Ovarian Vein Thrombosis


HJOG 2022, 21 (4), 173-186 | doi: 10.33574/hjog.0516

Theoni Kanellopoulou

Department of Clinical Haematology, Blood Bank and Haemostasis, Onassis Cardiac Surgery Centre, Athens, Greece

Correspondence: Theoni Kanellopoulou, Onassis Cardiac Surgery Centre, Athens, Greece, e-mail: theokanel@gmail.com


Ovarian vein thrombosis (OVT) is a rare type of venous thromboembolism most common diagnosed in the postpartum period and peaking around 2-6 days after delivery. Clinical symptoms are not specific including fever and abdominal pain and the right ovarian vein is more frequently involved (70-80% of cases). The diagnosis of OVT is a clinical challenge because there are multiple other conditions that can present similarly, including ovarian torsion, tubo-ovarian abscess, pelvic inflammatory disease, puerperal endometritis, appendicitis, inflammatory bowel disease and pyelonephritis. Ultrasound Doppler is the first-line imaging; however, most cases are confirmed with computed tomography or magnetic resonance imaging. Mortality related to ovarian vein thrombosis is low due to the combination treatment of broad-spectrum antibiotics and anticoagulation. Extension of thrombus to inferior vena cava or renal veins and rarely pulmonary embolism could also occur. OVT is actually a type of deep vein thrombosis that could be life-threatening however mortality is low due to the combination treatment of broad-spectrum antibiotics and anticoagulation. Anticoagulant treatment duration of 3 to 6 months has been recommended like typical cases of venous thromboembolism.

Keywords: Anticoagulation, ovarian vein, postpartum, thrombosis


Ovarian vein thrombosis (OVT) is a rare condition most often seen in the immediate postpartum period that has been reported in approximately 0.01–0.18% of vaginal and in 2% of caesarian births. Although most cases occur in puerperal patients, OVT could also occur in other conditions like pelvic inflammatory diseases, malignancy, sepsis, pelvic surgeries and hypercoagulable states including autoimmune diseases or inherited thrombophilia factors. However, in 4 to 16% of cases, it can be classified as idiopathic.1-3

OVT remains poorly understood with no consensus regarding its importance and the best treatment approach. In this review article an attempt is made to highlight the risk factors that predispose to OVT, the common symptoms, the diagnostic approach, the complications and the recommended treatment.

Review of the Literature

A Pubmed search of English literature was performed in order to review reported cases of non-malignant OVT during the period 1980-2021.

Demographic Data – Risk Factors (Table 1)

Review of the literature revealed 208 patients with median age 31 years (range, 15-73 years). Cases with insufficient data were not analyzed.

Most cases (74.6%) were diagnosed postpartum;3-118 52.5% after vaginal delivery4,5,7,9,13-15,18,19,21-24, 27,29-34,36,38,41-48,50,51,55,60,62-64,66,71,74,76,77,79,80,84,86,88,92,93,96-101,105,108,111,113-115,118 and the rest after caesarian section.3,6,8,10-12,16,19,20,26,28,35,37,39,40,42,49,52,53,57-59,61,65,67,70,73,78,88-91,95-97,102,106,107,109,116,117 The analysis of puerperal patients shown 17 cases with multiple pregnancies (mostly twin)18,19,40,42,52,53,88,91,92,94,96,97,99,107,109,112 and in 28 cases a pregnancy complication was reported like urgent or preterm delivery, HELLP (Hemolysis, Elevated Liver Enzymes and low Platelets) syndrome, or other less frequent complications.8,17,30,39,49,54,56,57, 61,67,73,75,82,87,88,90,93,97,99,102,106,115,116

In non-puerperal related cases a possible endometrial reason was reported most common fibroids (11 cases)4,23 or intrauterine device (IUD) (4 cases).112 Twenty-one patients underwent pelvic surgery or other gynecological procedures, mostly hysterectomy (11 cases).10,16,21,25,26,59,60,120,122,124,125

Thrombophilia screening was performed only in a minority of cases. The most common inherited risk factor was heterozygocity of FV-Leiden. Other procoagulant risk factors included the presence of antiphospholipid antibodies or other risk factors including past medical history of thromboembolic disease or use of oral contraceptive pills (OCP).11,28,31,36,39,47,62,68,70,73,88

During COVID-19 pandemic, 7 cases have already been reported within a recent infection and more cases are expected to be published within 2022.7,13,128

Yet, in 17 cases a causal related-factor could not be prescribed and the case was reported as idiopathic.14,64,132


Symptoms are nonspecific. They include mainly lower abdominal tenderness with or without flank pain and fever that could be associated with tachycardia, chills, nausea and vomiting.

