There are no standard or specialty society guidelines for the management of these patients as data are limited. There is a theoretical risk that the patient will develop signs of sepsis, but perhaps the most worrisome complications are inferior vena cava extension and subsequent embolization (ie, pulmonary embolism). Estimates (from all causes of OVT) put the risk for pulmonary embolism at an alarming 25 percent, with an associated mortality of 4 percent.7 Clearly, this suggests a need for anticoagulation to help reduce this risk. Historically, systemic anticoagulation has been initiated with heparin, followed by bridging to warfarin until a therapeutic international normalized ratio is achieved.7 The increasing popularity of direct oral anticoagulants offers a potentially useful alternative. However, the efficacy of these drugs for the treatment of OVT has not been studied.
Explore This Issue
ACEP Now: Vol 36 – No 06 – June 2017Disposition for these patients will likely depend on patients’ presentation, laboratory and imaging results, symptom control, and provider discretion. Patients with sepsis physiology will require admission and gynecological or surgical evaluation. In patients with an incidental finding whose symptoms are controlled and have a reassuring workup, disposition may depend on the anticoagulation plan and ability to secure follow-up and outpatient referral.
Expert consultation for nonsurgical patients may pose a challenge. Recently delivered patients should be evaluated by their obstetrician. However, in non-peripartum patients without acute gynecologic pathology, a gynecologist may or may not manage the condition. Patients will likely require hematology referral or evaluation for consideration of an underlying hypercoagulable state and to both monitor and determine the duration of anticoagulation.
Case Resolution
The patient’s pain continues to improve with oral acetaminophen. Given her normal vital signs, labs, and otherwise benign CT scan as well as established outpatient follow-up, you make a shared decision with the patient and her husband to manage her OVT in the outpatient setting using a direct oral anticoagulant. You consult hematology over the phone, screen the patient for her bleeding risk on anticoagulation, and provide relevant education. The pharmacy helps start the patient on a 30-day starter kit of rivaroxaban, and you reinforce the importance of early follow-up and to return for worsening symptoms. The patient will see her primary care doctor in one week, with subsequent hematology referral.
Dr. Constantine is an EMS fellow and junior faculty at Carolinas Medical Center in Charlotte.
References
- Austin OG. Massive thrombophlebitis of the ovarian veins; a case report. Am J Obstet Gynecol. 1956;72(2):428-429.
- Harris K, Mehta S, Iskhakov E, et al. Ovarian vein thrombosis in the nonpregnant woman: an overlooked diagnosis. Ther Adv Hematol. 2012;3(5):325-328.
- Quane LK, Kidney DD, Cohen AJ. Unusual causes of ovarian vein thrombosis as revealed by CT and sonography. AJR Am J Roentgenol. 1998;171(2):487-490.
- Ortín X, Ugarriza A, Espax RM, et al. Postpartum ovarian vein thrombosis. Thromb Haemost. 2005;93(5):1004-1005.
- Prieto-Nieto MI, Perez-Robledo JP, Rodriguez-Montes JA, et al. Acute appendicitis-like symptoms as initial presentation of ovarian vein thrombosis. Ann Vasc Surg. 2004;18(4):481-483.
- Heavrin BS, Wrenn K. Ovarian vein thrombosis: a rare cause of abdominal pain outside the peripartum period. J Emerg Med. 2008;34(1):67-69.
- Kodali N, Veytsman I, Martyr S, et al. Diagnosis and management of ovarian vein thrombosis in a healthy individual: a case report and a literature review. J Thromb Haemost. 2017;15(2):242-245.
Pages: 1 2 3 | Single Page
7 Responses to “Ovarian Vein Thrombosis Diagnosis, Management Tips for Emergency Physicians”
June 25, 2017
Jonathan G - Scottsbluff, NebraskaGreat case! Thanks!
December 6, 2017
Melissa MathewsDo you know how many total cases have been reported? I am currently in the hospital diagnosed with this.
March 26, 2018
Sinead millsI had this but my pain was left sided. No recent pregnancies no surgeries. Doctors believed I had a torted ovary until they went in and found the thrombosis, ovary on left was necrotic as where both tubes. I’m now on xarelto for life. I presented with bad left flank pain that had been going on for three days.
June 19, 2018
DonnaI am on warfarin for life because of this and at the same time found out I had an aneurysm
November 25, 2018
CharI was just diagnosed with left side gonadal thrombosis I think that’s how they said it I had left pain in my flank and my upper back put me on Xarelto but I’m still in pain kinda scary
March 3, 2019
AislingI had OVT in both ovaries following a partial laparoscopic hysterectomy. I was treated with Lovenox injections for a year and then was told to stop. It has been three years since the initial surgery and I still have severe pain in my right flank. It is the exact pain that I had with the OVT. It is pretty much always constant and is seriously affecting my life. My hematology dr said he doesn’t know what to do other than send me to a pain management specialist. Does anyone have anything similar to thiis and if so what relief have you found? I’m a full time nursing student and can’t be on pain medication 24/7. I’m so desperate for relief from this pain.
April 6, 2019
Pamela HairstonI was just diagnosed with a DVT in the vein leading to my right ovary, haven’t had any surgeries on my stomach since 2015, the last surgery was on my right knee Jan1 2019 was having severe pain in my stomach and right side thought it was appendicitis until they did a CT scan now I have to be on blood thinner for the next 6 months.