Ruptured ovarian cyst is a common occurrence amongst women of the reproductive age group, and can be either symptomatic or asymptomatic. Ovarian cysts are sacs filed with fluid which develop on the ovaries.
Patients suffering from ruptured ovarian cysts may present with the following symptomatology:
- Acute abdominal pain after a physical exercise: Usually the inciting event of the ruptured ovarian cyst.
- Vaginal bleeding: Ruptured dermoid cysts and endometrioma may bleed in the uterus and get out of the vagina.
- Nausea and vomiting: These are common signs of acute abdomen with impending peritonitis due to spillage of blood and sebaceous fluids in the peritoneal cavity.
- Syncope or near syncope: Hemorrhagic shock or hypovolemic shock may herald this sign due to inadequate blood volume pumped to the brain.
- Weakness and fatigue: Progressive anemia due to bleeding may cause tissue hypoxemia and consequently fatigue with weakness among patients.
- Shoulder tenderness or dull pain: this symptom is a pain caused by the peritoneal irritation with the eminent peritonitis.
- Hemodynamic instability: This may present with hypotension, tachycardia and thready pulses due to the ongoing hypovolemic shock secondary to the internal bleeding.
- Abdominal tenderness: This may present with direct tenderness, rigidity, hypoactive bowel sounds, and rebound tenderness due to acute peritonitis .
- Low grade fever may present as an initial sign of inflammation and impending peritoneal infection.
The following laboratory diagnostics and tests are performed to patients with high suspicion for ruptured ovarian cyst:
- Urine Human Chorionic Gonadotropin (hCG) tests: This hormone sensitive test confirms the possibility of pregnancy to rule out cases of ectopic pregnancy which is a primary differential diagnosis.
- Complete blood count and urinalysis: This routine laboratory tests are done to rule out pelvic infections and urinary tract infections which may mimic the same symptomatology as with ruptured ovarian cyst. Blood typing and cross matching may already be done early for patients who will undergo abdominal surgery requiring blood transfusion.
- Serial hemoglobin and hematocrit monitoring: The serial monitoring of these complete blood count parameter may herald overt hemorrhage which may happen with ruptured ovarian cysts and ovarian torsion. Patients are not discharged until their blood picture becomes stable with no signs of bleeding.
- Blood tests: The blood determination of C-reactive proteins (CRP) in patients presenting with acute pelvic pain may differentiate ruptured ovarian cyst from ovarian torsion. Ruptured ovarian torsion will show a rapid increase in CRP after 10 hours form onset of abdominal pain .
- Ultrasound: The use of ultrasound in the diagnosis of gynecologic disorders and hemoperitoneum has been found to be very sensitive and fast .
- Pelvic Computed Tomography (CT): This procedure may be required if ultrasound reveals inconclusive results. The CT imaging studies of the pelvis with contrast media may show a detailed view of the corpus luteum and the other cystic structures .
- Diagnostic laparoscopy: This is done with a slender flexible scope inserted through the navel to visually check the condition of the ovary for signs of bleeding. This procedure is usually performed when physical and laboratory examination doesn’t reveal any conclusive evidence of an ovarian cyst rupture.
- Diagnostic laparotomy: This is done by making a small incision in the hypogastric area to surgically evaluate the ovaries and the other neighboring structures for signs of bleeding or ectopic pregnancy. This procedure is performed with the same indication with diagnostic laparoscopy but definitive surgery may be performed if diagnosis is confirmed to be positive during the pelvic exploration.
The majority of cases of ruptured ovarian cysts are treated conservatively due to their self-limiting clinical courses. Oral pain relievers to alleviate abdominal pain may be given and patients are advised bed rest. Although patients with high risk of evolving abdominal pain may benefit from anticipatory management of serial ultrasound and frequent abdominal examination to ascertain the need for surgery .
Surgical laparotomy may be opted when there are substantial signs of peritoneal hemorrhage where the cyst is either removed, cauterized, sutured or ligated to stop the bleeding . In the extreme event, that bleeding is not surgically suppressed, options of salpingoophorectomy may be considered during the laparotomy.
Patients presenting with recurrent luteal cyst rupture may benefit from the intake of oral contraceptive pills to suppress ovulation and prevent ovarian cysts rupture in the future .
The general prognosis for ruptured ovarian cysts is good. A tolerable abdominal pain and a self-limiting bleeding may be the only symptom. Symptoms may spontaneously resolve in days to weeks depending on the amount of blood spillage or fluid accumulation in the peritoneal cavity. This medical condition may rarely cause death in cases of circulatory collapse, hemorrhagic shock, and disseminated intravascular coagulation (DIC).
The following clinical conditions are common in a ruptured ovarian cyst:
The exact etiology associated with the ruptured ovarian cyst is still unclear up to date. There are many theories according to which this problem may be caused by abdominal trauma or a long term anti-coagulation therapy . Ruptured ovarian cyst only occurs in the reproductive age groups of 18-35 year old.