Diagnosis (Table 2)

In 84% of patients the diagnosis was made with non-invasive imaging techniques, mainly by computer tomography (CT) with contrast augmentation. In 15% of patients the diagnosis was made intraoperatively.4,30,38,42,43,46,47,54,59,71,76,83,86,87,92-94,99,101,103,111,112,114-116,118,136,140 88% of patients for whom the diagnosis was made during operation were postpartum and there was a highly suspicion of acute abdomen due to appendicitis before the diagnosis of OVT.

The localization was the right ovarian vein in 54% of reported cases,3,5-8,10,11,15,16,18,20,23-28,30-32,35,37,38,40-56,60-66,69,71-74,76-78,82,86,89,90-94,96-98,102,107,108,111,115,119,123,125,126,128-131,134-136,138,140,141,146,149 the left in 37%4,14,19,21,29,34,39,57,67,70,73,80,83,93,120,121,122,124,127,133,139,143,145 and both veins in 9%. 17,19,22,36,52,59,79,86,87,93,95,132,137,142

Extension of thrombus in inferior vena cava (IVC) was observed in 81 cases,5,6,9,11,12,16,18,20,22-28,31,35,37-42,45,46,48,50,53,55,56,61-67,71,73-75,77-79,85-90,93,96-99,102,105-109,115,118-120,126,129,132,140,146,149,154,157,161,162,164 in renal veins in 27 cases,21,22,28,29,39-41,59,66,70,77,93,96-98,103,106,109,124,127,133,149,157,158,164 iliac veins 11 cases.40,42,62,65,71,79,88,93,98,105 In 25 patients pulmonary embolism (PE) was also diagnosed.11,20,26, 40,42,48,61,62,65,71,73,79,89,98,119,120,126,132,139,140,149,157,161,162


Anticoagulation treatment was given in the majority of cases (97%). Unfractionated heparin (UFH) or low molecular weight heparin (LMWH) was initiated in 70% of the cases and subsequently bridging to vitamin K antagonists (VKAs) in 40%.4,7,9,10,12,14,17,19,21, 23-28,30,34,36,39,42-46,48,51,55,59,60,64,65,67,73,74,79,82,89,91,96,98,99,102,105,106,109,115,118,120,121,122,129,138,144-147,152,154,159,161 In 14 patients novel direct oral anticoagulants (DOACs) were used.11,16,20,119,125,128,132,134,136,140-143,150 Thrombolysis with alteplase (tissue-type plasminogen activator-tPA) was given in 8 patients.66,71,77,78,90,105,133,149 One patient was treated with antiplatelet treatment with aspirin.101 IVC filter was implanted in 6 patients40,42,58,75,85,133,164 and surgical treatment with ligation was performed in 23 patients.22,38,53,61,63,76,80,83,84,88,95-97,100,113,114,116, 117,123,160,163

Septic thrombophlebitis was demonstrated in few cases with positive cultures (Table 3). However, antibiotics were administered in 123 patients (59%).4-7,9-12,15,17-19,22-34,37,38,41,43-48,51-53,56-60,62,63,65-67,71,72,74-80,82,84-86,88-99,101,102,105-109,111,114-118,120-124,126-128,135,144,154,156,160 In 4 patients a ureteral intervention was performed (either aspiration, stent insertion or nephrostomy).36,42,50,131 Three patients were also treated with immunosuppressive drugs.150,159,161


The duration of anticoagulation treatment varied from less than one month to more than a year and in most of the cases there were no data about actual duration. Improvement was observed in 115 patients4,5,7,9,12,14-23,25-32,34,36,37,39-44,46-51,54,55,60,62-67,69-80,82-84,86,87,90,91,96-99,101,106-109,111,15,116,118-123,127,129,130,132-134,136,138,140,143,145-147,149,150,152,159-162 and adverse events in 6 patients53,84,93,95,126,139 including death in 3 patients.84,126,139


Austin described the first known case of OVT in the postpartum setting in 1956.165 With the improvement in antiseptic techniques and the use of antibiotics, mortality has improved, but complications of OVT continue to be reported and include thrombus extension, PE, and ureteral obstruction.166

The pathogenesis of postpartum OVT is not clearly understood. The changes in fibrinolysis and coagulation during pregnancy are possibly the most important factors resulting in hypercoagulability in combination with the increase in the diameter and the capacity of the ovarian veins during pregnancy. It has also been demonstrated that the velocity of the blood flow in the ovarian veins decreases considerably immediately following delivery.1,166 History of thromboembolic disease, inherited thrombophilia or other concomitant diseases associated with hypercoagulability have not been directly correlated. Ιn the majority of reported cases of OVT, screening for thrombophilia risk factors was not performed. Salomon et al. retrospectively analyzed 22 patients with postpartum OVT and reported inherited prothrombotic risk factors in 50% of them; Five had heterozygocity of FV-Leiden and the rest either protein S deficiency or MTHFR C677T homozygocity. However, it should be noted that 73% had a caesarian section delivery.167 In present review of the literature, thrombophilia screening was performed in a minority of reported cases and the most common reported inherited prothrombotic risk factor was heterozygocity of FV-Leiden.

