Ovarian apoplexy

Apoplexy is a rupture of the ovary, which most often occurs in the middle or in the second phase of the menstrual cycle.

Surgical treatment is not performed for all patients with such a disease. Some of them, due to the unclear clinical picture, are given other diagnoses, so, apparently, the frequency of this pathology exceeds the figures given.

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Epidemiology

Ovarian apoplexy is rare. Among women operated on for internal bleeding, ovarian rupture is found in 0.5-3% of cases.

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Causes ovarian apoplexy

The possibility of ovarian bleeding is inherent in the physiological changes occurring in it during the menstrual cycle. Ovulation, powerful vascularization of the fragile tissues of the corpus luteum, premenstrual hyperemia of the ovary - all this can cause the formation of a hematoma, tissue integrity violation and bleeding into the abdominal cavity, the volume of which varies - from 50 ml to 2-3 liters. Predisposing factors for ovarian apoplexy include previous inflammatory processes localized in the small pelvis, leading to sclerotic changes in the ovarian tissue and blood vessels, congestive hyperemia and varicose veins. The role of endocrine factors is not excluded. Bleeding from the ovary can be facilitated by blood diseases with impaired coagulation. In the last 10-15 years, an increase in ovarian bleeding has been noted, associated with long-term use of anticoagulants by patients after cardiac valve replacement.

Rupture of the ovary can occur in different phases of the menstrual cycle, but in the vast majority of cases - in the second phase, therefore in modern literature this pathology is often referred to by the term "rupture of the corpus luteum".

Rupture of the corpus luteum can occur in uterine and ectopic (extrauterine) pregnancies. In approximately 2/3 of cases, the right ovary is affected, which many authors explain by the topographic proximity of the appendix. There are other hypotheses: some explain this fact by the difference in the venous architecture of the right and left ovaries.

The main causes of ovarian apoplexy:

• Neuroendocrine disorders.
• Inflammatory processes.
• Anomalies in the position of the genitals.
• Abdominal injuries.
• Physical stress.
• Sexual intercourse.
• Nervous and mental stress.
• Cystic degeneration of the ovaries.
• Persistence of the corpus luteum.

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Symptoms ovarian apoplexy

The leading symptom of ovarian apoplexy is acute, increasing pain in the lower abdomen and increasing symptoms of intra-abdominal bleeding with normal menstrual function.

• Sudden onset of pain, predominantly one-sided, often radiating to the epigastric region.
• Positive phrenicus symptom.
• Weak tension in the abdominal wall of the lower abdomen.
• Weakness, cold sweat, nausea, vomiting.
• Signs of increasing anemia (tachycardia, acrocyanosis, pallor).
• Increasing symptoms of hemorrhagic shock.

Ovarian apoplexy most often affects women of reproductive age with a two-phase menstrual cycle. There are 3 clinical forms of the disease: anemic, painful and mixed.

In the clinical picture of the anemic form of ovarian apoplexy, symptoms of intraperitoneal bleeding predominate. The onset of the disease may be associated with trauma, physical exertion, sexual intercourse, etc., but it may begin without an apparent cause. Acute intense abdominal pain appears in the second half or in the middle of the cycle. In a third of women, the attack is preceded by a feeling of discomfort in the abdominal cavity, lasting 1-2 weeks. The pain may be localized above the pubis, in the right or left iliac regions. Often the pain radiates to the anus, external genitalia, sacrum; phrenicus-snimptom may be observed.

The attack of pain is accompanied by weakness, dizziness, nausea, sometimes vomiting, cold sweat, fainting. During examination, attention is drawn to the pallor of the skin and mucous membranes, tachycardia at normal body temperature. Depending on the amount of blood loss, blood pressure decreases. The abdomen remains soft, may be slightly swollen. There is no tension in the abdominal wall muscles. Palpation of the abdomen reveals diffuse pain throughout the lower half or in one of the iliac regions. Symptoms of peritoneal irritation are expressed to varying degrees. Percussion of the abdomen may reveal the presence of free fluid in the abdominal cavity. Examination in mirrors gives a normal picture: normal-colored or pale mucous membrane of the vagina and exacerbation, no hemorrhagic discharge from the cervical canal. Bimanual examination (quite painful) reveals a normal-sized uterus, sometimes an enlarged spherical painful ovary. In case of significant bleeding, overhang of the posterior and/or lateral vaginal fornix is found. In the clinical blood analysis, the picture of anemia predominates, white blood changes less often.

It is easy to see that the anemic form of ovarian rupture has a great similarity with the clinical picture of a disrupted ectopic pregnancy. The absence of a delay in menstruation and other subjective and objective signs of pregnancy tips the scales in favor of ovarian apoplexy, but their evidence is very relative. The determination of the chorionic hormone and laparoscopy help with differential diagnostics, but their implementation is not necessary, since the presence of internal bleeding forces the doctor to proceed to emergency laparotomy, during which the final diagnosis is established.

The painful form of ovarian apoplexy is observed in cases of hemorrhage into the tissue of the follicle or corpus luteum without bleeding or with slight bleeding into the abdominal cavity.

