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Everything about ovarian apoplexy: first symptoms, causes and current methods of treatment. Ovarian apoplexy: causes, symptoms and treatment

Ovarian apoplexy(apoplexia ovarii) is defined as a sudden hemorrhage into the ovary due to rupture of the vessels of the Graafian vesicle, ovarian stroma, follicular cyst or corpus luteum cyst, accompanied by a violation of the integrity of its tissue and bleeding into the abdominal cavity.

Etiology and pathogenesis. Apoplexy has a complex pathogenesis, caused by physiological cyclic changes in blood supply to the pelvic organs. In 90-94% of patients, ovarian apoplexy occurs in the middle and second phase of the menstrual cycle, which is associated with the characteristics of the ovarian tissue. Apoplexy of the right ovary is 2-4 times more common than the left, which is explained by the fact that the right ovarian artery arises directly from the aorta, and the left one from the renal artery.

Predisposes to ovarian rupture inflammatory processes pelvic organs, leading to sclerotic changes both in the ovarian tissue and in its vessels, as well as congestive hyperemia and varicose veins of the ovarian veins. Bleeding from the ovary can be caused by blood diseases and long-term use of anticoagulants. Among exogenous causes include abdominal trauma, physical stress, violent or interrupted sexual intercourse, horse riding, douching, vaginal examination, etc. Endogenous reasons There may be an incorrect position of the uterus, mechanical compression of blood vessels that disrupts blood flow in the ovary, pressure on the ovary by a tumor, adhesions in the pelvis, etc. In a number of patients, ovarian rupture occurs for no apparent reason at rest or during sleep.

The leading role in the pathogenesis of ovarian apoplexy is currently assigned to hormonal imbalances . One of the main causes of ovarian rupture is considered to be an excessive increase in the amount and changes in the ratio of gonadotropic hormones of the pituitary gland, which contributes to hyperemia of the ovarian tissue.

An important role in the occurrence of ovarian apoplexy belongs to dysfunction of the higher parts of the nervous system, recorded by EEG and REG. As a result of stressful situations, psycho-emotional lability, exposure to environmental factors, living conditions.

Ovarian apoplexy is not only a complex of serious disorders of the reproductive system, but also a disease of the entire body involving various levels of the nervous system.

Classification.

There are painful, anemic and mixed forms of ovarian apoplexy.

Also - hemorrhagic form:

I degree - mild (intra-abdominal blood loss does not exceed 150 ml);

II degree - average (blood loss 150-500 ml);

III degree - severe (blood loss more than 500 ml).

Clinic and diagnostics. The main clinical symptom of ovarian apoplexy is sudden pain in the lower abdomen. Weakness, dizziness, nausea, vomiting, and fainting are associated with intra-abdominal blood loss.

Painful form Ovarian apoplexy is observed with hemorrhage into the tissue of the follicle or corpus luteum without bleeding into the abdominal cavity. The disease manifests itself as an attack of pain in the lower abdomen without radiating, sometimes with nausea and vomiting. There are no signs of intra-abdominal bleeding. Clinical picture The painful and mild hemorrhagic form of ovarian apoplexy is similar. Palpation reveals pain in the iliac region, often on the right; there are no peritoneal symptoms. Percussion free fluid in the abdominal cavity is not determined. On gynecological examination, the uterus is of normal size, the ovary is somewhat enlarged and painful. The vaginal vaults are deep and free. Pelvic ultrasound almost never directly visualizes an ovarian rupture, but it can detect fluid accumulation in the retrouterine (pouch of Douglas) space. In the painful form of ovarian apoplexy, there is a small amount of fluid in the pouch of Douglas; it is hypoechoic with a fine suspension (follicular fluid mixed with blood). There are no pronounced changes in the clinical blood test; sometimes moderate leukocytosis is detected without a shift of the formula to the left.

In the clinical picture, moderate to severe hemorrhagic (anemic) form Ovarian apoplexy, the main symptoms are associated with intra-abdominal bleeding. The disease begins acutely and is often associated with external causes (sexual intercourse, physical stress, injury, etc.). Pain in the lower abdomen often radiates to the anus, leg, sacrum, external genitalia, and is accompanied by weakness, dizziness, nausea, vomiting, and fainting. The severity of symptoms depends on the amount of intra-abdominal blood loss.

On examination, the skin and visible mucous membranes are pale, and there is cold, sticky sweat on the skin. Blood pressure is reduced, tachycardia. The tongue is dry, the stomach is tense, there may be slight bloating. On palpation, sharp pain is detected in one of the iliac regions or throughout the hypogastrium. Peritoneal symptoms are most pronounced in the lower sections. Percussion determine free fluid in sloping areas of the abdomen (right, left lateral canals).

