Case Report
Idiopathic Ovarian Vein Thrombosis in a Nonperipartum Patient Kathleen Doherty, BA, and Melinda New, MD BACKGROUND: Ovarian vein thrombosis is a rare diagnosis typically seen in the early peripartum period but also in other thrombophilic states such as postsurgery, pelvic inflammatory disease, malignancy, or sepsis. We describe a case of idiopathic ovarian vein thrombosis in a healthy woman far outside the peripartum window. CASE: The patient is a 29-year-old woman, gravida 3 para 2102, with no significant surgical or medical history referred for 8 months of severe left lower quadrant pain. An ultrasonogram revealed a nonocclusive left ovarian vein thrombosis. Hypercoagulable workup and all other laboratory tests were normal. The thrombus resolved within 2 months of starting oral anticoagulation therapy. CONCLUSION: This case demonstrates the importance of including idiopathic ovarian vein thrombosis in the differential diagnosis of nonperipartum females with pelvic pain. (Obstet Gynecol 2015;125:1468–70) DOI: 10.1097/AOG.0000000000000648
O
varian vein thrombosis is a rare condition most commonly seen in the peripartum period as a result of pelvic venous stasis and a hypercoagulable state.1–6 Ovarian vein thrombosis is also associated with hypercoagulability resulting from surgery, malignancy, pelvic inflammatory disease, Crohn’s disease, sepsis or thrombophilia.1–5 However, ovarian vein thrombosis with no underlying cause is extremely uncommon,7 and its presentation may be difficult to From the Vanderbilt University Medical School and the Department of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, Tennessee. The authors thank Lynne Black for her assistance with preparing the manuscript as well as Dr. Rochelle Andreotti for contributing the figures. Corresponding author: Kathleen Doherty, BA, 3120 Belwood Street, Nashville, TN 37203; e-mail: [email protected]. Financial Disclosure The authors did not report any potential conflicts of interest. © 2015 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0029-7844/15
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Teaching Points 1. Ovarian vein thrombosis should be included in the differential diagnosis of pelvic pain, even in patients outside the peripartum window or without thrombophilic risk factors. 2. Although ultrasonography with Doppler flow can be a useful tool for the diagnosis of ovarian vein thrombosis, computed tomography is the preferred method.
distinguish from other types of lower abdominal pain. Diagnosis relies on detailed assessment of imaging through ultrasonography, computed tomography (CT), or magnetic resonance imaging.1,2,4 Treatment focuses on anticoagulation with or without antibiotics.1–3 If left untreated, complications of ovarian vein thrombosis can include ovarian infarction, thrombus extension, pulmonary embolism, sepsis, and death.1,2 In this case report, we emphasize the importance of considering idiopathic ovarian vein thrombosis in the differential diagnosis for pelvic pain in healthy, nonperipartum women.
CASE A 29-year-old woman, gravida 3 para 2012, was referred for an 8-month history of acute-onset, severe left lower quadrant pain. The pain was constant, sharp, achy, and localized to just left of the rectus muscle, 2 cm above the pubic symphysis. When severe, the pain radiated to the left hip and back. The pain was associated with a feeling of fullness and swelling in the area and was aggravated by intercourse, menses, ovulation, lifting, and sudden movement. She denied associated nausea or vomiting. She had seen a physician three times since the onset of the pain and had been given morphine and prescribed over-thecounter pain medications with only temporary relief. An abdominal ultrasonogram had been performed with normal findings. Obstetric history was significant for two term pregnancies complicated by vaginal varicosities, ovarian cysts, and third-degree lacerations. Her last delivery occurred 16 months before onset of the pain. Her gynecologic history was significant for menorrhagia. She began taking low-dose estrogen–progesterone combination pills 6 months after the onset of pain and had been on them for 2 months. She had no history of sexually transmitted infections, and all prior Pap test results were normal. She denied any prior abdominal or pelvic surgeries and her personal, and family histories were negative for clotting disorders. Other medical history was noncontributory, and her family history was