The disease begins acutely with an attack of pain in the lower abdomen, accompanied by nausea and vomiting against the background of normal body temperature. There are no signs of internal bleeding: the patient has a normal color of the skin and mucous membranes, pulse rate and blood pressure figures are within normal limits. The tongue is moist, not coated. The abdomen is often soft, but some tension of the abdominal wall muscles in the iliac regions may be detected. Palpation of the abdomen is painful in the lower sections, more often on the right; moderate symptoms of peritoneal irritation are also determined there. Free fluid in the abdominal cavity cannot be detected. There is no bloody discharge from the genital tract. An internal gynecological examination reveals a normal-sized uterus, the displacement of which causes pain, and a slightly enlarged round painful ovary. The vaginal vaults remain high. There are no pathological discharge from the genital tract.

The clinical picture of the disease resembles acute appendicitis, which is more common than ovarian apoplexy, so the patient may be referred to a surgical hospital. These diseases can be differentiated by the following signs. With appendicitis, there is no connection with the phases of the menstrual cycle. The pain begins in the epigastric region, then descends to the right iliac. Nausea and vomiting are more persistent. Body temperature rises. Sharp pain at the McBurney point and other symptoms of appendicitis appear. The tension of the abdominal wall muscles of the right iliac region is expressed significantly. Clear symptoms of peritoneal irritation are also determined here. Internal gynecological examination does not reveal pathology of the uterus and appendages. Clinical blood test is quite indicative: leukocytosis, neutrophilia with a shift in the formula to the left.

In doubtful cases, one can resort to a puncture of the recto-uterine pouch through the posterior vaginal fornix. In case of ovarian rupture, blood or serous-bloody fluid is obtained.

Differential diagnostics of appendicitis and ovarian apoplexy is of fundamental importance for developing further tactics of patient management. Appendicitis requires unconditional surgical treatment, and in case of apoplexy, conservative therapy is possible. In unclear cases, the diagnosis can be established using laparoscopy, and in the absence of such an opportunity, it is more rational to lean in favor of appendicitis and establish an accurate diagnosis during laparotomy.

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Forms

According to the clinical course:

• anemic;
• painful;
• mixed form

By severity:

• light;
• moderate;
• heavy

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Diagnostics ovarian apoplexy

Diagnosis of ovarian apoplexy is based on:

• assessing the nature of complaints;
• conducting a general examination of the patient;
• the use of special additional research methods (ultrasound of the pelvic organs, which allows the presence of free fluid to be detected, and puncture of the posterior vaginal fornix, which can yield liquid or clotted blood).

A modern diagnostic method is laparoscopy.

A clinical blood test does not reveal significant deviations from the norm; sometimes moderate leukocytosis is detected without a pronounced shift in neutrophils.

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Differential diagnosis

Differential diagnosis for this pathology must be carried out with such diseases as:

• ectopic pregnancy;
• acute adnexitis;
• acute appendicitis;
• torsion of the ovarian tumor pedicle or subserous fibromatous node;
• urolithiasis.

Treatment ovarian apoplexy

Treatment of ovarian apoplexy depends on the degree of intra-abdominal bleeding.

In mild cases – conservative treatment (cold on the lower abdomen, bed rest, observation, examination).

Moderate and severe forms – surgical treatment.

In preparation for surgery, the following is required:

• replenishment of circulating blood volume;
• intravenous administration of blood substitutes and blood;
• laparoscopy (laparotomy) – blood evacuation, coagulation of the bleeding area of the ovary;
• ovarian resection.

The anemic form of the disease requires surgical treatment, the scope of which may vary. If the corpus luteum has ruptured, it should be sutured with hemostatic Z-shaped sutures placed within the healthy ovarian tissue. The corpus luteum tissue should not be excised to avoid termination of pregnancy.

The most typical operation is ovarian resection, which is possible in 95% of patients. The entire ovary must be removed in cases where all of its tissue is saturated with blood. In those rare cases where ovarian bleeding complicates long-term anticoagulant therapy after cardiac valve replacement, appendage removal is necessary to ensure reliable hemostasis. Preventing bleeding from the corpus luteum of the remaining ovary in such women is very difficult, since the ovulation suppression recommended in such cases requires the use of agents with thrombogenic properties.

In recent years, it has become possible to perform gentle operations using laparoscopy, during which the blood that has spilled into the abdominal cavity is evacuated and the bleeding area of the ovary is coagulated.

The painful form of ovarian apoplexy without clinical signs of increasing internal bleeding can be treated conservatively. In such cases, rest, cold on the lower abdomen and hemostatic drugs are prescribed: 12.5% etamsylate (dicynone) solution, 2 ml 2 times a day intravenously or intramuscularly; 0.025% adroxone solution, 1 ml per day subcutaneously or intramuscularly; vitamins; 10% calcium chloride solution, 10 ml intravenously.

Conservative treatment of ovarian apoplectic disease should be carried out in a hospital under 24-hour supervision of medical personnel.

Ovarian apoplexy in women suffering from blood diseases with hemostasis defects (autoimmune thrombocytopenia, von Willebrand disease, etc.) should be treated with conservative methods. After consultation with a hematologist, specific therapy for the underlying disease is administered: corticosteroids, immunosuppressants - for autoimmune thrombocytopenia, infusion of cryoprecipitate or antihemophilic plasma - for von Willebrand disease, etamsylate (dicynone) - in both cases. Such conservative therapy, aimed at correcting blood clotting disorders, is usually quite effective.