Ovarian apoplexy

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

Surgical treatment is not available to all patients with a similar disease. Some of them because of the ambiguity of the clinical picture put other diagnoses, so, apparently, the frequency of this pathology exceeds the figures given.

[1], [2],

Epidemiology

Apoplexy of the ovary is rare. Among women who are operated for internal bleeding, an ovarian rupture is found in 0.5-3% of cases.

[3], [4],

Causes of the apoplexy of the ovary

The possibility of bleeding from the ovary is already contained in the physiological changes that occur in it throughout the menstrual cycle. Ovulation, a powerful vascularization of the fragile tissues of the yellow body, premenstrual hyperemia of the ovary - all this can cause the formation of a hematoma, a violation of the integrity of the tissue and bleeding into the abdominal cavity, the volume of which varies - from 50 ml to 2-3 liters. Predisposing factors of ovarian apoplexy include the transferred inflammatory processes localized in the small pelvis, which led to sclerotic changes in ovarian and vascular tissue, to congestive hyperemia and varicose veins. The role of endocrine factors is not excluded. Bleeding from the ovary can contribute to blood diseases with a violation of its coagulation. In the last 10-15 years, there has been an increase in ovarian bleeding associated with prolonged intake of anticoagulants by patients after prosthetic heart valves.

Ovarian rupture can occur in different phases of the menstrual cycle, but in the vast majority of cases - in the second phase, so in modern literature, this pathology is often denoted by the term "rupture of the yellow body.

Rupture of the yellow body can occur with uterine and ectopic (ectopic) pregnancy. Approximately 2/3 of the cases affect the right ovary, which many authors explain by the topographical closeness 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 of the position of the genital organs.
• Injuries to the abdomen.
• Physical stress.
• Sexual intercourse.
• Neuropsychiatric stress.
• Cystic ovarian degeneration.
• Persistence of the yellow body.

[5], [6], [7]

Symptoms of the apoplexy of the ovary

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

• Suddenly, aching pains, mostly one-sided, often with irradiation into the epigastric region.
• Positive frenicus-symptom.
• Weak tension of the abdominal wall of the lower abdomen.
• Weakness, cold sweat, nausea, vomiting.
• Signs of increasing anemia (tachycardia, acrocyanosis, pallor).
• The growing symptoms of hemorrhagic shock.

Apoplexy of the ovary more 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 anemic forms of ovarian apoplexy, symptoms of intraperitoneal bleeding predominate. The onset of the disease can be associated with injuries, physical stress, sexual intercourse, etc., but may begin without a visible cause. Acute intense pains in the abdomen appear 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, continuing for 1 to 2 weeks. Pain can be located above the pubis, in the right or left iliac regions. Often the pain radiates into the anus, the external genitalia, the sacrum; can be observed frenicus-snmptom.

A painful attack is accompanied by weakness, dizziness, nausea, sometimes vomiting, cold sweat, fainting. On examination, attention is paid to the pallor of the skin and mucous membranes, tachycardia at normal body temperature. Depending on the magnitude of blood loss, blood pressure decreases. The abdomen remains soft, may be somewhat bloated. The muscle tension of the abdominal wall is absent. Palpation of the abdomen reveals diffuse soreness over the entire lower half of it or in one of the iliac regions. Symptoms of irritation of the peritoneum are expressed in different degrees. Percussion of the abdomen can reveal the presence of free fluid in the abdominal cavity. Inspection in the mirrors gives the usual picture: normal color or pale mucous membrane of the vagina and exacervix, hemorrhagic discharge from the cervical canal is absent. In bimanual examination (quite painful), the normal size of the uterus is determined, sometimes an enlarged spherical painful ovary. With significant bleeding, an overhanging of the posterior and / or lateral arches of the vagina is found. In the clinical analysis of blood the picture of anemia prevails, white blood changes less often.

It is easy to see that the anemic form of rupture of the ovary has a great similarity with the clinic of impaired ectopic pregnancy. Absence of delay of monthly and other subjective and objective signs of pregnancy tends to weigh the scale in favor of ovarian apoplexy, but their evidence is very relative. Differential diagnostics are supported by the definition of chorionic hormone and laparoscopy, but their conduct is not necessary, since the presence of internal bleeding causes the doctor to begin emergency abdominal cortexing, during which the final diagnosis is established.

Painful form of apoplexy of the ovary is observed in cases of hemorrhage into the tissue of the follicle or yellow body without bleeding or with a slight bleeding into the abdominal cavity.