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
significant only for breast and hepatic cancer in seconddegree relatives. Her medications included 10 mg Lexapro daily, Sprintec once daily, and a prenatal vitamin. She denied use of tobacco, alcohol, or drugs, and her only allergies were to shellfish and lactose. On physical examination she was normotensive, afebrile, and not tachycardic. Moderate tenderness without guarding was found over the left adnexa. No adnexal masses were appreciated. Additionally, a pelvic floor examination was positive for tenderness of the levators, obturators, and piriformis muscles bilaterally, greater on the left than the right. There was no abnormal cervical discharge. Pelvic and transvaginal ultrasonograms were ordered and showed a normal-sized, anteverted uterus with an unremarkable cervix, myometrium, and endometrial echo. Ovaries were of normal size and configuration. However, distended veins were seen in the left adnexa, which contained an echogenic nodular structure within a large vein. Color Doppler flow revealed reversal of flow in the left ovarian vein with Valsalva (Fig. 1). These findings were consistent with nonocclusive ovarian vein thrombosis and associated pelvic varices (Fig. 2). Her laboratory workup included a complete blood count with differential, platelets, and a hypercoagulability profile that included prothrombin time, partial thromboplastin time, MTHFR gene, protein S antigen, factor V Leiden mutation, Dilute Resell’s Viper Venom, antithrombin activity, antithrombin antigen, and protein C antigen. All laboratory results were within normal limits with the exception of slightly low monocytes. A CT scan showed no evidence of extension of the clot beyond the ovarian vein. She was treated as an outpatient with warfarin for 6 weeks with international normalized ratio monitoring. A 2-month follow-up pelvic ultrasonogram showed distended adnexal vessels but no evidence of thrombus. Because the patient remained afebrile with a normal white blood cell count, and given the lack of evidence-based recommendations to add antibiotic therapy in the outpatient treatment setting, no antibiotics were administered.
Fig. 1. Color Doppler study showing reversal of flow in the left ovarian vein with Valsalva. Doherty. Idiopathic Left Ovarian Vein Thrombosis in a Healthy Woman. Obstet Gynecol 2015.
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Doherty and New
Fig. 2. Transvaginal ultrasonogram showing nonocclusive ovarian vein thrombosis and associated pelvic varices. Arrow indicates the location of the thrombus. Doherty. Idiopathic Left Ovarian Vein Thrombosis in a Healthy Woman. Obstet Gynecol 2015.
She reported symptom resolution after 3 weeks of therapeutic anticoagulation, though she still had occasional pain with intercourse. A follow-up examination after 6 weeks of therapeutic anticoagulation revealed only mild pelvic floor myalgia.
DISCUSSION Although ovarian vein thrombosis is most common in the early peripartum period, it is seen after only 1 in 500–2,000 pregnancies.5 The literature describing ovarian vein thrombosis primarily focuses on the cases related to recent childbirth or another cause for hypercoagulability such as pelvic inflammatory disease, surgery, malignancy, thrombophilia, or sepsis.1–4 The patient described here was not identified as having any of these risk factors for developing an ovarian vein thrombosis and was well out of the early peripartum period. Right-sided ovarian vein thrombosis occurs in approximately 90% of all postpartum cases.3 This may be a result of the uterine dextroversion during pregnancy that compresses the right ovarian vein, antegrade flow, or relatively less competent valves in the right ovarian vein.1,3 However, ovarian vein
Idiopathic Left Ovarian Vein Thrombosis in a Healthy Woman 1469
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
