Isaiah M. Johnson and Adrienne L. Gentry
History of present illness
A 26-year-old gravida 1, para 1 woman presented to the emergency department with a chief complaint of abdominal and lower back pain. The patient reported a normal last menstrual period that had begun 21 days prior to presentation.
The pain began two days prior to presentation and was con- fined to the left lower quadrant. The pain acutely worsened the day she presented for evaluation. The pain was described as constant and sharp. She rated the pain as 9 (on a scale of 1–10) and reported that it was not relieved by acetaminophen. She denied any other associated symptoms, such as fever, chills, nausea, vomiting, diarrhea, constipation, dysuria, urgency, or difficulty voiding.
She reported being sexually active with one partner. She uses condoms for contraception. She denies any past medical or surgical history. She takes no medications.
Physical examination
General appearance:Well-nourished woman in mild discomfort
Vital signs:
Temperature: 36.5°C Pulse: 82 beats/min
Blood pressure: 119/65 mmHg Respiratory rate: 16 breaths/min Oxygen saturation: 100% on room air
Abdomen:Soft, no masses, normoactive bowel sounds, moderately tender to palpation in left lower quadrant, voluntary guarding present; no rebound tenderness, masses, or suprapubic tenderness
Musculoskeletal:No costovertebral angle tenderness External genitalia:Unremarkable
Vagina:Nontender, with minimal vaginal discharge Cervix:No lesions, no cervical motion tenderness or cervical discharge
Uterus:Anteverted, normal size, nontender, mobile Adnexa:No masses or fullness appreciated, tender to palpation over left adnexa
Laboratory studies:
Urine pregnancy test: Negative
Leukocyte count: 8200/μL (normal 4000–10 500/μL) with no left shift
Hb: 13.2 g/dL (normal 12.0–16.0 g/dL)
Urinalysis: Negative for blood, nitrites, and leukocyte esterase
NAATs: For gonorrhea and chlamydia collected from cervix
Imaging:A transvaginal ultrasound was performed (Figs 49.1and49.2)
Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
Fig. 49.2 Ruptured ovarian cyst. Fluid of mixed echogenicity is identified in the posterior cul de sac. In light of a negative pregnancy test and thefinding of a hemorrhagic ovarian cyst, this is consistent with intra-abdominal bleeding following cyst rupture.
Fig. 49.1 Hemorrhagic ovarian cyst. High frequency transvaginal ultrasound imaging revealed a 3.3 × 2.6 × 2.1 cm mildly complicated cyst with low level internal echoes and slight wall thickening consistent with a hemorrhagic ovarian cyst.
How would you manage this patient?
The patient has a ruptured hemorrhagic ovarian cyst. The transvaginal ultrasound revealed a 3 × 3 × 2 cm, heterogeneous, complex left ovarian cyst (Fig. 49.1), as well as free fluid and heterogeneous material consistent with blood clots in the pos- terior cul-de-sac (Fig. 49.2). The freefluid in the cul-de-sac is consistent with rupture of the hemorrhagic cyst, leading to the patient’s sharp pain. The patient’s pain improved with intraven- ous analgesia, and she remained hemodynamically stable during the course of her evaluation. The patient was discharged from the emergency department with oral analgesia. A follow- up appointment a week later noted the patient’s pain had completely resolved. A transvaginal ultrasound performed eight weeks later noted complete resolution of the cyst and freefluid.
Ruptured ovarian cysts
Ruptured ovarian cysts are a well-known cause of acute abdom- inal pain in women of reproductive age. The presentation of patients with ruptured ovarian cysts can vary greatly from an asymptomatic incidentalfinding to severe pain and hemody- namic instability depending on the nature of the ruptured cyst.
The rupture of follicular or functional cysts or benign cystade- nomas may be associated with minimal symptoms, as the serous or mucinousfluid released does not typically provoke a significant peritoneal inflammatory response. On the other hand, rupture of a dermoid cyst may result in a painful chem- ical peritonitis with long-term sequelae. Hemorrhagic ovarian cysts are usually associated with unilateral pain if unruptured, and more generalized lower abdominal and pelvic pain if rupture occurs causing the development of hemoperitoneum.
The pain associated with a ruptured hemorrhagic ovarian cyst can persist for days to weeks while the hemoperitoneum is resorbed. This patient’s presentation is consistent with a hemorrhagic corpus luteum with subsequent rupture and hemoperitoneum. She initially developed left lower quadrant pain due to bleeding into the corpus luteum and distention of the ovarian capsule. The pain acutely worsened after the cyst ruptured and hemoperitoneum developed.
Hemorrhagic ovarian cysts develop when vessels in the highly vascular corpus luteum are disrupted, resulting in hem- orrhage into the ovary. If rupture of the cyst occurs, the resultant hemoperitoneum will cause significant peritoneal irri- tation and severe pain. Many patients will report intermittent, cramping pain for one to two weeks preceding this onset of acute severe pain, which is thought to reflect hemorrhage into the ovary and distention of the ovarian capsule prior to rupture [1]. Most ruptured hemorrhagic ovarian cysts occur on days 20–26 of the menstrual cycle [1]. While the majority of hemor- rhagic ovarian cysts occur in reproductive age women, rupture and hemoperitoneum may develop in adolescents prior to the onset of menarche and recently menopausal women [1]. Inter- estingly, rupture of a hemorrhagic cyst occurs more frequently on the right side, which may be due to a protective effect of the rectosigmoid colon on the left ovary [1]. The quantity of blood
loss may vary significantly, and massive hemorrhage may occur in patients with hereditary or acquired bleeding diathesis or on chronic anticoagulation [1,2].
