A ruptured ovarian cyst is a common phenomenon, with presentation ranging from no symptoms to symptoms mimicking an acute abdomen.[1] Sequelae vary. Menstruating women have rupture of a follicular cyst every cycle, which is either asymptomatic or with mild transient pain (mittelschmerz). In less usual circumstances, the rupture can be associated with significant pain. In very rare circumstances, intraperitoneal hemorrhage[2, 3, 4] and death may occur.[5] The most pressing issues facing clinicians encountering patients with potential cyst rupture in the acute setting are to rule out ectopic pregnancy, ensure adequate pain control, and rapidly assess the patient for hemodynamic instability to allow appropriate triage. Although most patients require only observation, some need analgesics for pain control and laparoscopy or laparotomy for diagnosis or to achieve hemostasis.
While some hemorrhage associated with ovarian cyst rupture has unclear etiology, there are recognized risk factors. These include abdominal trauma and anticoagulation therapy.[6] The condition most commonly occurs in reproductive-aged women of 18-35 years.
See also the Medscape Reference article Ovarian Cysts.
Each month, a mature ovarian follicle ruptures, releasing an ovum so the process of fertilization can begin. Occasionally, these follicles may bleed into the ovary, causing cortical stretch and pain, or at the rupture site following ovulation. Similarly, a corpus luteum cyst may bleed subsequent to ovulation or in early pregnancy. As blood accumulates in the peritoneal cavity, abdominal pain and signs of intravascular volume depletion may arise.
The etiology of this increased bleeding is unknown, although abdominal trauma and anticoagulation treatments may increase the risk. Nonphysiologic cysts, such as cystadenomas and mature cystic teratomas (dermoid cysts), may, in rare cases, rupture and cause symptoms. In addition to hemorrhage, significant pain can accompany rupture of a dermoid cyst, presumably from spillage of sebaceous fluid, resulting in a diffuse chemical peritonitis.
Although circulatory collapse, hemorrhagic shock, disseminated intravascular coagulation (DIC), and death have been reported, these are quite rare. Most cyst ruptures are self-limiting, requiring only expectant management and oral analgesics for relief of abdominal pain. Duration of symptoms varies from a few days to several weeks and may depend, in part, on the type (hemorrhagic vs nonhemorrhagic) and volume of cyst fluid in the pelvis.
The patient often presents with an acute onset of abdominal pain, typically during strenuous physical activity, such as exercise or sexual intercourse. Given that follicular cyst rupture is more common than corpus luteal cyst rupture, the onset tends to be midcycle. Other associated symptoms include the following:
Vital signs are usually within normal range. Physical findings can range from mild unilateral low abdominal tenderness to those of an acute abdomen with severe tenderness, guarding, rebound, and peritoneal signs.[7]
Low-grade fever is sometimes observed, and an adnexal mass may be palpable, although absence of such findings on examination has no diagnostic value as many cysts decompress after rupture. Orthostatic changes are consistent with a sizable hemorrhage.
Perform a urine pregnancy test. If the pregnancy test is positive, make sure to rule out an ectopic pregnancy. Evaluate for ovarian torsion before discharge. If a diagnosis of bleeding ruptured ovarian cyst is considered, make sure the hemoglobin level is stable before discharging the patient. It is appropriate to admit the patient for observation and pain control.
Perform a diagnostic laparoscopy and/or laparotomy if the patient is hemodynamically unstable or if a specific diagnosis is unclear, yet a definitive diagnosis is necessary.