During a gynecological examination, the vaginal mucosa is of normal color or pale. Bimanual examination may be difficult due to severe tenderness of the anterior abdominal wall. The uterus is of normal size, painful; on the side of apoplexy, a painful, slightly enlarged ovary is palpated. The vaginal vaults hang over, traction on the cervix is sharply painful.

A clinical blood test shows a decrease in hemoglobin levels, but with acute blood loss in the first hours, an increase in hemoglobin levels is possible as a result of blood thickening. Some patients experience a slight increase in leukocytes without a shift to the left.

Ultrasound of the internal genitalia reveals a significant amount of free fine- and medium-dispersed fluid in the abdominal cavity with irregularly shaped structures of increased echogenicity (blood clots).

To diagnose a disease without pronounced disturbances in hemodynamic parameters, it is used puncture of the abdominal cavity through the posterior vaginal fornix. However, laparoscopy has become the method of choice in diagnosing ovarian apoplexy. Ovarian apoplexy during laparoscopy looks like an ovulation stigma (a small spot with a diameter of 0.2-0.5 cm raised above the surface with signs of bleeding or covered with a blood clot), in the form of a cyst of the corpus luteum in a “collapsed” state, or in the form of the corpus luteum itself with a linear a tear or round tissue defect with or without signs of bleeding.

Treatment . In case of pain and minor intra-abdominal blood loss (less than 150 ml) without signs of increasing bleeding, it can be performed conservative therapy. It includes rest, ice on the lower abdomen (promotes vasospasm), hemostatic drugs (etamsylate), antispasmodics (papaverine, no-spa), vitamins (thiamine, pyridoxium, cyanocobalamin), physiotherapeutic procedures (electrophoresis with chloride calcium, microwave therapy).

With a repeated attack of pain, deterioration in general condition, hemodynamic instability, and an increase in the amount of blood in the abdominal cavity, 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, which is confirmed by physical examination and ultrasound, with stable hemodynamic parameters and satisfactory condition of the patient;

ineffectiveness of conservative therapy for 1-3 days, signs of ongoing intra-abdominal bleeding confirmed by ultrasound;

differential diagnosis of acute gynecological and acute surgical pathology.

Surgical intervention for ovarian apoplexy should be as gentle as possible: coagulation of the rupture site, opening or puncture of the cyst and removal of the contents using aquapurator-suction, resection of the ovary. If the damage is severe and there is no possibility of saving the ovary, it is removed.

Indications for laparotomy:

signs of intra-abdominal bleeding leading to hemodynamic disturbances with a serious condition of the patient (hemorrhagic shock);

impossibility of performing laparoscopy (due to adhesions, increased bleeding from damaged ovarian vessels).

Surgical intervention is performed using an inferomedial approach or a suprapubic Pfannenstiel incision. The scope of the intervention does not differ from laparoscopic. During laparotomy, reinfusion of blood that has spilled into the abdominal cavity is possible.

Prevention . In patients who have suffered a hemorrhagic form of ovarian apoplexy, dysfunction of the higher parts of the central nervous system, changes in hormonal status and disturbances in ovarian blood flow are usually persistent. For 3 months, therapy is carried out to correct the activity of brain structures: nootropics are prescribed to improve metabolic processes in the central nervous system, drugs that improve cerebral perfusion (Cavinton, tanakan, vinpocetine), tranquilizers, and for intracranial hypertension - diuretics. To suppress ovulation and correct the hormonal profile, combined estrogen-gestagen monophasic low- and micro-dose oral contraceptives are used for 3-6 months.

Forecast . With a 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 treatment measures. Decompensated irreversible hemorrhagic shock, which occurs when blood loss exceeds 50% of the blood volume, can lead to death if the ovary ruptures.

The appearance of acute abdominal pain in a woman can signal that a serious problem has arisen - hemorrhage in the ovary. Regular visits to the gynecologist help avoid unpleasant consequences. During childbearing years, you need to know the symptoms of the disease in order to seek emergency help. Under these conditions, there is hope of getting pregnant.

A woman’s body works with enviable regularity. Every month, a follicle is formed in the ovary, which, when fully developed, ruptures, releasing a mature egg. Ovulation occurs, and the corpus luteum forms in the vacant space, producing hormones and preparing the body for pregnancy. With pathologies that arise for various reasons, ovarian rupture can occur - apoplexy. According to the international classification, the disease has ICD-10 code No. 83.

