Ovarian Vein Thrombosis Resulting in Cardiac Arrest Following Caesarean Delivery Under General Anaesthesia

Eanna Mulvihill, Doireann O’Flaherty, Jennifer Kielty

The Coombe Hospital, Dublin

 

Introduction 

Ovarian vein thrombosis (OVT) is rare (incidence 0.049% - 0.18%) (1)

Symptoms are nonspecific (2)

DIagnosis is via imaging (Contrast CT/MRI recommended) (3)

The mainstay of treatment is anticoagulation and antibiotics (2,4)

Mortality is estimated at 5% and usually relates to malignant cases or those involving pulmonary embolism (PE) (5)

Pre eclampsia is a risk factor for developing venous thromboembolism (6) 

 

Presentation 

Primiparous patient in her early 40s at 38+4 weeks gestation

Found to be in labour and experiencing preeclampsia 

PMH hypothyroidism and hypercholesterolaemia

BMI of 28. 

Cardiotocograph (CTG) and examination normal 

Commenced on labetalol and magnesium and transferred to delivery suite

 

Clinical Course

Poor progression of labour and grade two meconium 

Theatre for a trial of instrumental delivery > abandoned as high foetal position 

Decision to perform caesarean delivery 

Epidural top up > inadequate anaesthesia > proceed to general anaesthetic 

Caesarean delivery uneventful

In recovery room > rapid deterioration 

Obtunded, hypertensive crisis, rapid desaturation despite escalating oxygen 

Cardiac arrest > intubated > cardiopulmonary resuscitation for two minutes 

Return of spontaneous circulation, ECG sinus rhythm, bedside echo NAD 

Transfer to ICU for imaging and management

CTTAP > large ovarian vein thrombus extending to IVC, PEs and consolidation

Anticoagulation for thrombus and antibiotics for aspiration pneumonia 

Repatriation to maternity hospital and discharge home with haematology f/u 

 

Discussion

Differentials inc. pre eclampsia (pulmonary/cerebral oedema), amniotic fluid embolus, intracranial haemorrhage, local anaesthetic toxicity, high epidural, magnesium toxicity, anaphylaxis, intra abdominal bleed

Normal bedside echocardiogram - demonstrates high specificity, low sensitivity of echo in diagnosing PE. Good as a ‘rule in’ test, poor as ‘rule out’

Blood gases - mixed respiratory and metabolic acidosis with elevated lactate. Suggestive of tissue hypoxia/sepsis with concurrent respiratory pathology

Pro thrombotic processes - pre eclampsia, pregnancy, and maternal age leading to formation of large thrombus during pregnancy. ?Disruption of thrombus during labour/surgery leading to PEs and subsequent arrest.

 

Learning Points 

Ovarian vein thrombosis is rare but it’s sequelae may be catastrophic 

Presentation may be nonspecific and diagnosis is best made with contrast CT or MRI

Blood gases may demonstrate mixed metabolic and respiratory acidosis

Mainstay of treatment is antibiotics and anticoagulants

Bedside echocardiogram is specific but not sensitive in diagnosing PE