Pulmonary thromboembolism as a result of ovarian vein thrombosis after laparoscopic-assisted vaginal hysterectomy for uterine myoma

Potential critical risks of pulmonary thromboembolism from an asymptomatic postpartum ovarian vein thrombosis: a case report

Background

Ovarian vein thrombosis (OVT) may cause maternal mortality by inducing pulmonary thromboembolism (PTE). However, the prevalence, etiology, risk factors, prognosis, and optimal treatments for asymptomatic OVT during and after pregnancies are unclear, which therefore requires a high clinical index of suspicion for certain diagnoses due to its vague presentation. We herein present a case of asymptomatic postpartum OVT that extended toward the inferior vena cava (IVC), resulting in a potential risk of PTE.

Case presentation

A 30-year-old postpartum woman presented with slight dyspnea after an uneventful vaginal delivery at 40 weeks of gestation. We checked her laboratory data to exclude lethal thrombosis; D-dimer levels were 85.6 μg/mL. We performed computed tomography (CT) to search the presence of PTE and deep vein thrombosis (DVT); although no signs of PTE and DVT in her legs were detected, CT and trans-abdominal ultrasonography (TAUS) revealed a right OVT. Heparin was administered, and D-dimer levels decreased; warfarin at a dose of 2 mg/day was subsequently administered to control anti-coagulopathy. However, D-dimer was re-elevated despite adequate anticoagulation treatment, and extension of the right OVT to the IVC was detected by CT and TAUS. With warfarin administration, CT and TAUS showed the disappearance of right OVT. The patient was discharged from the hospital 17 days after delivery.

Conclusions

Even asymptomatic postpartum OVT may lead to PTE. Universal screening guidelines and optimal treatment strategies for asymptomatic OVT in pregnant and postpartum women should be established through future studies.

Ovarian vein thrombosis after total laparoscopic hysterectomy with unilateral adnexectomy: A case report

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Symptoms are often not specific and may include fever, abdominal pain, flank and back pain.

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Treatment is controversial and there is no standard evidence – based protocol; anticoagulation therapy and antibiotics remain the main basic therapy.

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The application of bipolar electrocautery and the pexy of the ovary are possible contributing mechanisms for the thrombus formation.

Introduction

Ovarian vein thrombosis is a rare but potentially serious complication after surgical and gynecologic procedures such as oophorectomy and hysterectomy. The association of this event with laparoscopic hysterectomy in particular, is very rare. Only two cases have been described so far.

Presentation of case

We present a case of ovarian vein thrombosis after laparoscopic hysterectomy in a 40-year-old with deep endometriosis and multiple intramural uterine myomas. Laparoscopic hysterectomy, left oophorectomy, right salpingectomy, and suspension (ovariopexy) of the right ovary on the ipsilateral round ligament of the uterus were performed, using bipolar electrocautery as a hemostatic tool.

Discussion

The 7th postoperative day the patient presented to our hospital complaining of abdominal pain and fever. An abdominal CT scan demonstrated a filling defect and enlargement of the right ovarian vein, a finding compatible with ovarian vein thrombosis. She was treated with low molecular weight heparin (LMWH). On the 19th postoperative day, an MRI scan was performed and did not reveal any pathological findings of the right ovarian vein. The patient was discharged on LMWH for three months. Post treatment evaluation for thrombophilia was negative for pathological findings.

Conclusion

Our case is a very rare condition. Only two ‘similar’ cases have been described in the literature so far. Bipolar electrocautery and ovariopexy on the ipsilateral round ligament during laparoscopic hysterectomy should be evaluated further as possible contributing mechanisms for the thrombus formation.

Transient elevations of liver enzymes and ovarian vein thrombosis arising after total laparoscopic hysterectomy

Ovarian vein thrombosis in non-pregnant patient is a rare clinical entity. Among 170 patients who underwent total laparoscopic hysterectomy (TLH) in our hospital from December 2011 to December 2015, we have one case of ovarian vein thrombosis (0.0059%). A 42-year-oId woman had a fever of 39 °C on the fourth day after TLH. A blood test revealed elevations of liver enzymes and D-dimer (AST 1157 U/L, ALT 942 U/L and D-dimer >30 μg/L). Computed tomography (CT) scan with intravenous contrast agent demonstrated right ovarian vein thrombosis which caused decline in blood flow to liver and acute liver dysfunction. Low-molecular weight heparin was initiated and liver enzymes reduced rapidly. On the seventeenth day after TLH, CT scan revealed a recanalization of the ovarian vein. We report the clinical outcomes of the case attempted with a small review of the literature.

Portomesenteric Vein Thrombosis After Excision of Parasitic Peritoneal Myomas

An enlargement of multiple asymptomatic pelvic masses was detected during a regular checkup of a 39-year-old woman. Twelve years earlier, she had undergone laparoscopic-assisted myomectomy, at which time an uncontained manual extraction of a posterior intramural myoma was performed. This was followed by 2 uneventful cesarean deliveries after spontaneous conceptions. Diagnostic imaging revealed at least 3 abdominal masses, 1 of which received its major blood supply from the inferior mesenteric artery. Gasless single-port laparoscopic excision of the peritoneal masses, was performed along with laparoscopic-assisted vaginal hysterectomy and bilateral salpingo- oophorectomy. The masses were histopathologically diagnosed as parasitic peritoneal myomas. The patient's immediate postoperative course was uneventful; however, on day 6 after surgery, she complained of severe periumbilical abdominal pain and vomiting. Anticoagulant therapy was initiated after hematologic examination revealed an elevated D-dimer level and dynamic computed tomography angiography showed portomesenteric vein thrombosis. Vaginal stump bleeding, which occurred 17 days after the initiation of anticoagulant therapy, was managed conservatively, and there was no recurrence of venous thrombosis in the year after surgery. To avoid significant morbidities and potential mortality when parasitic peritoneal myomas with aberrant neovascularization are excised, attention should be given to the perioperative development of venous thromboembolic events in rare locations.