What is Ovarian Apoplexy?
Ovarian apoplexy is defined as a sudden onset of hemorrhage in the ovary at rupture of the vessels of a graaf bladder, ovarian stroma, follicular cyst or cystic of the corpus luteum, accompanied by a violation of the integrity of its tissue and bleeding into the abdominal cavity.
Ovarian apoplexy occurs between the ages of 14 and 45, more often in 20-35 years. However, there are cases of hemorrhage in the ovary in young girls. The frequency of ovarian apoplexy among gynecological pathology is 1-3%. Relapse of the disease reaches 42-69%.
Causes of Ovarian Apoplexy
Apoplexy has a complex pathogenesis due to physiological cyclical changes in the blood supply to the pelvic organs. Most researchers highlight “critical moments” for damage to the ovary. Thus, in 90-94% of patients, ovarian apoplexy occurs in the middle and in the second phase of the menstrual cycle. This is due to the peculiarities of the ovarian tissue, in particular, the increased permeability of the vessels and an increase in their blood supply during the period of ovulation and before menstruation.
Apoplexy of the right ovary occurs 2-4 times more often than the left, which is explained by a more abundant blood circulation of the right ovary, since the right ovarian artery departs directly from the aorta, and the left – from the renal artery.
Inflammatory processes of the pelvic organs predispose to ovarian rupture, leading to sclerotic changes both in the ovarian tissue (stroma sclerosis, epithelial fibrosis, periophoritis) and in its vessels (sclerosis, hyalinosis), and congestive hyperemia and varicose ovarian veins. Bleeding from the ovary can contribute to blood disorders and long-term use of anticoagulants, leading to disruption of the blood coagulation system. These conditions create a background for exogenous and endogenous factors leading to ovarian apoplexy. Exogenous causes include trauma to the abdomen, physical exertion, violent or interrupted sexual intercourse, horseback riding, douching, vaginal examination, etc. Endogenous causes can be abnormal position of the uterus, mechanical pressure of vessels, impaired blood flow in the ovary, pressure on the ovary by a tumor, adhesions in the pelvis, etc. In a number of patients, an ovary is ruptured for no apparent reason at rest or during sleep.
Pathogenesis During Ovarian Apoplexy
The leading role in the pathogenesis of ovarian apoplexy is currently assigned to hormonal status disorders. One of the main causes of ovarian rupture is considered an excessive increase in the number and changes in the ratio of pituitary gonadotropic hormones (FSH, LH, prolactin), which contributes to hyperemia of ovarian tissue.
An important role in the occurrence of ovarian apoplexy belongs to the dysfunction of the higher parts of the nervous system, recorded during EEG and REG. As a result of stressful situations, psychoemotional lability, the impact of environmental factors, living conditions.
Ovarian apoplexy is not only a complex of serious disorders of the reproductive system, but also a disease of the whole organism with the involvement of various levels of the nervous system.
Pain, anemic and mixed forms of ovarian apoplexy are distinguished. The staff of the clinic G.M. Savelieva proposed a classification that takes into account the severity of intra-abdominal blood loss:
- Pain form.
- Hemorrhagic form:
– I degree – light (intra-abdominal blood loss does not exceed 150 ml); –
– II degree – medium (blood loss 150-500 ml);
– III degree – severe (intra-abdominal blood loss of more than 500 ml).
Symptoms of Ovary Apoplexy
The main clinical symptom of ovarian apoplexy is sudden pain in the lower abdomen. The pain is associated with irritation of the receptor field of the ovarian tissue and the effect on the peritoneum of spilled blood, as well as with spasm in the pool of the ovarian artery.
Weakness, dizziness, nausea, vomiting, fainting are associated with intraperitoneal blood loss.
The painful form of ovarian apoplexy is observed when hemorrhaging into the tissue of the follicle or corpus luteum without bleeding into the abdominal cavity. The disease manifests an attack of pain in the lower abdomen without irradiation, sometimes with nausea and vomiting. There are no signs of intra-abdominal bleeding.
The clinical picture of pain and mild hemorrhagic ovarian apoplexy is similar.
On examination, the skin and visible mucous membranes of normal color. Pulse and blood pressure within normal limits. The tongue is clean, wet. The abdomen is soft, although slight tension of the muscles of the anterior abdominal wall in the lower sections is possible. Palpation marked soreness in the iliac region, often to the right, there are no peritoneal symptoms. Percussion free fluid in the abdominal cavity is not defined. During a gynecological examination of the uterus of normal size, the ovary is somewhat enlarged and painful. The arches of the vagina are deep, free. Ultrasound of the pelvic organs almost never allows you to visualize directly the rupture of the ovary, but fluid accumulation in the dorsal (douglas) space can be detected. When the painful form of ovarian apoplexy is a small amount of fluid in the Douglas space, it is hypoechoic with a fine suspension (follicular fluid mixed with blood). In the clinical analysis of blood there are no pronounced changes, sometimes moderate leukocytosis is detected without shifting the formula to the left.
In the clinical picture of moderate and severe hemorrhagic (anemic) forms of ovarian apoplexy, the main symptoms are associated with intraperitoneal bleeding. The disease begins acutely, often due to external causes (sexual intercourse, physical stress, trauma, etc.). Pain in the lower abdomen often radiates to the anus, leg, sacrum, external genital organs, accompanied by weakness, dizziness, nausea, vomiting, fainting. The severity of symptoms depends on the size of intra-abdominal blood loss.
