Ovarian apoplexy (ovarian rupture): causeseffects

Update: October 2018

Ovarian apoplexy refers to emergency conditions and requires
emergency medical care, often operational
interventions. Compared with other gynecological
diseases, this pathology occurs quite often and
makes 17% or 3 place in structure of female diseases. The reasons
разрыва яичника разнообразны, а effects при несвоевременно или
inadequate treatment can be very sad
(infertility as a result of pronounced adhesions).

ATнутрибрюшное кровотечение, которое имеет место при ряде
gynecological diseases, in 0.5 – 2.5% due to apoplexy
ovary. Symptoms of ovarian rupture are most often diagnosed in
young women (20 – 35 years), but the occurrence of pathology is possible and
in other age groups (14 – 45 years).

Ovaries: Anatomy and Function

The ovaries are the sex glands (female gonads) and
refer to paired organs. Located in the pelvis, in which
fasten with ligaments (mesentery and suspending ligament of the ovary). One
from the ends facing the fallopian tube (the egg that came out of the ovary
immediately enters the tube). In appearance, the ovaries resemble peach
bones and scarred – traces of past ovulations,
the formation and disappearance of yellow bodies. The size of the bodies is small:
20-25 mm wide and up to 35 mm long. ATес яичников достигает 5 – 10
gram. The blood in the gonads comes from the ovarian arteries,
moreover, the right ovarian artery branches immediately from the abdominal aorta,
in view of which its diameter is somewhat larger, and the right blood supply
body is better. Accordingly, the right gland is large
compared to the left.

AT функции половых гонад входит образование эстрогенов и
androgens (in small quantities), and most importantly, production
ovum ready for fertilization.

Oocytes are formed from follicles that have been laid yet
at the stage of intrauterine development of the fetus.

The female sex glands are made up of:

  • germinal epithelium (covers the organ from above and delimits
    him from neighboring organs);
  • the tunica alba is composed of connective tissue and contains
    elastic fibers);
  • parenchyma, which has 2 layers: outer (cortical) and
    internal (cerebral).

AT корковом слое железы располагаются незрелые фолликулы и
ripening. Reaching a state of maturity (graphs bubble),
the follicle bulges somewhat above the surface of the gland and
torn from where the finished egg comes out (ovulation phase). By
as the egg enters and advances through the tube at the site of the former
a bursting follicle forms a yellow body – the second stage of the cycle.
The corpus luteum actively produces progesterone, necessary for
support of the coming pregnancy. If conception did not happen,
the corpus luteum undergoes a process of reverse development (involution) and
becomes a white body (connective tissue), which over time
disappears completely.

ATнутренний (мозговой) слой находится в самом глубине желез,
It has a well-developed circulatory system and nerve endings.

Pathology definition and classification

Byд термином «апоплексия яичника» подразумевают кровоизлияние в
him which happened suddenly amid integrity breach
(tearing) of ovarian tissue. The disease is accompanied
progressive bleeding in the abdomen and severe pain
syndrome. Other pathology names are ovarian rupture or
hematoma, less heart attack. Hemorrhage in the gonad can
to happen when the cyst of the corpus luteum ruptures, at the time of injury
vessels graafovogo vesicle or organ stroma.

The disease is divided:

Forms:

  • painful form (it is also called pseudoapppendicular) –
    characterized by severe pain, which
    accompanied by nausea and fever;
  • anemic form (or hemorrhagic) – according to the clinic is similar to
    rupture of the tube during ectopic pregnancy, cardinal
    the sign is intra-abdominal bleeding.
  • mixed – signs of both forms are combined.

By величине потери крови и проявлений клинических признаков
distinguish degrees:

  • light (the volume of blood that is poured out is 0.1 – 0.15 liters);
  • medium (blood loss is 0.15 – 0.5 liters);
  • heavy (free blood in the abdomen exceeds 0.5 liters).

Anemic and painful forms are diagnosed equally often.

The reasons и механизм развития

AT механизме развития заболевания лежат нейроэндокринные
disorders and inflammation of the internal genital organs.
ATследствие этих факторов в яичниках развиваются склеротические
changes, and in the vessels of the small pelvis stagnation of blood, which leads to
varicose ovarian veins. Due to a variety of changes in blood vessels
genital gonad (their varicose dilatation, hardening of the vascular
walls), hyperemia and inflammation of ovarian tissue, education
many small cysts of the wall of the ovarian vessels become
inferior, their permeability increases, which provokes
further rupture of the vessel / vessels.

