Ovarian apoplexy
Ovarian apoplexy is a spontaneous rapidly progressive hemorrhage into the ovary followed by the flow of blood beyond its limits. Apoplexy of the ovary refers to acute gynecological pathology. Often hemorrhage occurs during ovulation( middle of the cycle) or at the stage of the heyday of the yellow body in times of increased vascularization of the ovary tissues. It occurs in 2.5% of patients who have not overcome the 35-year-old line, and is much less likely to be diagnosed in other age groups.
In the ovaries of young women there are many primordial follicles - "bubbles" with liquid contents. In each of them an egg develops. In a time equal to one menstrual cycle, one ovule manages to mature in the ovary. When it completes its development, the wall of the follicle is destroyed, and the ovum leaves the ovary, retaining its viability for no longer than two days. This process occurs in the middle of the menstrual cycle and is called ovulation. The maturing follicle stimulates the synthesis of estrogens in the ovary, the first phase of the menstrual cycle is controlled by the follicle stimulating hormone of the pituitary( FSH), which stimulates the growth and maturation of follicles.
A yellow body develops at the site of death of the follicle. In the absence of fertilization, it does not live longer than two weeks. The second phase of the cycle is accompanied by an increased content of luteinizing hormone of the pituitary( LH).
The source of bleeding during apoplexy of the ovary is the vessels of the stroma of the ovary, primordial follicle, follicular cyst or cyst of the yellow body.
If ovulation occurs during ovulation or formation of the yellow body, the ovarian blood vessels become inferior, poorly cut and easily damaged. During the rupture of the wall of the follicle due to hemorrhage, first appears a hematoma - a cavity with blood, delimited by surrounding tissues. Then the wall of the hematoma is destroyed, and the blood is poured into the abdominal cavity. The amount of blood loss can sometimes reach two liters. Abdominal bleeding is a threatening condition and requires immediate surgical intervention. Qualified emergency care with ovarian apoplexy helps save the patient's life.
Ovarian apoplexy can provoke any condition leading to a pathological change in the mechanisms of normal menstrual cycle formation. It can be caused by external factors, such as excessive physical exertion, increasing intra-abdominal pressure. Because of better blood supply, apoplexy of the right ovary develops more often.
Symptoms of ovarian apoplexy depend on the stage and form of the disease. Sometimes bleeding is minor, and the symptoms are not pronounced. However, more often the disease develops rapidly and has the features of acute surgical pathology. Therefore, apoplexy of the right ovary is masked for acute appendicitis. The leading symptom of the disease is a characteristic acute pain on the side of the lesion.
In rare situations, patients with mild apoplexy clinic can be conservatively treated, but in most cases it is a preparatory period for subsequent surgery.
As with any emergency, the diagnosis of ovarian apoplexy should take a little time. The laparoscopy method simultaneously allows visually, with an accuracy of 98%, to assess the nature of organ damage and eliminate the cause of the disease.
Laparoscopic operation with apoplexy of the ovary is less traumatized, takes less time and shortens the period of postoperative recovery.
To the extent possible, during the surgical treatment of apoplexy, surgeons tend to keep the ovary and eliminate only the site with hemorrhage. If the pathological changes in ovarian tissue are common, you have to remove the ovary.
Causes of ovarian apoplexy
At the heart of ovarian apoplexy there is a long-term disruption of the integrity of one( more rarely - several) ovarian vessels that occurred after its rupture. The blood emerging from the vessel, passing through the stage of the hematoma, pours into the abdominal cavity.
This condition can be provoked by:
- Changes in normal intra-abdominal pressure upward. Often the rupture of the ovary is preceded by excessive physical exertion( weight lifting or overload in the gym, riding and the like) or violent sexual intercourse. Especially dangerous are physical overloads before or during menstruation( in the middle).
- Pathological changes of ovarian vessels in the form of sclerosis, thinning of the wall or varicose dilatation. Such conditions prevent the blood from circulating normally, it "stagnates" in any part of the blood vessel, stretches the vascular wall and can cause its rupture.