If the ovary bursts (ovarii), the condition is accompanied by sudden acute pain, hemorrhage, life-threatening and having dire consequences. Pathological processes more often occur on the right side, which benefits from intensive blood supply from the aorta. The left ovarii can burst, but less often - it has less nutrition from the renal artery. A woman needs:

quick and accurate diagnosis;
prompt medical assistance.

Based on the symptoms of ovarian tissue rupture, there are 3 forms of apoplexy:

pain – accompanied by nausea, symptoms similar to appendicitis, requiring differential diagnosis to exclude other diseases;
hemorrhagic form - characterized by the presence of signs of bleeding and anemia - pallor, dizziness, fainting;
mixed - combines symptoms of ovarian rupture of both types - painful and anemic forms.

Consequences

It is very important to take the woman to the clinic if symptoms occur. Timely assistance from gynecologists will help avoid insidious consequences, including death due to large blood loss. A tear in the ovary can lead to:

inflammation of the reproductive organs, abdominal cavity;
menstruation disorders;
adhesions due to stagnation of blood in the peritoneum.

In the absence of emergency assistance, serious complications after apoplexy are possible. The following unsafe consequences are likely:

hemorrhagic shock caused by large loss of blood;
peritonitis;
hormonal disorders;
repeated rupture;
sepsis;
during pregnancy - miscarriage;
complete removal of ovarii – oophorectomy;
ectopic pregnancy;
infertility.

There are several reasons why an ovary can burst, including blood diseases and organ displacement. The reason for the violation of integrity is the use of anticoagulants, the moment of ovulation. The causes of ovarian rupture in women are often diseases of the organ itself:

varicose veins;
polycystic disease;
inflammation;
stromal sclerosis;
hyalinosis;
changes in the capillaries of ovarian tissue;
tumors.

There are risk factors that provoke ovarian rupture during ovulation:

abdominal injuries;
physical activity;
stressful state;
lifting weights;
hypothermia;
compression of blood vessels in the abdomen by excess fatty tissue;
horse riding;
too active sex;
improper douching;
interrupted sexual intercourse;
gynecological examination during menstruation;
hormonal imbalance;
stimulating ovulation with medications.

Symptoms

Characteristic signs of a burst ovary are severe pain and bleeding. The disease is accompanied by:

weakness;
nausea;
headache;
stool disorder;
dizziness;
vomiting;
fainting caused by blood loss;
pain radiating to the legs, anus, lower back;
cold sweat;
decreased blood pressure;
tachycardia.

Upon examination, the following symptoms of apoplexy are determined:

tense stomach;
dry mouth;
pale skin;
sharp pain on palpation;
increase in temperature;
frequent urination;
presence of fluid determined by percussion;
disruptions in the functioning of the cardiovascular and respiratory systems;
bloody discharge;
urge to have a bowel movement.

Diagnostics

The pathology has symptoms similar to other diseases. A correct diagnosis of the disease must be made. To rule out other diseases:

invite a urologist or surgeon to a consultation;
organize a patient interview;
perform a gynecological examination;
do a blood test - check the hemoglobin level, the number of leukocytes;
Ultrasound determines the presence of fluid in the peritoneum;
do a laparoscopic examination;
a puncture is performed in the posterior vaginal fornix;
final recognition occurs during surgery.

Treatment of ovarian apoplexy

If there are micro-tears, a painful form of the pathology, or minor blood loss, conservative treatment is carried out. If the condition worsens, tests are poor, there are indications as a result of an ultrasound examination, or increased bleeding, surgical intervention is recommended. Treatment in this situation is carried out using surgical laparoscopy:

coagulation of the rupture zone;
opening the cyst;
suturing small tears;
wedge resection of the ovary;
adnexectomy - removal of the fallopian tubes and appendages in case of serious damage.

Urgent Care

When a woman develops acute abdominal pain, prompt hospitalization is required. If emergency assistance is needed for ovarian apoplexy, you should:

lay the woman on a flat surface;
urgently call an ambulance for hospitalization;
To make an accurate diagnosis in the clinic, it is forbidden to give painkillers at home, apply heat or ice, so as not to distort the picture of the attack.

Conservative treatment

Treatment of a woman with a painful form of the disease, when microapoplexy is observed in the absence of large blood losses, begins in the hospital immediately after the correct diagnosis is made. The procedures are carried out under round-the-clock supervision. Conservative treatment includes:

ensuring peace;
ice for vasospasm in the lower abdomen;
Etamsylate is a hemostatic drug;
antispasmodics – Papaverine, No-Shpa;
vitamins – Thiamine, Cyanocobalamin;
suppositories with Antipyrine;
physiotherapy.