First, a hematoma forms in the ovary, which causes
sharp pain as a result increase the pressure in the ovary. Then from
excessive vnutriyashnikovogo pressure vessel / vessels bursts that
leads to bleeding, often massive (even with a small
break).

Ovarian apoplexy occurs in any phase of the cycle, but more often in
ovulatory and luteal (second). During this period increases
blood flow to the genital glands, the yellow body blossoms, and
possibly forming a luteal cyst. Probability does not exclude
rupture of the corpus luteum in the first trimester of pregnancy.

It is characteristic that the right ovary is often torn, which is explained
its best blood supply compared to the left.

The reasons

The reasons, которые создают благоприятный фон для разрыва яичника
(endogenous factors):

  • inflammation of the ovaries / appendages;
  • varicose ovarian veins (provoke severe
    physical labor, repeated pregnancies, hormonal intake
    contraceptives, hyperestrogensia);
  • anomalies of the location of the genital organs (retroflection or bend
    uterus, ovarian compression by a tumor of a neighboring organ);
  • adhesions in the pelvis, especially when constricting the ovary
    adhesions;
  • diseases of the blood coagulation system;
  • sclerocystic ovaries (the protein membrane becomes too
    dense, breaking it with ovulation “requires considerable effort from
    follicle “).

External causes (exogenous) that increase the risk
ovarian apoplexy:

  • rough sex or interrupted sexual intercourse (the influx increases
    blood to the reproductive glands and increases intra-arterial
    pressure);
  • heavy lifting, sudden movements (tilting, turning) or heavy
    physical labor);
  • abdominal trauma (hit, fall on the belly);
  • drug stimulation of ovulation (one of the side effects
    Clomiphene, which stimulate ovulation is education
    luteal cysts, which is fraught with apoplexy of ovarian cysts);
  • defecation (increase in intra-abdominal pressure);
  • horse riding (shaking);
  • rough gynecological examination;
  • visiting the bath, sauna;
  • long reception of anticoagulants.

Practical example

A young woman entered the gynecological department at night. 22
years with signs of intra-abdominal bleeding. Preliminary
diagnosis after inspection and abdominal puncture through the posterior
vaginal arch: “Apoplexy of the left ovary, mixed form.” AT
history of sclerocystic ovary, no pregnancies during
years of regular sexual life (the patient recently married). Was
recorded in the queue for a paid laparoscopic surgery
for sclerocytosis of the ovaries in the regional hospital (operation
appointed a week after admission to our hospital). ATо
laparotomy in the abdominal cavity detected liquid blood with
clots up to 900 ml, the gap of the right ovary about 0.5 mm. Held
resection of both ovaries, sanitation of the abdominal cavity and stratified
wound closure tightly. The postoperative period without complications
discharged in satisfactory condition.

The cause of ovarian rupture in this case was sclerocystic.
The woman had, one can say, the first independent ovulation.
in life, which led to a rupture of the gland and bleeding. With another
hand, the patient did not have to go for a paid operation
(resection of both ovaries was planned).

After 5 months, the woman was registered for pregnancy in our
female consultation.

Clinical picture

Signs of ovarian apoplexy depend on intensity.
bleeding and concomitant (background) gynecological pathology.
AT клинической картине превалирующими симптомами апоплексии яичника
are intra-abdominal bleeding and severe pain.  AT случае
mixed forms of pathology are equally revealed signs
internal bleeding and pain.

Pains

AT большинстве случаев боли возникают внезапно, характер их
sharp, very intense, and often a painful attack precedes
provoking factors (hypothermia, sudden movements, rapid
sex). It is possible and the emergence of pain on the background of complete well-being,
for example, in a dream. Occasionally on the eve of an acute pain attack
a woman may notice a weak dull / aching pain or tingling in
left or right iliac region. Such aching pains are caused
small hemorrhages (hematoma formation) in the ovarian tissue,
either swelling or redness of the gland. Localization of the patient’s pain
more often they determine exactly, lower abdomen, right or left, are possible
lower back pain. Acute pain due to irritation of the nerves
receptors in the ovarian tissue, as well as gushing blood in the abdominal
cavity and peritoneal irritation. ATозможна иррадиация боли в ногу,
under and above the collarbone, into the sacrum, the anus or into the perineum.