- Injuries of the abdominal cavity.
- Tumor organs tumors.
- Abnormal arrangement of genital organs.
- Incorrect vaginal examinations, especially on the eve or during menstruation.
- Adhesive process in the pelvic region.
- Pathological structural changes in ovarian tissue against the background of an infectious-inflammatory process. With inflammation, the tissues of the ovary become friable and vulnerable. Inflamed ovary easily injured and may burst.
- The moment of ovulation( 12 - 14 day of the cycle).During the rupture of the wall of the follicle on the surface of the ovary is a microtrauma, in this place with an incorrect ovulatory process, tissue tissue breaks.
- The next stage of ovulation is the formation and vascularization of the yellow body( 20 - 22 day cycle), when due to the fragility of the vessels it starts to form a hematoma.
- Long-term use of anticoagulants - drugs that reduce blood clotting.
Apoplexy of the ovary during pregnancy is associated with a rupture of the yellow body and proceeds similarly to that of non-pregnant patients.
The relative frequency of rupture of the ovary with subsequent bleeding is explained by the peculiarities of the blood supply of this organ. The ripe follicle and the yellow body are braided with a large number of full-blooded branching blood vessels.
Ovarian apoplexy is associated with disorders of neuroendocrine regulation, namely, increased pituitary glandularization of luteinizing hormone, which provokes the development of hemorrhage into the ovarian tissue.
The highest incidence of ovarian apoplexy is recorded in the second half of the cycle, because in the first half of the cycle, ripening follicles are poor in blood vessels.
The area of the left appendages of the uterus contains fewer blood vessels, so the apoplexy of the left ovary develops less often than the right one.
Unfortunately, it is not always possible to establish the exact cause of ovarian apoplexy. Sometimes a break in the tissue of the ovary occurs in completely healthy patients during a period of complete rest or even during sleep.
Symptoms and signs of ovarian apoplexy
The source of bleeding during apoplexy of the ovary is the yellow body or the cyst formed in its place. The process of formation of the cyst of the yellow body starts immediately after ovulation.
In healthy women, the yellow body performs a temporary hormonal function: it synthesizes the hormone progesterone necessary for the proper development of a potential pregnancy. In the absence of fertilization, the yellow body is destroyed several days after ovulation.
Under the influence of external provoking factors( hypothermia or overheating, stress, physical overstrain and the like) or under the influence of internal negative causes( inflammation, hormonal dysfunction and others), the yellow body is formed incorrectly, and instead of the prescribed reverse development begins to accumulate fluid followed by the formation of a cyst. The accumulating fluid presses the cysts on the inner wall of the shell and damages the vessels in it. As a result, hemorrhage develops into the cystic cavity, the subsequent rupture of its membrane and the flow of blood beyond the ovary.
The clinical picture of apoplexy is always accompanied by two leading symptoms - pain and bleeding. Depending on the dominance of one of the symptoms of the disease, the following are conventionally isolated:
- Painful form with signs of acute appendicitis and the leading symptom is pain.
- An anemic form resembling an aborted tubal pregnancy.
- A mixed form that has the features of the two previous ones.
This division of ovarian apoplexy by its forms is not entirely reliable because the severity of the disease and its consequences depend primarily on the amount of blood loss. Therefore, it is more reliable to determine the shape of ovarian apoplexy according to the volume of the lost blood, such as:
- mild( up to 100 ml);
- medium( up to 500 ml);
- heavy( over 500 ml).
Primary diagnostics of ovarian apoplexy is more often performed by "ambulance" doctors, and the patient is hospitalized in a surgical hospital with the diagnosis of "acute abdomen".Unfortunately, the primary correct diagnosis is put only in 4 - 5% of cases.
