disease. Sonographic findings in deep leg veins and iliac veins were normal in all cases. Complete thrombophilia studies did not reveal any abnormalities. The uterine venous plexus thrombosis could not be detected on transabdominal sonography and was shown better by transvaginal sonography compared with magnetic resonance imaging. During 3 months of anticoagulation therapy, the thrombi gradually disappeared in all cases.

CONCLUSIONS

Focusing on the pelvic veins while performing a transvaginal sonographic study during pregnancy may reveal important findings, which may have clinical implications. The therapeutic treatment of uterine venous plexus thrombosis is controversial and still empirical.

Body MR venography

MRV offers unique diagnostic possibilities for detection and characterization of venous disease. It allows evaluation of perivascular and vascular anatomy, evolution of thromboembolic events, and assessment of vascular flow. MRI is a diagnostic tool that can be tailored for a variety of clinical dilemmas, not only DVTs. Continued improvements in hardware and software will expand the role of MRV.