A 29-year-old woman, gravida 2 para 2, comes to the emergency department with fever, crampy abdominal pain, and right flank pain 8 days after an uncomplicated vaginal delivery. Temperature is 38.3 C (101 F) and blood pressure is 110/60 mm Hg. Physical examination shows tenderness in the right lower quadrant and flank. The patient is hospitalized and started on intravenous antibiotics for presumed postpartum endometritis, but her fever persists. Urine and blood cultures show no bacterial growth. CT scan of the abdomen and pelvis reveals right ovarian vein thrombosis. If this patient remains untreated, she is at risk for extension of the thrombus into which of the following vessels?

Question

A 29-year-old woman, gravida 2 para 2, comes to the emergency department with fever, crampy abdominal pain, and right flank pain 8 days after an uncomplicated vaginal delivery.  Temperature is 38.3 C (101 F) and blood pressure is 110/60 mm Hg.  Physical examination shows tenderness in the right lower quadrant and flank.  The patient is hospitalized and started on intravenous antibiotics for presumed postpartum endometritis, but her fever persists.  Urine and blood cultures show no bacterial growth.  CT scan of the abdomen and pelvis reveals right ovarian vein thrombosis.  If this patient remains untreated, she is at risk for extension of the thrombus into which of the following vessels?

Quizplus · Accepted Answer

11ec160b_3576_76f8_9249_855f54277068_MD0001_00 Ovarian vein thrombosis occurs when a thrombus forms in the ovarian vein and becomes infected (eg, septic pelvic thrombophlebitis). It is a rare complication associated with the postpartum period, pelvic surgery, or malignancy. The classic presentation is persistent fever and focal abdominal pain despite broad-spectrum antibiotics. Ovarian vein thrombosis is more commonly right sided (90%) due to greater tortuosity of the right ovarian vein. In addition, peripartum dextrorotation of the uterus (rotation of the uterus to the right due to presence of the colon) increases compression on the right ovarian vein, thereby increasing the risk of thrombosis. Because ovarian venous drainage is asymmetric, the laterality of the affected ovarian vein determines which other vessels are at risk for thrombus extension. The right ovarian vein drains directly to the inferior vena cava (IVC), whereas the left ovarian vein drains first into the left renal vein, which then drains to the IVC. (Choices B and C) Most of the female pelvis is drained by the internal iliac veins, which then drain into the common iliac veins that form the IVC. Because neither the right internal iliac nor the right common iliac vein directly drains the right ovarian vein, they are unlikely to be affected by thrombus extension from the right ovarian vein. (Choice D) Unlike the left renal vein, which drains the left ovarian vein, the right renal vein does not drain the right ovarian vein and is therefore less likely to be affected by thrombus extension. (Choice E) The uterine vein is part of the uterine venous plexus that drains to the internal iliac vein, common iliac vein, and IVC. Although a small portion of the uterine venous plexus can drain to either ovarian vein, thrombus extension from the ovarian vein to the uterine venous plexus is less likely due to directionality of venous drainage from distal (uterine plexus) to proximal (ovarian vein). Educational objective: Ovarian vein thrombosis (infected ovarian vein thrombus) is a rare complication associated with the postpartum period and is typically right sided. Because ovarian venous drainage is asymmetric, a thrombus in the right ovarian vein can extend into the inferior vena cava. In contrast, a left ovarian vein thrombosis would extend first to the left renal vein. __________ References: Diagnosis and management of postpartum ovarian vein thrombosis. (http://www.ncbi.nlm.nih.gov/pubmed/29222252)

A 29-Year-Old Woman, Gravida 2 Para 2, Comes to the Emergency