Diagnostic errors are explained by the fact that the clinical signs of ovarian apoplexy are similar to those in many other acute acute conditions. Similar clinics have:
- acute appendicitis;
- an ectopic pregnancy interrupted by the type of rupture of the fallopian tube;
- torsion( abnormal nutrition) of the leg of the ovarian cyst;
- rupture of the pyosalpinx;
- acute pancreatitis;
- intestinal obstruction;
- perforation of the stomach ulcer.
Sometimes apoplexy of the left ovary is clinically similar to left-sided renal colic.
The disease most often begins acutely in the middle or the second half of the cycle. Suddenly, sharply expressed pain occurs in the lower abdomen, more often in one of the iliac regions corresponding to the localization of apoplexy. The pain radiates into the external genitalia, lower back, anus and even the leg.
Severe pain accompanied by severe nausea and even vomiting, increased heart rate. Then there are signs of internal bleeding: pale skin, increased heart rate, lower blood pressure, the appearance of cold sweat, weakness and dizziness. With large blood loss, hemorrhagic shock may occur.
Sometimes, patients may develop short-term bleeding. Because of this, ovarian apoplexy is difficult to differentiate with interrupted ectopic pregnancy.
During examination, there is a sharp soreness in the lower abdomen or on the side of the ruptured ovary. Positive symptoms of irritation of the peritoneum indicate the presence of heavy internal bleeding.
Gynecological examination is accompanied by soreness on the side of the lesion, in case of large blood loss, the pain may acquire a diffuse character. Visually determined pale shade of the vaginal mucosa, the presence of a small amount of bloody discharge. If much blood accumulates in the pelvic cavity, it drains into the area bordering the posterior or lateral vaginal vault. In this situation, during the examination, one can detect their bulging( overhanging) in the vaginal cavity. At palpation the enlarged painful ovary is determined. When you try to move the cervix to the side, pain appears. Uterus has normal dimensions, dense and painless.
Distinguishing clinical symptoms of ovarian apoplexy during pregnancy does not. However, the presence of pregnancy complicates the situation by the need to preserve the fetus.
Diagnosis of ovarian apoplexy
The success of treatment of ovarian apoplexy depends on how quickly and correctly diagnosed, because increasing internal bleeding aggravates the patient's condition, and sometimes threatens her life.
When entering any hospital profile, a joint consultation of surgeons and gynecologists is needed to conduct differential diagnosis of the disease with similar emergency pathologies.
The primary stage is the examination of complaints, external and gynecological examination. Laboratory diagnostics include:
- a general blood test to determine the degree of anemia;
- study of the blood coagulation system;
- determination of the hormone HCG in the blood for suspected interrupted ectopic pregnancy;
A reliable diagnosis of ovarian apoplexy can not be made without special instrumental methods of examination, because the signs of the disease are similar to those in all urgent situations.
If during the examination there is a suspicion of free fluid in the pelvic cavity( overhanging the vaginal vaults), a puncture of the posterior vaginal vault is performed, when a special needle connected to the syringe pierces the vaginal wall and then "sucks" the existing fluid. The presence of blood in the resulting fluid indicates bleeding, and its absence - on the infectious and inflammatory nature of the disease.
Ultrasound scanning allows to detect in the affected ovary a large formation( cyst) with signs of hemorrhage in its cavity. With significant bleeding, there are echoes of blood in the abdomen.
The most reliable diagnosis of apoplexy is only on condition of its laparoscopic confirmation. Laparoscopic operation with apoplexy of the ovary combines the signs of a diagnostic and therapeutic procedure.
During a direct examination, the following is often found:
- the presence of free blood( sometimes with clots);
- unchanged appearance and size of the uterus;
- possible inflammatory changes in the fallopian tubes( thickening, change in length and / or adhesion);
- a pronounced adhesion process can be visualized in the pelvic cavity.
The damaged ovary has normal dimensions, but can be enlarged if the cyst( follicular or yellow body) is large. When the cyst ruptures, the ovary stains a crimson color. On the surface of the affected ovary a small gap is visible, it can bleed or be closed by blood clots( thrombi).