A study by Shiota et al indicated that C-reactive protein (CRP) levels can be used preoperatively to differentiate a ruptured ovarian cyst from ovarian torsion. In a retrospective evaluation of 98 patients diagnosed with a benign ovarian cyst, it was found that 21 patients with a ruptured cyst and 77 patients with ovarian torsion had mean preoperative CRP levels of 6.6 and 0.9 mg/dL, respectively; the mean size of the ovarian cysts also differed significantly between the two groups (6.7 cm and 9.7 cm, respectively). The investigators mentioned another study, however, that indicated that patients with ovarian torsion who present over 10 hours after the onset of acute abdomen with elevated CRP levels are at risk of necrosis. They suggested, therefore, that by taking into account imaging findings, CRP levels, and time of acute abdomen onset, clinicians can preoperatively differentiate ovarian cyst rupture from ovarian torsion.[8]
Tanaka et al suggest that plasma D-dimer levels may be markers for endometriotic ovarian cyst rupture.[9] In their study of 6 patients with emergent endometriotic cyst rupture and 16 control patients with unruptured endometriotic cysts, significantly elevated plasma D-dimer levels were seen in the group with the ruptured cysts. The investigators also noted that differences in white blood cell count and serum CRP levels between the two groups were statistically significant.[9]
Serum or urine pregnancy testing should be performed. In the case of a positive result, the patient should be evaluated for ectopic pregnancy. If concerned regarding possible hemorrhage, monitor the hematocrit (serially, if necessary) to ensure there is no continued bleeding.
If the diagnosis is unclear, urinalysis should be performed to identify a possible urinary tract infection or renal or bladder stones. Blood, urine, and cervical cultures may also be indicated rule out pelvic inflammatory disease or urinary tract infections.
Blood type and cross-match are indicated in patients with significant peritoneal signs or hemodynamic instability, because such patients may require surgical intervention or blood transfusion.
Ultrasonography is the preferred imaging modality for assessing gynecologic structures, given its low cost, availability, and sensitivity in recognizing adnexal cysts and hemoperitoneum.[10, 11] Despite this, there remain instances in which the ultrasound findings are nonspecific, particularly after rupture and decompression of a cyst in the setting of apparent physiologic levels of fluid in the pelvis.
If ultrasound yields ambiguous results in a patient with significant pain, computed tomography (CT) of the pelvis with contrast should be performed. CT features of corpus luteum cysts have been previously described.[12, 13, 14]
Although commonly performed in the past, culdocentesis has been largely abandoned in favor of ultrasonography and CT scanning, as both can readily identify fluid collections in the cul-de-sac. Culdocentesis is still acceptable, however, in locations where imaging is not available.
A case study of 34-year-old woman who presented with severe bilateral lower quadrant abdominal pain after sexual intercourse found that even though no evidence of cysts were observed on CT or intraoperatively, histopathological examination revealed a hemorrhagic corpus luteal cyst.[15]
Patients with presumed cyst rupture are typically managed conservatively. Conservative medical care may consist of outpatient treatment with oral analgesics in the stable patient, or if the clinical picture is evolving, admission and anticipatory management with serial abdominal examinations and laboratory testing, repeat imaging, and pain relief with an analgesic of choice.[16] Medications may range from oral acetaminophen to intravenous morphine via patient-controlled analgesia (PCA) infusion pumps. If continued bleeding is a concern or if the patient is unstable hemodynamically, proceed with surgery.[16]
Surgical care may entail laparoscopy or laparotomy, depending on clinical presentation, amount of blood in the abdomen, patient stability, and operator skill.[17, 18] Most bleeding can be stopped with suturing, cautery, cystectomy, or wedge resection. Occasionally, salpingo-oophorectomy is necessary.
For the patient with multiple episodes of ruptured physiologic cysts or following a single severe episode, it is reasonable to consider suppression of ovulation with oral hormonal contraception, as this may help reduce the risk of recurrence of ovarian cysts.[19]
Medical therapy consists of appropriate pain relief. Pain relief medications can include acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), narcotics, or an analgesic of choice.
Clinical Context: Acetaminophen is the drug of choice for pain in patients with documented hypersensitivity to aspirin or nonsteroidal anti-inflammatory drugs; those with upper GI disease; or those who are taking oral anticoagulants.
Clinical Context: Morphine sulfate is the drug of choice for narcotic analgesia, owing to its reliable and predictable effects, safety profile, and ease of reversibility with naloxone. Intravenous administration may be dosed in a number of ways and commonly is titrated until desired effect is obtained.
For chronic severe pain unremitting to alternative therapy, oral immediate–release and extended-release morphine sulfate may be warranted. Arymo ER is a morphine sulfate abuse-deterrent formulation.
Pain control is essential to quality patient care. These medications ensure patient comfort and have sedating properties, which are beneficial in the treatment of pain.
A review of opioid equivalents and conversions may be found in the following reference article:
http://emedicine.medscape.com/article/2138678-overview