High frequency transvaginal ultrasound imaging of the pelvis is the preferred method for imaging patients with sus- pected pelvic pathology or ovarian cysts [3]. The diagnosis of a ruptured hemorrhagic ovarian cyst is complicated by the sig- nificant variation in appearance based on the timing of imaging in relation to development of symptoms. Immediately following rupture, the fresh blood will appear as anechoic freefluid and a rounded well-defined heterogeneous ovarian mass may be iden- tified [4]. As clots form in the peritoneal cavity, they will appear characteristically heterogeneous and may obscure visualization of the ovary or the hemorrhagic cyst. Hemorrhagic ovarian cysts may also mimic ovarian neoplasms, having fine linear echoes that may be mistaken for septations, or a retracted clot that may be interpreted as a mural nodule [4,5]. The ability of hemorrhagic cysts to mimic other gynecologic conditions such as dermoids, endometriomas, ovarian neoplasms, and ectopic pregnancies has caused some to refer to it as“the great imitator” [5]. CT imaging may be a useful adjunct to distinguish between cyst rupture and an inflammatory process.
As the presentation of a ruptured ectopic pregnancy and ruptured hemorrhagic ovarian cyst are similar, the initial testing must include a urine or serum assay for the beta subunit of human chorionic gonadotropin. A complete blood count to evaluate current hemoglobin levels, platelet count, and type and screen should also be ordered in patients pre- senting with suspected significant intrabdominal bleeding.
Urinalysis should be ordered to evaluate for hematuria, which may suggest nephrolithiasis, and leukocytes, to evaluate for urinary tract infection. Adequate venous access should be obtained andfluid rescuscitation initiated.
Orthostatic vitals may be useful in evaluating the hemody- namic stability of younger patients, as significant hemoperito- neum may not result in tachycardia and has been associated with paradoxical bradycardia [6]. Hemodynamically stable patients with minimal freefluid and appropriate pain control may have outpatient management. This patient met these criteria and was managed as an outpatient.
Patients with moderate to large amounts of blood in the abdomen, anemia due to acute blood loss, signs of hemodynamic instability, or with uncertain diagnosis should be admitted for observation. Surgery is an appropriate option when there are signs of ongoing bleeding, or the diagnosis of cyst rupture is not certain and there is concern for other surgical emergencies such as appendicitis or ovarian torsion. In most cases, ovarian cystect- omy and evacuation of hemoperitoneum may be accomplished laparoscopically. Oophorectomy should be reserved for cases where hemostasis cannot be achieved through cystectomy or there is a suspicion of other ovarian pathology.
Given the varied appearance of hemorrhagic ovarian cysts, repeat imaging with transvaginal ultrasound to document resolution of the cyst eight weeks after initial evaluation is reasonable in most patients. Combined oral contraceptives
are not effective in hastening the resolution of ovarian cysts, but they may decrease the risk of developing new follicular or corpus luteal cysts [7]. Cases series have demonstrated that some women are a risk for developing recurrent ruptured cysts [1,4]. Women who are not attempting to conceive may benefit from the use of combined oral contraceptives as long as there are no contraindications.
Key teaching points
Ruptured ovarian cysts are a common cause of acute pelvic pain and may be difficult to distinguish from pelvic
inflammatory disease, ovarian torsion, and ectopic pregnancy.
Transvaginal ultrasound is the preferred method of imaging patients with acute pain and suspected ovarian pathology.
Most patients with ruptured ovarian cysts may be managed conservatively and do not require surgical intervention.
Urgent surgical intervention is indicated in unstable patients, massive hemoperitoneum, or if other surgical emergencies cannot be satisfactorily excluded.
References
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rare complication of congenital and acquired coagulation abnormalities.
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3. American College of Obstetrics and Gynecology. Management of adnexal masses. Practice Bulletin No. 83.Obstet Gynecol2007;110(1):
201–14.
4. Baltarowich OH, Kurtz AB, Pasto ME, et al. The spectrum of sonographic findings in hemorrhagic ovarian cysts.
AJR Am J Roentgenol1987;148(5):
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5. Yoffe N, Bronshtein M, Brandes J, Blumenfeld Z. Hemorrhagic ovarian
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sonography: the great imitator.Gynecol Endocrinol1991;5:123–9.
6. Adams SL, Greene JS. Absence of a tachycardic response to intraperitoneal hemorrhage.J Emerg Med1986;4(5):
383–9.
7. American College of Obstetrics and Gynecology. Noncontraceptive uses of hormonal contraceptives. Practice Bulletin No. 110.Obstet Gynecol 2010;115(1):206–18.
Case 49: A 26-year-old woman with acute pelvic pain and freefluid in the pelvis