In some cases, the laparoscopic picture does not allow to determine the cause of rupture of the ovary, but only establishes its presence.
Contraindications for laparoscopy are a pronounced chronic adhesive process and a large bleeding( hemorrhagic shock and loss of consciousness).In the presence of such it is necessary to resort to the standard medical-diagnostic method - laparotomy.
An insignificant amount of blood loss can sometimes be accompanied by small symptoms, then the initial diagnosis is performed without hospitalization of the patient, but ultimately apoplexy of the ovaries in any form requires a surgical intrusion.
Treatment of ovarian apoplexy
Primary emergency care for ovarian apoplexy usually occurs by ambulance doctors "on site" before the patient arrives at the hospital. There are no independent attempts at treatment, as spontaneous taking of drugs can worsen the condition and complicates the subsequent diagnosis. For example, independent use of analgesic or anti-inflammatory drugs leads to a false temporary "improvement" of well-being, but does not eliminate internal bleeding.
Patients with a mild form of ovarian apoplexy do not always agree to surgical treatment, because they relate the severity of the disease to its symptoms - slightly pronounced abdominal pain.
Regardless of the chosen method of therapy, the patient is hospitalized in a hospital for permanent observation. If the background of conservative methods of treatment shows an increase in symptoms and signs of internal bleeding, immediate surgical intervention is performed.
Conservative therapy for ovarian apoplexy may include:
- complete rest;
- cold on the lower abdomen to increase vasospasm and reduce bleeding;
- hemostatic drugs;
- antispasmodics to reduce spasm of smooth muscles and pain relief;
- anti-anemic drugs.
Conservative treatment of mild apoplexy is possible, but does not guarantee the absence of complications. Almost in 86% of patients, on the background of conservative therapy, there is an adhesive process, and in 43% infertility is registered. In addition, conservative therapy increases the risk of recurrence of ovarian apoplexy in every second treated patient.
The high percentage of complications after the non-operative treatment of apoplexy is due to the fact that the blood coming in after the rupture of the ovary into the abdominal cavity is not removed. Over time, it forms numerous clots that are organized and transformed into spikes. Ovary capsule rupture during the conservative treatment can heal incorrectly and provoke a new episode of apoplexy.
Prevent these consequences only surgically, removing blood from the pelvic cavity and correctly restoring the integrity of the ovary.
During the operation, stop bleeding by coagulation( cauterization) of the rupture site or by bandaging the bleeding vessel. If at the time of operation in the ovary there is a cyst, its cavity is opened and carefully removed the contents. Remaining after removal of the cyst, the damaged area coagulates or sutures. In the case of extensive damage to the ovary tissues, it is necessary to resort to resection( excision) of the unreliable site with the subsequent restoration of the integrity of the organ.
The operation is carried out with the most gentle methods to preserve the reproductive function of the ovary. However, it is not always possible to keep the ovary. The removal of the ovary( adnexectomy) is performed in the case of irreversible disorders in its tissues or when apoplexy is combined with another pathology in the appendages.
During laparoscopy, the pelvic cavity is washed and all clots are formed.
Ovarian apoplexy during pregnancy on a background of rupture of a yellow body is subject to surgical treatment. In such a situation, laparoscopy is not performed, as it can provoke a change in intra-abdominal pressure and miscarriage. The ruptured yellow body is sutured without resection to preserve the pregnancy.
Ovary apoplexy is bilateral, often combined with ectopic pregnancy and acute appendicitis. The scope of surgical intervention is determined immediately after a close inspection of all pelvic structures.
A week after laparoscopy, the patient returns to her usual life, but is on dispensary supervision.
Consequences of ovarian apoplexy
The consequences of previous ovarian apoplexy can be divided into early and late complications.
Early complications include negative situations that occurred during surgical treatment or during the postoperative period. The most dangerous complication of rupture of the ovary is hemorrhagic shock - a serious condition that threatens the patient's life, associated with extensive blood loss.