thrombosis resulting from causes other than pregnancy are also more often described on the right.1–3 Ovarian vein thrombosis presents with fever in an estimated 80% of patients1 with nausea, vomiting, and tachycardia as other common associated symptoms.1,2,6 The differential diagnosis for ovarian vein thrombosis includes appendicitis, endometritis, pelvic inflammatory disease, pyelonephritis, nephrolithiasis, tubo-ovarian abscess, and ovarian torsion.1 In this patient, the left-sided and more chronic presentation of pain without any associated tachycardia or nausea made classical ovarian vein thrombosis a less obvious diagnostic consideration. Descriptions of idiopathic ovarian vein thrombosis such as the patient reported are extremely limited. The three reported cases of ovarian vein thrombosis with no underlying cause for a hypercoagulable state have been from Turkey in 2005,6 the United States in 2006,8 and Australia in 2010.7 They have described otherwise well, premenopausal females presenting with sudden onset of right-sided pelvic pain associated with nausea in the preceding 2 weeks or less.6–8 Identification of an ovarian vein thrombosis relies on prompt and thorough radiologic examination. Doppler ultrasonography, as used with this patient, has a sensitivity of roughly 50% for diagnosing ovarian vein thrombosis, whereas CT scan has an estimated sensitivity of more than 95%.1,2 The sensitivity of magnetic resonance imaging for ovarian vein thrombosis diagnosis is unknown. Thus, highresolution CT imaging with intravenous contrast is viewed as the most optimal imaging modality for ovarian vein thrombosis diagnosis.1,2,4 Health care providers should consider ordering a CT scan with contrast in patients presenting with acute-onset, unilateral pelvic pain with negative ultrasound findings. Treatment for peripartum ovarian vein thrombosis involves typically involves inpatient intravenous anticoagulation, intravenous antibiotics, or both. Intravenous anticoagulation is the mainstay of treatment followed by 3–6 months of outpatient oral anticoagulation. In patients with concern for infection, a 1-week course of oral antibiotics has also been recommended.1–3 However, no clinical guidelines have been published for the administration of antibiotics or for the length of administration.1–3,7
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In the few reported cases of idiopathic ovarian vein thrombosis, 6 months of oral anticoagulation has been standard treatment.6,7 In one case, thrombus resolution was documented within 2 months,7 similar to our reported patient outcome. The report from Turkey documented improved but persistent thrombus at 40 days with calcification of the thrombus after 6 months.6 Complications of ovarian vein thrombosis can include thrombus extension to the inferior vena cava or renal vein, ovarian infarction, sepsis, and death.1,6,7 Pulmonary embolism is seen in 25% of patients with postpartum ovarian vein thrombosis and thrombus extension.1,6 These serious potential sequelae make the timely diagnosis and treatment of an ovarian vein thrombosis crucial. Ovarian vein thrombosis occurs very rarely outside the context of recent childbirth or another hypercoagulable state. However, this case and the few prior reports of idiopathic ovarian vein thrombosis highlight the importance of including it in the broad differential diagnosis for female pelvic pain. REFERENCES 1. Heavrin BS, Wrenn K. Ovarian vein thrombosis: a rare cause of abdominal pain outside the peripartum period. J Emerg Med 2008;34:67–9. 2. Dessole S, Capobianco G, Arru A, Demurtas P, Ambrosini G. Postpartum ovarian vein thrombosis: an unpredictable event: two case reports and review of the literature. Arch Gynecol Obstet 2003;267:242–6. 3. Ortin X, Ugarriza A, Espax RM, Boixadera J, Llorente A, Escoda L, et al. Postpartum ovarian vein thrombosis. Thromb Haemost 2005;93:1004–5. 4. Quane LK, Kidney DD, Cohen AJ. Unusual causes of ovarian vein thrombosis as revealed by CT and sonography. AJR Am J Roentgenol 1998;171:487–90. 5. Salomon O, Apter S, Shaham D, Hiller N, Bar-Ziv J, Itzchak Y, et al. Risk factors associated with postpartum ovarian vein thrombosis. Thromb Haemost 1999;82:1015–9. 6. Yildirim E, Kanbay M, Ozbek O, Coskun M, Boyacioglu S. Isolated idiopathic ovarian vein thrombosis: a rare case. Int Urogynecol J Pelvic Floor Dysfunct 2005;16:308–10. 7. Stafford M, Fleming T, Khalil A. Idiopathic ovarian vein thrombosis: a rare cause of pelvic pain—case report and review of literature. Aust N Z J Obstet Gynaecol 2010;50: 299–301. 8. Murphy CS, Parsa T. Idiopathic ovarian vein thrombosis: a rare cause of abdominal pain. Am J Emerg Med 2006;24:636–7.
