Abstract
BACKGROUND: The occurrence of ovarian vein thrombosis(OVT) prior to delivery and during cesarean section is exceedingly rare. Presently, the literature contains minimal reports on this condition, and there is a lack of clinical experience regarding the management of OVT when identified intraoperatively during cesarean section. This case report describes a rare instance of non-right OVT identified during a cesarean section. The intraoperative procedures and postoperative coagulation management presented significant challenges. CASE PRESENTATION: A 31-year-old female, with a history of cesarean delivery five years ago, was admitted for elective cesarean section. During the cesarean section, the patient exhibited bilateral pelvic venous distension. Notably, the venous dilation was more pronounced in the left adnexal region, accompanied by the presence of purple, block-like thrombotic formations in the left ovarian vein. A gynecologist was consulted for a surgical evaluation. Following the exclusion of factors such as uterine wound bleeding and hematoma, the finding was considered suspicious for OVT with pelvic venous congestion. Because the abdomen was still open and the diagnosis was uncertain, with concern for venous bleeding or hematoma as well as thrombosis, the gynecologists and obstetricians selectively ligated the visibly abnormal venous branch as a pragmatic intraoperative risk mitigation step before closure. On the day of the surgical procedure, the coagulation parameters of the parturient indicated a trend towards hyperfibrinolysis. The patient received a fibrinogen infusion, and subsequent imaging studies suggested the presence of pelvic venous congestion and left OVT, while effectively excluding the possibility of secondary hemorrhage within the pelvic and abdominal cavities. Following an urgent multidisciplinary consultation, the patient was administered a therapeutic dose of anticoagulation in conjunction with anti-inflammatory treatment. Follow-up ultrasound at postpartum day 42 showed no sonographic evidence of residual thrombus in the left ovarian vein and a marked reduction in dilatation of the left parauterine vein. In contrast, the right parauterine vein, which did not undergo surgical intervention, remained more dilated than the left side. CONCLUSIONS: This case illustrates that when unexpected adnexal venous abnormalities are encountered prior to abdominal closure during cesarean delivery, OVT should be considered. In such situations, a structured differential diagnosis and multidisciplinary input are essential, and timely postoperative imaging should be obtained. In carefully selected scenarios under diagnostic uncertainty, selective ligation of a suspicious venous branch may be considered as an intraoperative risk-mitigation step, followed by standard therapeutic anticoagulation, with antibiotics administered when indicated. At 42-day follow-up, ultrasound showed no sonographic evidence of residual thrombus on the ligated side, with improved left-sided parauterine venous dilatation compared with the contralateral side.