On examination, the skin and visible mucous membranes are pale, with cold, sticky sweat on the skin. Blood pressure is reduced, tachycardia. The tongue is dry, the abdomen is tense, a slight swelling is possible. On palpation, a sharp pain is determined in one of the iliac regions or throughout the hypogastrium. Peritoneal symptoms are most pronounced in the lower sections. Perkutorno determine the free fluid in sloping areas of the abdomen (right, left side channels).
Diagnosis of Ovarian Apoplexy
During a gynecological examination, the mucous membrane of the vagina is normal or pale. Two-handed study may be difficult due to severe pain in the anterior abdominal wall. The uterus is of normal size, painful, on the side of apoplexy a painful, slightly enlarged ovary is palpated. Vaginal vaults hang, traction for the cervix sharply painful.
In the clinical analysis of blood, there is a decrease in the level of hemoglobin, but with acute hemorrhage in the first hours, hemoglobin levels may rise as a result of blood clots. In some patients, there is a slight increase in leukocytes without shifting the formula to the left.
When ultrasound of the internal genitalia is determined by a significant amount of free fine – and medium-dispersed fluid in the abdominal cavity with irregularly shaped structures, increased echogenicity (blood clots).
For the diagnosis of the disease without marked violations of hemodynamic parameters, puncture of the abdominal cavity through the posterior fornix of the vagina is used. However, laparoscopy has become the method of choice in the diagnosis of ovarian apoplexy. Ovarian apoplexy during laparoscopy looks like ovulation stigma (a small spot with a diameter of 0.2-0.5 cm elevated above the surface with signs of bleeding or covered with a blood clot), in the form of a yellow body cyst in a “collapsed” state or in the form of a yellow body with a linear rupture or a rounded tissue defect with or without bleeding.
Treatment of Ovarian Apoplexy
Treatment of patients with ovarian apoplexy depends on the form of the disease and the severity of intra-abdominal bleeding. With painful form and minor intra-abdominal blood loss (less than 150 ml) without signs of increasing bleeding, conservative therapy can be performed. It includes rest, ice on the lower abdomen (contributes to vascular spasm), hemostatic drugs (etamzilat), antispasmodics (papaverine, no-spa), vitamins (thiamine, pyridoxia, cyanocobalamin), physiotherapy (electrophoresis with calcium chloride, Microwave therapy).
Conservative therapy is carried out in the hospital under round-the-clock supervision. With a repeated attack of pain, deterioration of the general condition, instability of hemodynamics, an increase in the amount of blood in the abdominal cavity, the indications for surgical intervention (laparoscopy, laparotomy) appear clinically and with ultrasound scanning.
Indications for laparoscopy:
- more than 150 ml of blood in the abdominal cavity, as confirmed by physical examination and ultrasound, with stable hemodynamic parameters and a satisfactory condition of the patient;
- the ineffectiveness of conservative therapy for 1 to 3 days, signs of continuing intra-abdominal bleeding, confirmed by ultrasound;
- differential diagnosis of acute gynecological and acute surgical pathology.
Surgical intervention in ovarian apoplexy should be as gentle as possible: coagulation of the site of rupture, opening or puncture of the cyst and removal of the contents using an aquapurator suction, resection of the ovary. With large injuries and no possibility of preserving the ovary, it is removed.
Indications for laparotomy:
- signs of intra-abdominal bleeding, leading to hemodynamic disturbances with the patient’s severe condition (hemorrhagic shock);
- inability to perform laparoscopy (due to adhesions, increased bleeding from damaged ovarian vessels).
Surgical intervention is performed by the lower-middle access or suprapubic incision according to Pfannenstiel. The scope of the intervention is no different from laparoscopic. With laparotomy, it is possible to reinfuse blood that has poured into the abdominal cavity.
Prevention of Ovarian Apoplexy
In patients with painful form of ovarian apoplexy, disorders of the central nervous system, hormonal profile and blood circulation in the ovary are reversible, and therefore specific preventive measures are not required. In patients who have suffered a hemorrhagic form of ovarian apoplexy, dysfunction of the higher parts of the CNS, changes in hormonal status and impaired ovarian blood flow are usually persistent. Such patients are shown a comprehensive drug therapy, breaking a vicious pathogenetic circle. For 3 months, they conduct therapy, correcting the activity of brain structures: prescribe nootropics to improve the metabolic processes in the central nervous system, drugs that improve cerebral perfusion (Cavinton, Tanakan, Vinpocetine), tranquilizers, and intracranial hypertension – diuretic drugs. To suppress ovulation and correct the hormonal profile for 3-6 months, combined estrogen-gestagenic monophasic low and microdosing oral contraceptives (marvelon, regulonon, zhanin, femoden, silest, novinet, mercilon, logest) are used.
Forecast. With painful form of ovarian apoplexy, the prognosis for life is favorable. In patients with hemorrhagic form, the prognosis for life depends on the timeliness of diagnosis and therapeutic measures. When a rupture of the ovary is lethal, decompensated irreversible hemorrhagic shock that occurs when blood loss exceeds 50% of BCC can result.
Preventive measures help to reduce the frequency of relapses.