Idiopathic Left Ovarian Vein Thrombosis in a Healthy Woman
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Idiopathic Ovarian Vein Thrombosis in a Nonperipartum Patient Kathleen Doherty, BA, and Melinda New, MD BACKGROUND: Ovarian vein thrombosis is a rare diagnosis typically seen in the early peripartum period but also in other thrombophilic states such as postsurgery, pelvic inflammatory disease, malignancy, or sepsis. We describe a case of idiopathic ovarian vein thrombosis in a healthy woman far outside the peripartum window. CASE: The patient is a 29-year-old woman, gravida 3 para 2102, with no significant surgical or medical history referred for 8 months of severe left lower quadrant pain. An ultrasonogram revealed a nonocclusive left ovarian vein thrombosis. Hypercoagulable workup and all other laboratory tests were normal. The thrombus resolved within 2 months of starting oral anticoagulation therapy. CONCLUSION: This case demonstrates the importance of including idiopathic ovarian vein thrombosis in the differential diagnosis of nonperipartum females with pelvic pain. (Obstet Gynecol 2015;125:1468–70) DOI: 10.1097/AOG.0000000000000648
O
varian vein thrombosis is a rare condition most commonly seen in the peripartum period as a result of pelvic venous stasis and a hypercoagulable state.1–6 Ovarian vein thrombosis is also associated with hypercoagulability resulting from surgery, malignancy, pelvic inflammatory disease, Crohn’s disease, sepsis or thrombophilia.1–5 However, ovarian vein thrombosis with no underlying cause is extremely uncommon,7 and its presentation may be difficult to From the Vanderbilt University Medical School and the Department of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, Tennessee. The authors thank Lynne Black for her assistance with preparing the manuscript as well as Dr. Rochelle Andreotti for contributing the figures. Corresponding author: Kathleen Doherty, BA, 3120 Belwood Street, Nashville, TN 37203; e-mail: [email protected]. Financial Disclosure The authors did not report any potential conflicts of interest. © 2015 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0029-7844/15
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VOL. 125, NO. 6, JUNE 2015
Teaching Points 1. Ovarian vein thrombosis should be included in the differential diagnosis of pelvic pain, even in patients outside the peripartum window or without thrombophilic risk factors. 2. Although ultrasonography with Doppler flow can be a useful tool for the diagnosis of ovarian vein thrombosis, computed tomography is the preferred method.
distinguish from other types of lower abdominal pain. Diagnosis relies on detailed assessment of imaging through ultrasonography, computed tomography (CT), or magnetic resonance imaging.1,2,4 Treatment focuses on anticoagulation with or without antibiotics.1–3 If left untreated, complications of ovarian vein thrombosis can include ovarian infarction, thrombus extension, pulmonary embolism, sepsis, and death.1,2 In this case report, we emphasize the importance of considering idiopathic ovarian vein thrombosis in the differential diagnosis for pelvic pain in healthy, nonperipartum women.
CASE A 29-year-old woman, gravida 3 para 2012, was referred for an 8-month history of acute-onset, severe left lower quadrant pain. The pain was constant, sharp, achy, and localized to just left of the rectus muscle, 2 cm above the pubic symphysis. When severe, the pain radiated to the left hip and back. The pain was associated with a feeling of fullness and swelling in the area and was aggravated by intercourse, menses, ovulation, lifting, and sudden movement. She denied associated nausea or vomiting. She had seen a physician three times since the onset of the pain and had been given morphine and prescribed over-thecounter pain medications with only temporary relief. An abdominal ultrasonogram had been performed with normal findings. Obstetric history was significant for two term pregnancies complicated by vaginal varicosities, ovarian cysts, and third-degree lacerations. Her last delivery occurred 16 months before onset of the pain. Her gynecologic history was significant for menorrhagia. She began taking low-dose estrogen–progesterone combination pills 6 months after the onset of pain and had been on them for 2 months. She had no history of sexually transmitted infections, and all prior Pap test results were normal. She denied any prior abdominal or pelvic surgeries and her personal, and family histories were negative for clotting disorders. Other medical history was noncontributory, and her family history was