The disease begins acutely with an attack of pain in the lower abdomen, accompanied by nausea and vomiting on the background of normal body temperature. There are no signs of internal bleeding: the patient has a normal color of skin and mucous membranes, the pulse rate and blood pressure figures are within the normal range. The tongue is moist, not coated. The abdomen is often mild, but some tension in the muscles of the abdominal wall in the ileum can be detected. Palpation of the abdomen is painful in the lower parts, more often on the right; there are also moderately expressed symptoms of peritoneal irritation. Free fluid in the abdominal cavity can not be detected. There are no bloody discharge from the genital tract. With internal gynecological examination, the normal size of the uterus is determined, the displacement of which causes pain, and a somewhat enlarged round painful ovary. Vaginal vaults remain high. Pathological discharge from the genital tract is absent.

The picture of the disease resembles a clinic of acute appendicitis, which occurs more often than apoplexy of the ovary, so the patient can be sent to a surgical hospital. Differentiate these diseases can be on the following grounds. With appendicitis, there is no connection with the phases of the menstrual cycle. The pain begins with the epigastric region, then descends into the right iliac. Nausea and vomiting are more stubborn. The body temperature rises. There are sharp soreness at the point of McBurney and other symptoms of appendicitis. The tension of the muscles of the abdominal wall of the right ileal region is markedly expressed. Here, clear symptoms of irritation of the peritoneum are determined. Internal gynecological examination does not reveal the pathology of the uterus and appendages. The clinical analysis of the blood is quite indicative: leukocytosis, neutrophilia with a shift of the formula to the left.

In doubtful cases, you can resort to a puncture of the rectum-uterine cavity through the posterior vaginal vault. When the ovary rupture, blood or serous-bloody fluid is obtained.

Differential diagnosis of appendicitis and apoplexy of the ovary is of fundamental importance for the development of further tactics of patient management. Appendicitis requires unconditional surgical treatment, and with apoplexy - conservative therapy is possible. In unclear cases, the diagnosis can be established with the help of 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 the abdominal process.

[8], [9], [10], [11]

Forms

According to the clinical course:

• anemic;
• painful;
• mixed form

By gravity:

• light;
• medium-heavy;
• Heavy

[12], [13]

Diagnostics of the apoplexy of the ovary

Diagnosis of ovarian apoplexy is based on:

• assessment of the nature of complaints;
• conducting a general examination of the patient;
• the use of special additional methods of examination (ultrasound of the pelvic organs, which allows to detect the presence of free fluid, and puncture of the posterior vaginal vault, at which it is possible to obtain blood liquid or with clots).

The modern method of diagnosis is laparoscopy.

A clinical blood test does not reveal significant abnormalities, sometimes a mild leukocytosis is found without pronounced neutrophil shift.

[14]

Differential diagnosis

Differential diagnosis for this pathology is required to be carried out with such diseases as;

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

Treatment of the apoplexy of the ovary

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

In mild form - conservative treatment (cold on the bottom of the abdomen, bed rest, observation, examination).

The medium-heavy and severe form is surgical treatment.

In preparation for the operation requires:

• carrying out replenishment of the volume of circulating blood;
• intravenous administration of blood substitutes and blood;
• laparoscopy (laparotomy) - evacuation of blood, coagulation of bleeding ovary;
• resection of the ovary.

The anemic form of the disease requires surgical treatment, the volume of which can be different. If there is a rupture of the yellow body, then it should be sewed with hemostatic Z-shaped sutures applied within the Healthy Ovarian tissue. To cut the tissue of the yellow body should not be to avoid the termination of pregnancy.

The most typical operation is resection of the ovary, it is possible in 95% of patients. Remove the ovary entirely in those cases when all of its tissue is soaked in blood. In those rare cases where bleeding from the ovary complicates prolonged therapy with anticoagulants after prosthetic heart valves, for reliable hemostasis one has to resort to the removal of appendages. Prevention of bleeding from the yellow body of the remaining ovary in such women is of great complexity, because the recommended suppression of ovulation in such cases requires the appointment of funds that have thrombogenic properties.

In recent years, it has become possible to carry out sparing operations with the use of laparoscopy, during which the evacuation of blood flowing to the abdominal cavity and coagulation of the bleeding area of the ovary is carried out.

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

Conservative treatment of apoplexy of the ovary should be carried out in a hospital under round the clock supervision of medical personnel.

Apoplexy of the ovary in women suffering from blood diseases with hemostasis defects (autoimmune thrombocytopenia, von Willebrand disease, etc.) should be treated with conservative methods. After consultation, a specialist in hematology conducts a specific therapy for the underlying disease: corticosteroids, immunosuppressants - for autoimmune thrombocytopenia, infusion of cryoprecipitate or antihemophilic plasma - for Wellebrunt's disease, etamzilate (dicinone) - in both cases. Such conservative therapy aimed at correcting blood clotting disorders is usually quite effective.