Signs of internal bleeding

ATыраженность симптомов при внутрибрюшном кровотечении зависит от
the amount of spilled blood in the abdomen, intensity and
prescription bleeding. With moderate to severe (blood loss
is more than 150 ml) to the forefront are signs of acute
anemia, and in severe cases of hemorrhagic shock. Arterial
pressure drops sharply, the patient feels very weak, possible
fainting. The pulse, skin, and mucous membranes become more frequent and weaker.
pale appear nausea / vomiting, signs join
peritoneal irritation (peritoneal symptoms). The patient complains
dry mouth, thirst, skin is cold, with perspiration.

Other symptoms

Also for this pathology is characteristic, but not always, the appearance
intermenstrual minor bleeding either
hemorrhage on the background of delayed menses The patient complains частое
urination and urge to stool (rectal irritation
poured out blood).

Gynecological and general examination

A general inspection confirms the picture of the internal
bleeding (pale, cold and wet skin,
tachycardia and low blood pressure, peritoneal symptoms,
abdominal distention).

A gynecological examination reveals: pallor of mucous membranes
vagina and cervix, smooth or overhanging posterior vaginal
arch (with large blood loss), painful and enlarged right
or left ovary. The uterus “floats” in the pelvis during palpation, and
the displacement behind the neck hurt.

Diagnostics

Only in 4 – 5% can a correct diagnosis be made, which is quite
explainable. Признаки заболевания схожи  с клиникой других
pathological processes. Differential diagnosis is carried out
with:

  • interrupted ectopic pregnancy;
  • acute adnexitis;
  • rupture of ovarian cysts;
  • pyosalpinx and its rupture;
  • appendicitis;
  • renal colic;
  • acute pancreatitis;
  • perforation of gastric ulcers;
  • intestinal obstruction.

Patients carefully collect complaints and study the history, conduct
general and gynecological examination, after which they are appointed
additional research methods:

  • Oak

Determination of red blood cells and hemoglobin is determined (the degree of their
reduction depends on the volume of blood loss), slight leukocytosis,
increase in ESR.

  • Coagulogram
  • Pelvic ultrasound

Inspection of the ovaries and determination of their size, taking into account the phase
menstrual cycle and the state of another gland. Damaged
The ovary is somewhat large, its stroma is determined
hypoechoic or heterogeneous in structure formation – yellow
body. The diameter of the yellow body is not larger than the maturing
follicle, and the follicular apparatus of the reproductive gland is normal
(liquid inclusions up to 4 – 8 mm). Behind the uterus is visualized
free liquid.

  • Culture Center

Puncture of the abdominal cavity through the posterior vaginal fornix
confirms / refutes the presence of liquid blood in the thoracic
a space that does not fold if apoplexy is “fresh”
or contains small clots – “old” bleeding.

  • Laparoscopy

Minimally invasive intervention, allowing not only to clarify
diagnosis, but also to carry out surgical treatment. AT процессе осмотра
are detected:

  • bleeding into the abdominal cavity, with or without clots;
  • enlarged, purple ovary with rupture, which either
    bleeds, or clot clogged;
  • the uterus is of normal size;
  • inflammatory changes in the tubes (crimpiness, hyperemia, thickening,
    spikes);
  • pelvic adhesions.

AT случае выраженного хронического спаечного процесса или
признаков геморрагического шока  проведение лапароскопии
contraindicated and proceeds to immediate therapeutic and diagnostic
laparotomy.

Treatment

Treatment патологии осуществляется в стационаре, так как все
patients come with symptoms of “acute abdomen” and in emergency
okay �”Sharp belly” requires not only a thorough diagnosis,
but also monitoring the patient’s condition. ATозможны 2 варианта лечения
diseases.

Conservative therapy

Conservative treatment is allowed for patients with
small blood loss (up to 0.15 l), which have already implemented their
reproductive function (children are and no longer planned). AT комплекс
Therapeutic interventions include:

  • Strict bed rest

Patient movements can provoke and strengthen the calmed down.
bleeding from the ovary, as well as increase the pain attack.

  • Cold

ATсем больным сразу же после проведения диагностических
events assigned to the cold on the lower abdomen (rubber heater with
ice), which causes vasospasm, stops bleeding and
reduces pain.

  • Hemostatic drugs

Also, hemostatic agents are administered to stop bleeding:
этамзилат, аскорбиновая кислота, викасол, витамины AT1, AT6 и
AT12.

