Address correspondence to: Robert S. Shapiro, M.D., The Mount Sinai Medical Center, Department of Radiology, One Gustave L. Levy Place, New York, NY 10029-6574; Ph: 212-241-7401; Fax: 212-427-8137.

Synonyms: None.

Definition: Thrombus present in the inferior vena cava in the puerperal setting.

Prevalence: Puerperal ovarian vein thrombosis occurs in 18:10,000 delivery.

Etiology: Hypercoagulability associated with pregnancy, or ana­tomic compression from gravid uterus.

Pathogenesis: Extension of throm­bus from the ovarian vein, or iliac veins to the inferior vena cava.

Associated anomalies: None.

Differential diagnosis: None.

Prognosis: Good.

Recurrence risk: Unknown.

Management: Anticoagulation or intravascular filter placement.

MESH Thrombosis-ultrasonography; thrombosis-etiology; thrombosis-surgery ICD9 671.4

Introduction

Inferior vena cava (IVC) thrombosis is a life-threatening condition that is rarely diagnosed in the postpartum period. In the puerperal setting it is presumably the result of extension of clot from either the iliac or ovarian veins. Ultrasound has proven a valuable means of demonstrating deep venous thrombosis in pregnancy^1-4. In the present case, postpartum IVC thrombosis was demonstrated using color flow Doppler ultrasound where the diagnosis was not suspected.

Case report

A 29-year-old G₂P₁₀₀₁ woman had a past medical history significant for vaginal delivery 6 years prior, complicated by retained placenta with placenta previa requiring a D&C. She delivered her second child vaginally without complication. On postpartum day 2 she began complaining of right lower extremity and right lower quadrant pain, worsened with ambulation. On physical examination she had right lower quadrant tenderness without rebound. The patient was afebrile, and the white blood cell count and differential were within normal limits. Right lower extremity pain was felt to be musculoskeletal in origin. The right lower quadrant pain worsened over the next three days with the development of peritoneal signs, although laboratory values remained within normal limits and the patient was still afebrile. On postpartum day 4, pelvic ultrasound examination was requested to rule out appendicitis.

Ultrasound examination demonstrated a large thrombus in the IVC partially attached to the wall with the superior margin floating freely (fig. 1,2). Color flow duplex study confirmed the finding demonstrating flow around the flapping portion of the thrombus (fig. 3). Color flow examination also demonstrated thrombosis of the right internal iliac vein (fig. 4). The common iliac, external iliac, and femoral veins were patent bilaterally.

Figure 1: A  longitudinal image through the inferior vena cava shows a thrombus (arrows) with a freely floating upper margin. 

Figure 2: Transverse image at the level of the right renal vein shows a thrombus (arrow) in the inferior vena cava. 

Figure 3: Color Doppler sonogram shows flow, encoded in blue (arrows), around the thrombus in the inferior vena cava. 

Figure 4: Color Doppler sonogram of the pelvis shows a patent external iliac vein (white arrow) and a thrombosed internal iliac vein (open arrow).

The patient was immediately taken to the operating room, and a Greenfield filter was placed at the level of the 12^th thoracic vertebra via an internal jugular approach. The postoperative course was unremarkable, and the patient"s pain resolved completely. She was placed on anticoagulation and  discharged home on postpartum day 10. A follow-up CT scan, performed 2 weeks later, demonstrated findings consistent with right ovarian vein thrombosis (fig. 5,6).

Figure 5: A CT scan of the mid-abdomen shows thrombosis of the right ovarian vein (white arrow).  The inferior vena cava is indicated by the black arrow.  The metallic densities at the periphery of the cava are the edges of the Greenfield filter.

Figure 6: CT scan of the lower abdomen shows thrombus distending the right ovarian vein (arrow).

Discussion

The IVC thrombosis, in this case, most likely resulted from extension of thrombus from the right ovarian vein. Unfortunately, bowel gas prevented evaluation of the ovarian veins at the time of presentation. The ipsilateral internal iliac vein thrombosis was an incidental finding. The possibility of thrombus extending upward along the internal iliac vein to involve the IVC seems unlikely, given that flow was clearly demonstrated in the common iliac vein proximal to the internal iliac vein thrombus.

Etiology

Puerperal ovarian vein thrombosis has a reported incidence of 0.18%^5,6 and is usually associated with unexplained fever with abdominal pain^5-8. Predisposing conditions include gynecologic surgery, endometritis, and hypercoagulable states^5,7.

Diagnosis

Contrast-enhanced CT has been reported to be effective for making this diagnosis^5,7. Although a CT or a venogram may have definitively established the cause of IVC thrombosis, the fear of an imminent catastrophic embolus precluded further initial diagnostic workup. Examination of the IVC is relatively simple and can be of potential great benefit. Color flow Doppler ultrasound represents an effective non-invasive means of diagnosing IVC thrombosis in this group of patients.

Management

Following the vivid ultrasonographic demonstration of a flapping IVC thrombus, the patient was taken immediately to the operating room for Greenfield filter placement.

Symptomatology

The signs and symptoms of thrombosis in the puerperal patient have a very low reliability³. In the postpartum patient referred for ultrasound evaluation of vague abdominal or pelvic pain, a high index of suspicion for venous thrombosis should be maintained.

References

1. Frede TE, Ruthberg BN:  Sonographic demonstration of Iliac venous thrombosis in the maternity patient. J Ultrasound Med 7:33, 1988.

2. Kierkegaard A: Incidence and diagnosis of deep vein thrombosis associated with pregnancy. Acta Obstet Gynecol Scand 62:239, 1983.

3. Polak JF, Wilkinson DL: Ultrasonographic diagnosis of symptomatic deep venous thrombosis in pregnancy. Am J Obstet Gynecol 165:625, 1991.

4. Polak JF, O"Leary DH: Deep venous thrombosis in pregnancy: noninvasive diagnosis. Radiology 166:377, 1988.

5. Khurana BK, Rao J, Friedman SA, Cho AC: Computed tomographic features of puerperal ovarian vein thrombosis. AM J Obstet Gynecol 159:905, 1988.

6. Munisch RA, Gillanders LA: A review of the syndrome of POVT. Obstet Gynecol Surv 181; 36:57.

7. Rozier JC, Brown EH, Berne FA: Diagnosis of puerperal ovarian vein thrombosis by computed tomography. Am J Obstet Gynecol 159:737, 1988.

8. Baka JJ, Lev-Toaff AS, Friedman AC, Radecki PD, Caroline DF:Ovarian vein thrombosis with atypical presentation: role of sonography and duplex Doppler. Obstet Gynecol 73:887, 1989.