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
significant only for breast and hepatic cancer in seconddegree relatives. Her medications included 10 mg Lexapro daily, Sprintec once daily, and a prenatal vitamin. She denied use of tobacco, alcohol, or drugs, and her only allergies were to shellfish and lactose. On physical examination she was normotensive, afebrile, and not tachycardic. Moderate tenderness without guarding was found over the left adnexa. No adnexal masses were appreciated. Additionally, a pelvic floor examination was positive for tenderness of the levators, obturators, and piriformis muscles bilaterally, greater on the left than the right. There was no abnormal cervical discharge. Pelvic and transvaginal ultrasonograms were ordered and showed a normal-sized, anteverted uterus with an unremarkable cervix, myometrium, and endometrial echo. Ovaries were of normal size and configuration. However, distended veins were seen in the left adnexa, which contained an echogenic nodular structure within a large vein. Color Doppler flow revealed reversal of flow in the left ovarian vein with Valsalva (Fig. 1). These findings were consistent with nonocclusive ovarian vein thrombosis and associated pelvic varices (Fig. 2). Her laboratory workup included a complete blood count with differential, platelets, and a hypercoagulability profile that included prothrombin time, partial thromboplastin time, MTHFR gene, protein S antigen, factor V Leiden mutation, Dilute Resell’s Viper Venom, antithrombin activity, antithrombin antigen, and protein C antigen. All laboratory results were within normal limits with the exception of slightly low monocytes. A CT scan showed no evidence of extension of the clot beyond the ovarian vein. She was treated as an outpatient with warfarin for 6 weeks with international normalized ratio monitoring. A 2-month follow-up pelvic ultrasonogram showed distended adnexal vessels but no evidence of thrombus. Because the patient remained afebrile with a normal white blood cell count, and given the lack of evidence-based recommendations to add antibiotic therapy in the outpatient treatment setting, no antibiotics were administered.
Fig. 1. Color Doppler study showing reversal of flow in the left ovarian vein with Valsalva. Doherty. Idiopathic Left Ovarian Vein Thrombosis in a Healthy Woman. Obstet Gynecol 2015.
VOL. 125, NO. 6, JUNE 2015
Doherty and New
Fig. 2. Transvaginal ultrasonogram showing nonocclusive ovarian vein thrombosis and associated pelvic varices. Arrow indicates the location of the thrombus. Doherty. Idiopathic Left Ovarian Vein Thrombosis in a Healthy Woman. Obstet Gynecol 2015.
She reported symptom resolution after 3 weeks of therapeutic anticoagulation, though she still had occasional pain with intercourse. A follow-up examination after 6 weeks of therapeutic anticoagulation revealed only mild pelvic floor myalgia.
DISCUSSION Although ovarian vein thrombosis is most common in the early peripartum period, it is seen after only 1 in 500–2,000 pregnancies.5 The literature describing ovarian vein thrombosis primarily focuses on the cases related to recent childbirth or another cause for hypercoagulability such as pelvic inflammatory disease, surgery, malignancy, thrombophilia, or sepsis.1–4 The patient described here was not identified as having any of these risk factors for developing an ovarian vein thrombosis and was well out of the early peripartum period. Right-sided ovarian vein thrombosis occurs in approximately 90% of all postpartum cases.3 This may be a result of the uterine dextroversion during pregnancy that compresses the right ovarian vein, antegrade flow, or relatively less competent valves in the right ovarian vein.1,3 However, ovarian vein
Idiopathic Left Ovarian Vein Thrombosis in a Healthy Woman 1469
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