  • Analgesics and antispasmodics

Baralgin, Drotaverinum, but-shpa effectively stop pain
attack.

  • Iron preparations

They are prescribed for antianemic purposes (tardiferone, sorbifer,
phenols).

Surgery

Surgery is performed either laparoscopically or
laparotomy access. Laparoscopic preference is given.
operations, especially in the case of women who in the future plan
pregnancy. Advantages of laparoscopic access:

  • psychological comfort (no rough scars in the area
    belly);
  • quick recovery from anesthesia;
  • early activation of the patient;
  • short time in hospital;
  • less use of painkillers after surgery
    about ovarian rupture;
  • low risk of formation of adhesions and preservation of reproductive
    functions.

Laparotomy is carried out in severe condition of the patient
(hemorrhagic shock) and in case of impossibility of performance
laparoscopy (lack of equipment, significant adhesions
abdominal process cavities).

Stages of surgery:

  • hemostasis (hemostasis) from the damaged ovary
    (coagulation, gap closure or wedge resection possible
    glands);
  • removal of blood and clots from the abdominal cavity;
  • sanitation (washing) with antiseptic solutions (aqueous solution
    chlorhexidine, saline).

Very rarely do you have to perform an ovariectomy – complete removal
ovary (in case of massive hemorrhage in the ovarian tissue).

Rehabilitation

After surgery for ovarian apoplexy patient
rehabilitation activities:

Prevention of adhesions

Actively appointed physiotherapy (starting from 3 – 4 days
postoperative period):

  • low frequency ultrasound;
  • SMT;
  • low intensity laser therapy;
  • electrostimulation of the fallopian tubes;
  • therapeutic electrophoresis (with zinc, lidazoy,
    hydrocortisone);
  • УATЧ.

ATосстановление гормонального фона

Patients after a rupture of the ovary are recommended to take
low-dose oral contraceptives for 1 – 3
months.

Dispensary registration

ATсе женщины, перенесшие апоплексию яичника подлежат
mandatory dispensary registration in the antenatal clinic for
of the year. The first inspection is appointed in a month, then in 3 and 6.

Effects

The prognosis in most cases after a rupture of the ovary (especially in
случае консервативного лечения)  благоприятный. But not
the consequences are excluded:

Adhesion process

Conservative therapy или отдаление сроков операции в 85%
cases leads to the formation of adhesions in the pelvis. By this
contributes to the presence of blood and clots in the abdomen, which with
time organized and cause the formation of adhesions. Besides,
provokes the occurrence of adhesions duration of the operation, open
abdominal wound (with laparotomy), the presence of chronic inflammation
appendages and complicated postoperative period.

Infertility

Infertility развивается у 42% больных, чему способствует
intensive spike formation, hormonal imbalance and chronic
inflammatory diseases of the ovaries and appendages. But if after
apoplexy and surgery remains healthy one
the ovary, the chances of getting pregnant in the future are great.

Disease recurrence

Repeated apoplexy of both damaged and healthy ovaries
occurs in 16% (according to some data in 50%) of cases
contribute to background diseases (hormonal imbalance,
chronic adnexitis).

ATнематочная беременность

ATозрастает риск возникновения эктопической беременности за счет
formation of adhesions in the pelvis, torsion and bending of the uterine
pipes.

ATопрос – ответ

How long after surgery are in the hospital?

As a rule, after surgery
ovarian apoplexy in the hospital, patients are 7 to 10 days.
Early discharge is performed after laparoscopic access and
smooth postoperative period.

I was undergoing conservative treatment for 3 days in
the hospital about the painful form of ovarian apoplexy. Laparoscopy
did not do an ultrasound and treated with hemostatic drugs.
ATыписали с улучшением, но дома я снова почувствовала боли, которые
give the lower back and anus, plus the temperature has risen to
37.5. What to do?

ATам необходимо срочно обратиться к гинекологу и возможно
perform laparoscopic surgery. ATсе признаки указывают на
continued ovarian bleeding and concomitant
inflammation. AT случае приступа острой боли немедленно вызывайте
ambulance

When can I start sex life after surgery (gap
ovary)?

About a month later.

How quickly you can get pregnant after surgery (apoplexy
ovary)?

AT случае отсутствия фоновых гинекологических болезней, приема
KOC only for a month after surgery, ovulation and conception
possible in the second menstrual cycle after surgery
treatment.

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