There are no available data as to the exact epidemiology of ruptured ovarian cyst. Although physiologic ruptures of follicular and luteal ovarian cysts are fairly common among women in their reproductive age, they are usually self-limiting and not usually worked up and sufficiently documented.
The pathophysiology of a ruptured ovarian cyst begins with the monthly rupture of a mature follicle to release the ovum in preparation for fertilization. In rare instances, the follicles may bleed and cause a cortical stretch and pain. Bleeding may sometimes emanate from the ruptured site of the follicle causing a direct hemorrhage to the peritoneal space. In the same way the corpus luteum may also bleed prior to ovulation or before a pregnancy.
The unabated intraperitoneal hemorrhage may cause signs and symptoms of hemodynamic instability among patients due to hemorrhagic shock. Non-physiologic cysts like dermoid cysts, endometrioma and cystadenomas may also rupture and cause bleeding. Although the exact cause of the spontaneous rupture is unknown, abdominal trauma and anticoagulation therapy is closely implicated in these phenomenon.
Women in reproductive age with history of ovarian cysts must avoid from contact sports and other recreational activities that may lead to abdominal trauma and cause ovarian cyst rupture. Patients on long term anti-coagulation therapy must take necessary steps to monitor any abdominal discomforts to prevent internal hemorrhage.
Ruptured ovarian cyst is a common clinical condition characterized usually by mild abdominal pain among women . In rare occasions, the associated abdominal pain may be severe enough to require some form of analgesia. Ruptured ovarian cyst may cause hemorrhages and may spontaneously resolve; however, there are rare cases which cause massive internal bleeding and death .
- Definition: Ruptured ovarian cysts are common amongst women of reproductive age group. Even premenopausal women can be affected by this complication.
- Cause: Many factors cause the ovarian cysts to rupture. These include abdominal trauma, indulging in intercourse, constipation, strenuous exercise, straining during bowel movements and pregnancy. In many cases, anticoagulation therapy has been associated with risk of hemorrhage in ruptured ovarian cyst.
- Symptoms: In many instances, women seldom experience any symptoms. In mild cases, they may suffer from normal abdominal cramps similar to those of menstrual cramps. In severe cases, women experience pain during intercourse, nausea accompanied by vomiting, sudden drop in blood pressure, vaginal bleeding and sudden onset of sharp pain in pelvic region.
- Diagnosis: Diagnosis begins with a urine pregnancy test. Tests should be done to rule out possibility of ectopic pregnancy. Imaging studies such as CT scan and ultrasound sonography would also be indicated. Ultrasound would provide a clear picture about the ruptured cyst and other associated abnormalities.
- Treatment: Treatment depends on the severity of the condition. In mild cases, medications should be enough to control the symptoms. In other cases, when the cysts have grown large and rupture, then surgical removal is indicated.
- Sivanesaratnam V, Singh A, Rachagan SP. Intraperitoneal haemorrhage from a ruptured corpus luteum. A cause of "acute abdomen" in women. Med J Aust. Apr 14 1986; 144(8):411, 413-4.
- Muller CH, Zimmermann K, Bettex HJ. Near-fatal intra-abdominal bleeding from a ruptured follicle during thrombolytic therapy. Lancet. Jun 15 1996; 347(9016):1697.
- Gupta N, Dadhwal V, Deka D, Jain SK, Mittal S. Corpus luteum hemorrhage: rare complication of congenital and acquired coagulation abnormalities. J Obstet Gynaecol Res. Jun 2007; 33(3):376-80.
- Tang LC, Cho HK, Chan SY. Dextropreponderance of corpus luteum rupture. A clinical study. J Reprod Med. Oct 1985; 30(10):764-8.
- Shiota M, Kotani Y, Umemoto M, et al. Preoperative differentiation between tumor-related ovarian torsion and rupture of ovarian cyst preoperatively diagnosed as benign: a retrospective study. J Obstet Gynaecol Res. Jan 2013; 39(1):326-9.
- Sickler GK, Chen PC, Dubinsky TJ, Maklad N. Free echogenic pelvic fluid: correlation with hemoperitoneum.J Ultrasound Med. Jul 1998; 17(7):431-5.
- Borders RJ, Breiman RS, Yeh BM, Qayyum A, Coakley FV. Computed tomography of corpus luteal cysts. J Comput Assist Tomogr. May-Jun 2004; 28(3):340-2.
- Raziel A, Ron-El R, Pansky M. Current management of ruptured corpus luteum. Eur J Obstet Gynecol Reprod Biol. Jun 1993; 50(1):77-81.
- Teng SW, Tseng JY, Chang CK, Li CT, Chen YJ, Wang PH. Comparison of laparoscopy and laparotomy in managing hemodynamically stable patients with ruptured corpus luteum with hemoperitoneum. J Am Assoc Gynecol Laparosc. Nov 2003; 10(4):474-7.
- Christensen JT, Boldsen JL, Westergaard JG. Functional ovarian cysts in premenopausal and gynecologically healthy women. Contraception. Sep 2002; 66(3):153-7.