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

Smokeless tobacco: knowledge, attitudes and usage in Pakistan

BACKGROUND

Smokeless tobacco (SLT) encompasses products that are not burnt but instead consumed orally or nasally. One-third of tobacco is consumed in the smokeless form in South Asia. Despite its widespread usage, there has been limited empirical research on the prevalence and factors influencing SLT consumption in Pakistan. This study aimed to provide an assessment of SLT knowledge, attitudes, and usage in Pakistan.

METHODS

Using an online questionnaire, a cross-sectional survey was conducted across Pakistan. Convenience sampling was used to disseminate, and expert approval was sought followed by a pilot study to validate the questionnaire. A comprehensive questionnaire was developed using elements from the Global Adult Tobacco Survey and other tools which had previously been utilized within Pakistan. Participants' responses were described using descriptive statistics, and SPSS version 26 was used to perform linear and logistic regression. A p-value of less than 0.05 was considered statistically significant.

RESULTS

Data was collected from 1,195 participants among which 85.86% of participants had heard of SLTs prior to the survey. Sex, province, household income and previous doctor visits were significant determinants to product knowledge through which 72.55% agreed that these products can lead to serious illnesses but 30% noted a lack of knowledge on legality. General attitudes agreed that it makes one feel unwell (44.1%), gives a sense of guilt (43.85%) and more research is needed on it (54.39%). Negative health effects were the biggest deterrent from pursuing these products for 60.33% of participants. Among significant factors influencing the use of SLTs, the greatest odds of use were found with use as an alternative to cigarettes (OR 4.45) and secondly, due to its availability in a liked flavor (OR 2.27). About 31% reported to have used the product once, with 69.82% of current users expressing a desire to quit.

CONCLUSIONS

Although adequate knowledge and aligning attitudes exist for SLTs, light is shed in the face of a sustaining public health problem. We offer important insights that can guide the creation of focused interventions meant to lower SLT use, and the health hazards associated with it in the Pakistani community by highlighting important myths, incentives, and deterrents.

Septic Pelvic Thrombophlebitis Status Post-Laparoscopic Hysterectomy: A Case Report Investigating a Rare Yet Perilous Adverse Outcome

Septic pelvic thrombophlebitis is defined as an endovascular thrombus of infectious etiology. It is frequently diagnosed only after excluding other more common pathologies. A high level of suspicion should be maintained in the context of a fever refractory to broad-spectrum antibiotics that improves after initiation of systemic anticoagulation. The risk of thromboembolic events following minimally invasive surgery is minute; however, it requires increased awareness, as prompt management is critical for decreasing morbidity and mortality. We discuss a case of septic thrombophlebitis in a 42-year-old female who was postoperative day six status post elective total laparoscopic hysterectomy, bilateral salpingectomy, and right ovarian cystectomy due to abnormal uterine bleeding. The case was complicated by a postoperatively diagnosed small bowel injury that necessitated resection. The patient continued to exhibit a fever of unknown origin despite the administration of broad-spectrum antibiotics; therefore, CT imaging with IV contrast was obtained. The imaging raised concerns about septic thrombophlebitis, and the symptoms were resolved with the administration of a 16-hour infusion of intravenous heparin. Despite its rarity, septic pelvic thrombophlebitis should be considered in patients with relevant risk factors and persistent fever refractory to antibiotics status post-laparoscopy. This report highlights the importance of awareness of SPT and encourages further research on thromboembolic events in laparoscopic surgeries.

Venous Tropism in Renal Cell Carcinoma: A Rare Imaging Presentation

Renal cell carcinoma (RCC) is one of the most prevalent malignancies in adults. Accurate staging and assessment of tumor extent are critical for effective management. RCC often demonstrates a tendency for venous invasion, commonly extending into the renal vein and inferior vena cava. However, RCC extending into the gonadal veins is an uncommon manifestation. In this report, we present the imaging features of a 62-year-old woman presented with left flank pain. The ultrasound examination revealed a large hyperechoic mass in the left renal fossa, replacing almost the entire left kidney with the contiguous extension of the tumor into the left renal vein and ovarian vein. Color Doppler showed the presence of flow within the thrombus, confirming the presence of a malignant thrombus. Contrast-enhanced CT examination revealed a large heterogeneously enhancing mass in the left kidney with the contiguous extension of tumor thrombus in the left renal vein, IVC, and into the left ovarian vein. This report highlights how imaging techniques can be instrumental in detecting and characterizing rare but significant tumor extensions, which can have crucial prognostic implications for overall patient management.

Safety and efficacy of anticoagulant treatment in patients with ovarian vein thrombosis: a systematic review and meta-analysis of observational studies

Background

The role of anticoagulation in ovarian vein thrombosis (OVT) is uncertain.

Objectives

We aimed to evaluate safety and efficacy of anticoagulant treatment in OVT patients.

Methods

A systematic search was conducted in MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases up to April 2024. Eligible studies included randomized controlled trials and observational studies enrolling at least 10 adult patients with objectively diagnosed OVT and treated with any anticoagulants. The protocol was prospectively registered in the International Prospective Register of Systematic Reviews (CRD42021270883).