Diagnosis requires a very high index of suspicion owing to its rarity and non-specific presentation. In the past, before the introduction into clinical practice of modern imaging techniques, diagnosis in most cases was based only on laparotomy. Nowadays, the diagnosis of OVT has become easier with non-invasive imaging techniques. Ultrasound is the initial imaging study of choice as it is inexpensive, free of radiation and doesn’t require intravenous contrast. However, detection rates for OVT are poor, because it may not show the entire length of the vein in most cases secondary to obesity and/or overlying bowel gas.168 In those cases the diagnosis could be made by CT with contrast augmentation or magnetic resonance imaging (MRI). On the other hand, symptomatic presentations are less common than those who are asymptomatic that makes the suspicion of OVT even more difficult. The rise in the use of imaging may identify OVT that may not have been otherwise clinically evident. The incidence of OVT is higher in the right ovarian vein, with 70–90% of cases occurring on the right side, whereas 11–14% is bilateral. This is apparently from the longer length and the lack of competent valves on the right side.151 Equivalent percentages are also observed in this review article and in almost 90% of cases the OVT occurred in the right ovarian vein. However, in the analysis by Assal et al. there was a similar incidence of right and left OVT (44.6 versus 41.4%, respectively) with a high percentage of bilateral thrombi (14.0%). Though, when the peripartum group was examined separately, a significantly higher incidence of right OVT (60%) and bilateral OVT (25%) was noted (P. 0.03).166

OVT is usually managed conservatively and most patients respond to antibiotics, anticoagulation, hydration and bed rest. Appropriate medical treatment should be started soon after diagnosis is confirmed to prevent serious complications. Heparin and warfarin have been traditionally used even in the postpartum period because are considered safe during lactation. To date, there are no data to support the use of DOACs in OVT. Single case reports and small series of patients have demonstrated good efficacy and safety in patients with portal vein thrombosis and cerebral venous thrombosis. These results are promising and may possibly extend the use of DOACs in other rare types of thrombosis as OVT. In literature there are few reports of patients with OVT treated with DOACs that showed similar efficacy with traditional treatment. However, in postpartum cases DOACs are contraindicated during lactation as they are excreted into breast milk. Thrombolytic drugs (alteplase, urokinase) have been used in few cases but are associated with a high risk of bleeding therefore they should be reserved for patients with massive thrombosis. Retrievable IVC filters can be used in cases of active bleeding including emergent surgical cases where anticoagulation is contraindicated or who have had a PE while on therapeutic anticoagulation. Surgical treatment with ovarian vein excision or ligation is rarely performed nowadays and is indicated only after the failure of conservative therapy or when the risk of PE is high. Initiation and appropriate duration of anticoagulation are also a matter of debate. Some argue that incidentally found OVT related to surgery may not need anticoagulation unless complications are noted116 while a majority of experts believe rare thrombosis should be treated like lower extremity deep vein thrombosis (DVT).169 There are no definitive guidelines for duration of anticoagulation. Some case reports suggest repeating imaging after 40 or 60 days and stopping anticoagulation if the resolution of thrombus or calcification is noted on follow-up imaging.

Even if prompt administration of anticoagulation is administered, thrombus expansion into the IVC and PE may develop. In fact, the risk of PE is up to 13% in cases with mortality of approximately 4%.170 In the cohort of Assal et al. 9.9% of patients experienced recurrent VTE events, mostly DVT (82%) with average time to recurrence 409 days. All patients with recurrence were not during postpartum period and there recurrence was more common in patients with left OVT and bilateral OVT as compared with right OVT (P 0.01). The VTE recurrence rate in patients with a history of VTE was almost twice that of the overall group (18.2%), but was not statistically significant. Conversely, no statistically significant association between recurrence rate and a predisposing factor has been found. Moreover, even if there was a reduction in venous thromboembolism recurrence in the group that received anticoagulation, the results were not significant.171

OVT associated with septic pelvic thrombophlebitis could evolve into septic shock or emboli, which have a high mortality rate. Thus, physicians should consider OVT in any woman in the peripartum period, after pelvic operations or in the setting of gynecological malignancy, with unexplained fever and lower abdominal pain not responding to antibiotics and analgesics and suggestive of acute appendicitis, endometritis, hydronephrosis, or ovarian torsion. A high index of suspicion and the ability to rule out other processes that may produce similar symptoms is important, because untreated OVT could even prove fatal. Prompt diagnosis and management especially in cases that mimic acute abdomen especially in the current endemic context of COVID-19 where thromboembolic complications are common. With the ongoing pandemic, the number of such cases is only expected to rise, and OVT should be a part of the differential.

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