Septic pelvic thrombophlebitis (SPT)

Ovarian vein thrombosis is a rare but potentially severe postpartum complication, occurring 80% to 90% of the time on the right side, and with a reported incidence of 1:600 to 1:2000 deliveries. Ovarian vein thrombosis can also occur in the immediate postoperative period after pelvic surgery or in conjunction with pelvic infection or thrombophilias such as factor V Leiden mutation. Spontaneous ovarian vein thrombosis without any of these predisposing conditions is exceedingly rare.

Ovarian vein thrombosis appears as a hypoechoic tubular mass cephalad to the ovary. Color Doppler typically shows an absence of flow within the mass.

A tubular painful mass in the right lower quadrant can mimic appendicitis. The ultrasound findings may be similar, although the appendix is typically located more anteriorly in the abdomen than is the ovarian vein, which is more dorsal. Doppler is also helpful in differentiating these two diagnoses, as abundant color flow is seen in the walls of the appendix and ovarian vein thrombosis has little flow. Other possible but less likely diagnoses when dealing with a painful lower quadrant mass, especially if left-sided, include ovarian torsion, broad ligament fibroid, hydrosalpinx, and pelvic inflammatory disease. The presence of a separate ovary, location of the mass, and color Doppler pattern are very helpful to arrive at the correct diagnosis.

Ovarian vein thrombosis should be considered in postpartum patients who present with abdominal or flank pain (right more frequently) and with fever, typically spiking, that is unresponsive to broad-spectrum antibiotics. These symptoms often mimic appendicitis, tubo-ovarian abscess, ovarian torsion, or broad ligament hematoma. Treatment is usually medical and may include parenteral broad-spectrum antibiotics with the addition of anticoagulant therapy.