Obstetrics and Gynecology - A. M. Gromova 2000

"Acute Abdomen" in Gynecology
"Acute Abdomen" Associated with Intra-Abdominal Hemorrhage
Ovarian Apoplexy

Ovarian apoplexy can be a cause of ACUTE ABDOMEN IN gynecological patients. This term refers to a sudden Hemorrhage into the Ovary, accompanied by the disruption of its integrity and bleeding into the Abdominal cavity.

Etiology AND Pathogenesis

Conditions favorable for The Development of apoplexy form throughout the Menstrual cycle. Predisposing factors include pelvic inflammatory disease, sclerotic changes in ovarian and Vascular Tissues, ovarian varices, pelvic congestion, and physical exertion during the middle of the menstrual cycle.

Traditionally, ovulation was considered the most likely time for apoplexy to occur. It is now understood that in most cases, ovarian rupture happens during the luteal phase of the menstrual cycle; therefore, modern literature often defines this pathology as a "rupture of the corpus luteum." Most frequently, the source of bleeding is the corpus luteum or its cyst. Premenstrual ovarian hyperemia and significant vascularization of the fragile Tissues of the corpus luteum lead to The formation of an ovarian hematoma, the rupture of which results in intraperitoneal hemorrhage. Rupture of the corpus luteum can occur in both intrauterine and ectopic pregnancies.

Clinical presentation and Diagnosis

Based on the clinical course, three forms of ovarian apoplexy are distinguished: anemic, painful, and mixed.

In the anemic form, symptoms of intraperitoneal hemorrhage come to the fore. In the middle or second half of the menstrual cycle—most commonly following physical exertion, trauma, sexual intercourse, or occasionally without any apparent cause—acute abdominal pain develops. The pain is localized in the suprapubic or iliac regions and radiates to the rectum, sacrum, and external genitalia. In cases of significant Blood loss, the phrenic nerve sign (Kehr's sign) may be observed.

Patients complain of nausea, vomiting, and lethargy. General examination reveals Skin pallor, tachycardia, and a drop in blood pressure. Abdominal Palpation reveals tenderness, especially in the lower abdomen, along with signs of peritoneal irritation. Gynecological examination shows pallor of the vaginal mucosa, a normal-sized Uterus, and an enlarged, tender ovary. In cases of substantial blood loss, flattening of the vaginal fornices is noted. Blood tests indicate anemia. Overall, the Clinical presentation of the anemic form resembles that of an Ectopic Pregnancy disrupted by tubal abortion. The absence of menstrual delay and pregnancy signs points toward ovarian apoplexy.

The painful form of ovarian apoplexy involves hemorrhages into the ovarian tissue (into a follicle or the corpus luteum) with minimal or no bleeding into the abdominal cavity.

The primary symptom of the painful form is a sudden onset of severe pain accompanied by nausea and vomiting. The patient's skin color is normal, and blood pressure and pulse remain practically unchanged. The abdomen is soft and tender upon palpation in the lower regions, with mild signs of peritoneal irritation. Internal gynecological findings are similar to those of the anemic form, except for the absence of bulging vaginal fornices. A complete blood count shows no significant deviations from the norm.

In doubtful cases, posterior colpotomy (culdocentesis) is performed; in ovarian apoplexy, the aspirate consists of non-clotting blood or serosanguineous fluid.

The mixed form of ovarian apoplexy represents a combination of the two clinical variants described above.

Treatment

Patient management depends on the form of apoplexy and the severity of blood loss. Surgical intervention is indicated for the anemic form. A wedge resection of the ovary within healthy tissue is performed, or the rupture is closed with a Z-shaped hemostatic suture. It should be noted that in cases of corpus luteum rupture, ovarian resection is undesirable; suturing the rupture is recommended to prevent early pregnancy loss that may result from resection.

With the integration of laparoscopy into gynecological practice, it is now possible to coagulate the bleeding part of the ovary and perform peritoneal lavage via laparoscopy.

Conservative management is an option for the painful form of ovarian apoplexy without signs of intraperitoneal hemorrhage. In such cases, the patient is hospitalized, and abdominal hypothermia and hemostatic agents are prescribed: Vikasol (menadione) – 1% solution – 1 mL 1–2 times daily intramuscularly; Dicynone 2 mL (250 mg) or 12.5% etamsylate solution 2 mL 2 times daily intravenously or intramuscularly; 10% calcium chloride solution 10 mL intravenously. Once the symptoms of ovarian rupture subside, a course of anti-inflammatory therapy is administered. Upon completion of the next menstruation, The Use of combined estrogen-progestin contraceptives is recommended.