Results

We included 17 observational studies (621 anticoagulated and 376 nonanticoagulated OVT patients); 9 studies enrolled mainly pregnancy/puerperium-related OVT. Most patients received heparins alone (45.7%) or proceeded to vitamin K antagonists (39.2%). The average treatment duration was ≤3 months in 8 studies (47.1%), >3 to ≤6 months in 6 studies (35.3%), and >6 months in 3 studies (17.6%). In treated patients, mortality rate was 2.43% (95% CI, 0.54%-5.41%; I2 = 53.8%; 12/406 patients; 13 studies), major bleeding was 1.27% (95% CI, 0.48%-2.38%; I2 = 2.5%; 7/583 patients; 15 studies), recurrent venous thromboembolism (VTE) was 3.49% (95% CI, 1.12%-6.95%; I2 = 63.5%; 22/482 patients; 15 studies), and vessel recanalization was 89.4% (95% CI, 74.6%-98.6%; I2 = 80.6%; 163/184 patients; 8 studies). The rate of recurrent VTE in untreated patients was 8.65% (95% CI, 2.61%-17.35%); however, the difference compared with treated patients was not statistically significant (risk ratio, 0.70; 95% CI, 0.36-1.37). At subgroup analyses, the rates of major bleeding and recurrent VTE were 0.80% (95% CI, 0.0-2%.17%) and 3.81% (95% CI, 0.42%-9.63%) in pregnancy/puerperium-related OVT, respectively, and 1.12% (95% CI, 0.32%-2.34%) and 1.78% (95% CI, 0.62%-3.46%), respectively, when analyzing only full-text studies.

Conclusion

There is paucity of literature regarding OVT. Our results suggest that anticoagulation is associated with low rates of major bleeding and recurrent VTE.

Postpartum ovarian vein thrombosis with left renal venous infarction after vaginal delivery

A primipara in her late 20s presented with abdominal pain and pain in the left flank 14 days after a ventouse delivery. She was treated with antibiotics, antiemetics and analgesics with the initial differential diagnosis of cystitis, pyelonephritis or nephrolithiasis. Despite the treatment, the patient experienced increased colic pain and nausea. An ultrasound showed an enlarged left kidney, suggesting pyelonephritis, and thereby, the antibiotic treatment was adjusted accordingly. Despite additional pain medication, pain relief could not be achieved. The diagnosis of ovarian venous thrombosis was considered, and an abdominal CT scan confirmed the diagnosis. The patient was treated with anticoagulant therapy. Hypercoagulability work-up revealed a heterozygous mutation of the Factor V Leiden. Our patient awaits a haematologic follow-up.

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.

Cancer-Associated Abdominal Vein Thrombosis

Cancer is associated with an increased risk of developing venous thromboembolism, due to its direct influence on the three pillars of Virchow's triad (e.g., compression on the blood vessels by the tumour, blood vessels invasion, and cytokine release), together with the effect of exogenous factors (such as chemotherapy, radiotherapy, surgery). In cancer patients, the risk of thrombosis at unusual sites, such as splanchnic, ovarian and renal vein thrombosis, is also increased. Abdominal vein thromboses are frequently incidental findings on abdominal imaging performed as part of the diagnostic/staging workup or the follow-up care of malignancies. There is little evidence on the management of unusual site venous thromboembolism in cancer patients since there are only a few specific recommendations; thus, the management follows the general principles of the treatment of cancer-associated deep vein thrombosis and pulmonary embolism. This narrative review summarises the latest evidence on cancer-associated abdominal vein thrombosis, i.e., thrombosis of the splanchnic, ovarian and renal veins.

Group B Streptococcus infection-induced ovarian vein thrombosis identified during cesarean section: A case report and a literature review

RATIONALE

Ovarian vein thrombosis (OVT) is a rare yet potentially life-threatening condition associated with thromboembolic events. Group B Streptococcus (GBS) is a type of β-hemolytic Gram-positive bacterium known for asymptomatic colonization in the lower genital and gastrointestinal tracts. Here we reported a 35-year-old multiparous woman with gestational diabetes who suffered from placental abruption, stillbirth, OVT, septic shock, and renal failure due to severe GBS infection.

PATIENT CONCERNS

A 35-year-old woman with gestational diabetes presented with acute and sustained lower abdominal cramping, vaginal bleeding, and fever at 35 gestational weeks.

DIAGNOSES

Based on preoperative ultrasound and intraoperative findings, the patient was diagnosed with placental abruption, intrauterine fetal demise, and right OVT. GBS was cultured from the amniotic fluid obtained during cesarean section.

INTERVENTIONS

The patient underwent a right adnexectomy during a cesarean section and received intravenous antibiotics. Subsequently, an ultrasound-guided uterine curettage was performed due to recurrent fever.

OUTCOMES

After a prolonged course of intravenous antibiotics for over a month, the patient recovered and was discharged from the hospital.

LESSONS

This case underscores the need for early initiation of anticoagulant protocols in cases of OVT, particularly when GBS infection is identified as a predisposing factor. Further research and awareness are warranted to better understand the relationship between GBS infection and OVT and to optimize management strategies in such cases.

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.