Apoplexy of the ovary may be one of the causes of the "acute abdomen" in gynecological patients. This term is understood as a sudden hemorrhage into the ovary, accompanied by a violation of its integrity and bleeding into the abdominal cavity.
Etiology and pathogenesis of ovarian apoplexy
During the menstrual cycle, conditions favorable for the onset of apoplexy are formed. Factors that predispose to the pathology include inflammation of the pelvic organs, sclerotic changes in the tissues of the ovaries and vessels, varicose veins of the ovaries, stagnant processes in the small pelvis, exercise in the middle of the menstrual cycle.
Traditionally, the most likely time for the onset of apoplexy was the period of ovulation. It is now believed that in most cases, the ovarian rupture occurs in the second phase of the menstrual cycle, so in modern literature this pathology is defined by the term "rupture of the yellow body." Most often, the source of bleeding may be the yellow body or its cyst. Premenstrual hyperemia of the ovary, a significant vascularization of the fragile tissues of the yellow body, cause the appearance of an ovarian hematoma, with the rupture of which there is intra-abdominal bleeding. A rupture of the yellow body can occur both in uterine and ectopic pregnancies.
Clinic and diagnosis of ovarian apoplexy
According to the clinical course, three forms of ovarian apoplexy are anemic, painful and mixed.
With anemic form, symptoms of intra-abdominal bleeding come to the fore. In the middle of the menstrual cycle or in the second half, more often after physical stress, trauma, sexual intercourse, and sometimes without a significant cause, there is acute pain in the abdomen. The pain is localized above the womb or in the iliac regions and irradiates into the anus, buttocks, external genitalia. With significant blood loss, a frenicus symptom is observed.
Patients complain of nausea, vomiting, lethargy. During a general examination, paleness of the skin, tachycardia, and lowering of blood pressure are noted. When palpating the abdomen is painful, especially in the lower parts. Symptoms of irritation of the peritoneum are determined. When gynecological examination, the pallor of the mucous membrane of the vagina, the uterus of usual size, one of the ovaries of increased size, painful is noted. In case of significant blood loss there is a flattening of the vaginal vaults. Anemia is noted when examining the blood. In general, the clinic of the anemic form of apoplexy of the ovary resembles a clinic of an ectopic pregnancy, broken by the type of tubal abortion. In favor of apoplexy of the ovary, there is no delay in menstruation and signs of pregnancy.
With painful form of ovarian apoplexy, hemorrhages in the ovarian tissue (into the follicle or into the yellow body) occur with little bleeding into the abdominal cavity or without it.
The main symptom of the painful form is an attack of severe pain, which is accompanied by nausea and vomiting. The skin of the patient is of normal color, blood pressure and pulse are practically unchanged. The abdomen is soft, painful on palpation in the lower parts, where markedly expressed symptoms of irritation of the peritoneum. The data of the internal gynecologic examination are similar to those in anemic form, except for the absence of overhanging vaginal vaults. A clinical blood test without significant abnormalities.
In doubtful cases, the puncture of the cavity is performed through the posterior vaginal fornix (with ovarian apoplexy punctate is blood that does not fold or serous-blood fluid).
A mixed form of ovarian apoplexy is a combination of the two described clinical variants.
Treatment of ovarian apoplexy
The management of the patient depends on the form of apoplexy and the expressiveness of blood loss. Anemic form shows surgical intervention. Conduct a wedge-shaped resection of the ovary within the healthy tissues or ligating the rupture with a Z-shaped hemostatic suture. It should be noted that in cases of rupture of the yellow body, resection of the ovary is undesirable. It is recommended to suture the rupture in order to prevent abortion of a minor term that occurs due to resection.
In connection with the introduction of laparoscopy into gynecological practice, now it is possible to coagulate part of the ovary that bleeds and sanitize the abdominal cavity through a laparoscope.
Conservative management is possible with painful form of ovarian apoplexy without signs of intra-abdominal bleeding. At the same time the patient is hospitalized, abdominal hypothermia and haemostatic drugs are appointed: vicasol - 1% solution - 1 ml 1-2 times a day, intramuscularly; dicinone 2ml (250mg) or 12.5% solution of etamzilate 2ml 2 times a day, intravenously or m, 10% calcium chloride solution 10ml intravenously. After elimination of symptoms of rupture of the ovary, a course of anti-inflammatory therapy is performed. At the end of the next menstruation, the appointment of combined estrogen-gestogenic contraceptives is recommended.