thrombosis resulting from causes other than pregnancy are also more often described on the right.1–3 Ovarian vein thrombosis presents with fever in an estimated 80% of patients1 with nausea, vomiting, and tachycardia as other common associated symptoms.1,2,6 The differential diagnosis for ovarian vein thrombosis includes appendicitis, endometritis, pelvic inflammatory disease, pyelonephritis, nephrolithiasis, tubo-ovarian abscess, and ovarian torsion.1 In this patient, the left-sided and more chronic presentation of pain without any associated tachycardia or nausea made classical ovarian vein thrombosis a less obvious diagnostic consideration. Descriptions of idiopathic ovarian vein thrombosis such as the patient reported are extremely limited. The three reported cases of ovarian vein thrombosis with no underlying cause for a hypercoagulable state have been from Turkey in 2005,6 the United States in 2006,8 and Australia in 2010.7 They have described otherwise well, premenopausal females presenting with sudden onset of right-sided pelvic pain associated with nausea in the preceding 2 weeks or less.6–8 Identification of an ovarian vein thrombosis relies on prompt and thorough radiologic examination. Doppler ultrasonography, as used with this patient, has a sensitivity of roughly 50% for diagnosing ovarian vein thrombosis, whereas CT scan has an estimated sensitivity of more than 95%.1,2 The sensitivity of magnetic resonance imaging for ovarian vein thrombosis diagnosis is unknown. Thus, highresolution CT imaging with intravenous contrast is viewed as the most optimal imaging modality for ovarian vein thrombosis diagnosis.1,2,4 Health care providers should consider ordering a CT scan with contrast in patients presenting with acute-onset, unilateral pelvic pain with negative ultrasound findings. Treatment for peripartum ovarian vein thrombosis involves typically involves inpatient intravenous anticoagulation, intravenous antibiotics, or both. Intravenous anticoagulation is the mainstay of treatment followed by 3–6 months of outpatient oral anticoagulation. In patients with concern for infection, a 1-week course of oral antibiotics has also been recommended.1–3 However, no clinical guidelines have been published for the administration of antibiotics or for the length of administration.1–3,7
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In the few reported cases of idiopathic ovarian vein thrombosis, 6 months of oral anticoagulation has been standard treatment.6,7 In one case, thrombus resolution was documented within 2 months,7 similar to our reported patient outcome. The report from Turkey documented improved but persistent thrombus at 40 days with calcification of the thrombus after 6 months.6 Complications of ovarian vein thrombosis can include thrombus extension to the inferior vena cava or renal vein, ovarian infarction, sepsis, and death.1,6,7 Pulmonary embolism is seen in 25% of patients with postpartum ovarian vein thrombosis and thrombus extension.1,6 These serious potential sequelae make the timely diagnosis and treatment of an ovarian vein thrombosis crucial. Ovarian vein thrombosis occurs very rarely outside the context of recent childbirth or another hypercoagulable state. However, this case and the few prior reports of idiopathic ovarian vein thrombosis highlight the importance of including it in the broad differential diagnosis for female pelvic pain. REFERENCES 1. Heavrin BS, Wrenn K. Ovarian vein thrombosis: a rare cause of abdominal pain outside the peripartum period. J Emerg Med 2008;34:67–9. 2. Dessole S, Capobianco G, Arru A, Demurtas P, Ambrosini G. Postpartum ovarian vein thrombosis: an unpredictable event: two case reports and review of the literature. Arch Gynecol Obstet 2003;267:242–6. 3. Ortin X, Ugarriza A, Espax RM, Boixadera J, Llorente A, Escoda L, et al. Postpartum ovarian vein thrombosis. Thromb Haemost 2005;93:1004–5. 4. Quane LK, Kidney DD, Cohen AJ. Unusual causes of ovarian vein thrombosis as revealed by CT and sonography. AJR Am J Roentgenol 1998;171:487–90. 5. Salomon O, Apter S, Shaham D, Hiller N, Bar-Ziv J, Itzchak Y, et al. Risk factors associated with postpartum ovarian vein thrombosis. Thromb Haemost 1999;82:1015–9. 6. Yildirim E, Kanbay M, Ozbek O, Coskun M, Boyacioglu S. Isolated idiopathic ovarian vein thrombosis: a rare case. Int Urogynecol J Pelvic Floor Dysfunct 2005;16:308–10. 7. Stafford M, Fleming T, Khalil A. Idiopathic ovarian vein thrombosis: a rare cause of pelvic pain—case report and review of literature. Aust N Z J Obstet Gynaecol 2010;50: 299–301. 8. Murphy CS, Parsa T. Idiopathic ovarian vein thrombosis: a rare cause of abdominal pain. Am J Emerg Med 2006;24:636–7.
Idiopathic Left Ovarian Vein Thrombosis in a Healthy Woman
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
