Background
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.
Pathophysiology
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. Chemical peritonitis can lead to further complications, such as fistula and adhesion formation. [7]
Prognosis
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.
Complications
The hemoperitoneum that results from a ruptured hemorrhagic ovarian cyst can pose a risk of hypovolemic shock. [8]
Li et al reported the case of a menopausal woman with a ruptured dermoid cyst, in whom peritonitis and bowel adhesions were discovered during surgery. Although dermoid cysts are benign, complications from their rupture include chemical peritonitis, bowel obstruction, and abscesses. [9]