In pregnant women, ovarian apoplexy can provoke an early or late miscarriage.
In case of untimely care, a patient with an ovarian rupture may die. Therefore, it is very important that, at the first symptoms of unwell in the pelvic cavity( especially severe pains), the patient does not aspire to be treated independently, but calls "ambulance".
In case of suspected ovarian rupture, the patient should be in a horizontal position, if possible, behave calmly. It is necessary to place something cold on the stomach and wait for the doctors of the ambulance to arrive. You can take advantage of the products available in the freezer, after placing them in a bag.
The largest number of complications of ovarian apoplexy is among the remote. These include:
- Adhesive process. Ovarian rupture is associated with the release of blood and inflammatory fluid into the surrounding space. During laparoscopy, the pelvic lavage is washed, but sometimes a small amount of blood remains in the abdomen, with time blood clots are formed and form spikes. Also, the adhesion process can develop in the presence of postoperative pelvic inflammatory diseases, the source of adhesion formation is inflammatory exudate in the abdominal cavity.
- Infertility. If the patient has a healthy ovary after the surgery for apoplexy, she has a good chance of becoming pregnant. But such a scenario is possible in the absence of adhesive process and normal hormonal regulation. If the basis of development of apoplexy is hormonal dysfunction, the risk of infertility increases.
- Ectopic pregnancy. In the presence of adhesions, the normal location of the fallopian tubes is disrupted, which leads to a mechanical obstruction to the egg in the uterus, for example, excessive bending of the tube. The egg stops before an obstacle, mistakenly believing that the endometrium has reached, implanted into the wall of the tube and begins to form a pregnancy.
- Recurrent rupture of the ovary. The recurrence of apoplexy can occur due to hormonal and vascular changes.
The largest number of complications occurs after the conservative treatment of apoplexy, when all consequences of rupture of the ovary remain in the abdominal cavity.
Prophylaxis of ovarian apoplexy
There are no clear ideas about methods of preventing ovarian apoplexy. The main goal of any preventive measures is to restore the proper reproductive function. As a rule, in patients with infertility, a complex of therapeutic measures implies prevention of ovarian rupture.
Ovary apoplexy rarely develops without an obvious cause. Even with successful therapy provided that these causes are not eliminated, a relapse of the disease may occur. Measures to prevent recurrences of apoplexy begin after surgical treatment and are aimed at preventing adhesion and restoring the normal rhythm of menstruation. Physiotherapeutic procedures and hormonal treatment are applied. The rehabilitation plan is made individually and takes into account:
- the amount of surgical intervention;
- the presence of relapses of apoplexy;
- presence of concomitant gynecological pathology;
- hormonal status of the patient;
- the state of reproductive function.
As a rule, most cases of ovarian apoplexy are registered among patients with hormonal dysfunction in the presence of cystic formations in the ovaries. In this group of patients, hormonal medication correction of the menstrual cycle is most often used. As a rule, under the influence of hormonal therapy, cyst regression occurs. In the absence of a positive effect of conservative treatment with an increase in the size of ovarian cysts, the question of their surgical removal is being solved.
During treatment the patient should be protected from pregnancy in order to avoid complications. If pregnancy does occur, there is a risk of recurrence of apoplexy, so such patients need a thorough dynamic ultrasound control of the appendages. In the presence of a yellow body cyst for the prevention of hemorrhage, its opening and evacuation of the contents is performed. The yellow body itself should be preserved, since without it continuation of pregnancy is impossible.
Taking into account the possibility of developing ovarian apoplexy in gynecologically healthy women, the measures to prevent its development include:
- elimination of excessive physical exertion, especially during menstruation, as well as stress and hypothermia;
- prevention of inflammatory diseases of the genitals;
- timely correction of hormonal disorders.
The most reliable way to prevent ovarian apoplexy is to visit the gynecologist's office regularly. Any disease is easier to prevent than treat, and the changes detected at an early stage can be eliminated without large losses.
