Laparoscopic surgery for left ovarian hemorrhage in a patient with an implantable left ventricular assist device on antithrombotic therapy and a history of right salpingo-oophorectomy open surgery for right ovarian bleeding: A case report

Abstract

Ovarian hemorrhage during antithrombotic therapy is sometimes difficult to manage. A 38-year-old woman, diagnosed with Marfan syndrome and implanted with a left ventricular assist device (LVAD) and taking aspirin and warfarin potassium, had a history of right adnexal oophorectomy via open surgery for a right ovarian hemorrhage at the age of 35 years. Thereafer, she had been treated with dienogest to suppress ovulation as much as possible. The patient was admitted to a local hospital with lower abdominal pain, and computed tomography showed a 10 cm left adnexal mass with suspected ovarian hemorrhage. Two days after the initiation of careful conservative treatment, with the cessation of antithrombotic therapy and monitoring of hemostasis, the patient was referred to a tertiary hospital. As the left ovarian hemorrhage continued 3 days after the transfer, emergency laparoscopic left salpingo-oophorectomy was performed due to the difficulty in conserving the left normal ovary. Although coagulopathy caused continuous oozing of blood from the pelvis after the removal of the left ovarian mass, hemostasis was successfully achieved laparoscopically. No postoperative bleeding was noted, and anticoagulant therapy was resumed on postoperative day 1 to prevent life-threatening thrombotic events associated with the LVAD. Postoperative pathological examination of the left ovary revealed an endometriotic cyst. To manage surgical menopause, complementary therapy using Japanese traditional herbal medicine was administered, as hormone replacement therapy was not recommended, to avoid the risk of fatal LVAD-associated thrombosis. Less invasive laparoscopic surgery for ovarian hemorrhage during anticoagulant therapy can be considered for reducing bleeding during and after surgery.