How should ovarian vein thrombosis be diagnosed in a 22‑year‑old woman, five weeks postpartum, presenting with severe epigastric pain?

Diagnostic Approach to Ovarian Vein Thrombosis in the Postpartum Period

Immediate Imaging Recommendation

CT with IV contrast of the abdomen and pelvis is the definitive diagnostic modality for ovarian vein thrombosis in this postpartum patient with severe epigastric pain. 1, 2, 3

Clinical Context and Presentation

Ovarian vein thrombosis (OVT) is a rare but serious postpartum complication that typically presents with:

• Lower quadrant or epigastric abdominal pain 4, 3
• Fever and leukocytosis 3, 5
• Symptoms that persist despite broad-spectrum antibiotics 3
• Most commonly occurs on the right side (80% of cases), left-sided in <6%, bilateral in 14% 5

Critical timing consideration: OVT typically manifests in the immediate postpartum period, making this 5-week postpartum presentation consistent with the diagnosis 2, 4, 6

Diagnostic Algorithm

First-Line Imaging: CT Abdomen/Pelvis with IV Contrast

CT with IV contrast is the gold standard for diagnosing OVT because:

• It can directly detect ovarian vein thrombosis as a complication of postpartum endometritis or other pelvic pathology 1
• Provides comprehensive evaluation of the abdomen and pelvis to identify associated complications 1
• Has high sensitivity and specificity for this diagnosis 5, 6

Alternative/Complementary Imaging Modalities

MRI pelvis can identify ovarian vein thrombosis and associated complications such as abscess or infected hematoma 1, though it is less commonly used in acute settings due to access limitations and longer acquisition times 1

Ultrasound with color Doppler can be useful for diagnosis and follow-up 2, 6, but is less definitive than CT in the acute setting for establishing the diagnosis 3

Key Diagnostic Pitfalls to Avoid

• Do not dismiss persistent abdominal pain and fever as simple endometritis if symptoms fail to respond to appropriate antibiotics—this should trigger imaging for OVT 3
• Do not assume right-sided presentation only—while 80% occur on the right, left-sided and bilateral cases occur 5
• Clinical diagnosis alone is insufficient—OVT has nonspecific clinical findings that overlap with other postpartum complications 2, 3

Serious Complications Requiring Early Detection

Untreated OVT can lead to:

• Sepsis 5, 6
• Pulmonary thromboembolism 5, 6
• Extension to inferior vena cava 5
• Extension to renal vein 5

Early recognition through appropriate imaging is critical to prevent these potentially fatal complications 4, 5

Treatment Implications

Once diagnosed, treatment consists of:

• Anticoagulation therapy (current standard recommendation) 6
• Intravenous antibiotics 2, 3
• This combination avoids the need for laparotomy in most cases 3