Rehabilitation after ovarian apoplexy

Recovery following treatment is aimed at preventing the appearance of adhesions and realizing the possibility of becoming pregnant. Rehabilitation after ovarian apoplexy involves correction of hormonal pathologies and contraception. Physiotherapy is used to prevent adhesions:

pulsed magnetic field;
electrical stimulation of the fallopian tubes;
laser therapy;
electrophoresis with lidase, zinc;
low frequency ultrasound.

Pregnancy after ovarian apoplexy

Conception following treatment of the disease can occur with partial removal of organ tissue. Pregnancy after ovarian apoplexy is possible if one of them is preserved. The resulting adhesions can create problems. In order for a woman to become pregnant, she must:

undergo diagnostic laparoscopy to assess the situation;
carry out rehabilitation measures;
conduct a course of anti-inflammatory treatment with antibiotics;
restore hormonal levels by taking pills;
protect yourself for at least six months.

Prevention

Unfortunately, after treatment, relapses of the disease are possible. It is possible that apoplectic pathologies may occur in women who have not previously been ill. This is especially dangerous during the childbearing period. Gynecologists recommend taking precautions, paying attention to your health at this time, and coming for examination twice a year.

Prevention covers the following activities:

exclusion of casual contacts to avoid sexually transmitted infections;
timely treatment of inflammation of the reproductive organs, venereal diseases;
monitoring hormonal levels and correcting them;
exclusion of stressful situations;
avoiding physical overload;
correct selection of contraceptives.

Video

The information presented in the article is for informational purposes only. The materials in the article do not encourage self-treatment. Only a qualified doctor can make a diagnosis and give treatment recommendations based on the individual characteristics of a particular patient.

sovets.net

Ovarian apoplexy - Symptoms, Emergency care

Bleeding from the ovary can occur in women at any age, but more often it occurs during the reproductive period, sometimes in girls who are not sexually active. In most cases, the immediate cause of bleeding from the ovary cannot be determined. Most often, ovarian apoplexy occurs when a mature follicle ruptures (days 12-14 of the normal menstrual cycle) or during vascularization of the corpus luteum (days 20-22 of the cycle). Usually there is apoplexy of one ovary, most often the right one.

Symptoms of Ovarian Apoplexy

The picture of the disease depends on the severity and rate of increase in internal bleeding. The pain is acute, localized in the lower abdomen, radiating to the leg, external genitalia and rectum. Due to irritation of the peritoneum by the spilled blood, nausea and often vomiting occur. Subsequently, the pain is accompanied by symptoms of internal bleeding (pallor, cold sweat, increased heart rate, decreased blood pressure, etc.). According to the characteristics of the clinical picture, three forms of ovarian apoplexy are distinguished: painful, anemic and mixed. The painful form has many similarities with the picture of acute appendicitis, and the anemic form has many similarities with the manifestation of an interrupted ectopic pregnancy. In the mixed form, there is a combination of pain and anemic syndrome.

In patients with ovarian apoplexy, the pulse is increased, blood pressure decreases with significant internal bleeding. When palpating the abdomen, tension in the muscles of the anterior abdominal wall and pain on the affected side are determined. Peritoneal phenomena are absent or mild. On vaginal examination, pain is noted when the cervix is displaced. The uterus is not enlarged, dense, the vaginal vaults are painful on the affected side. The uterine appendages are somewhat enlarged on one side and are painful on palpation. In the presence of peritoneal phenomena, palpation of the uterine appendages can be difficult. Sometimes bloody discharge appears from the genital tract (endometrial response to hormonal changes), which resembles the symptoms of a disturbed ectopic pregnancy.

Diagnosis of Ovarian Apoplexy

The diagnosis of ovarian apoplexy in most cases is made during surgery (often the operation is performed due to suspicion of a disturbed ectopic pregnancy). However, in some cases, the correct diagnosis can be made before surgery if the doctor pays attention to the absence of signs of pregnancy (no delayed menstruation, cyanosis of the mucous membranes of the vagina and cervix, enlargement and softening of the uterus, etc.), the coincidence of the onset of the disease with the middle or second half menstrual cycle.

Differential diagnosis for ovarian apoplexy

Differential diagnosis of ovarian apoplexy is carried out with a disturbed ectopic pregnancy, acute appendicitis, inflammation of the uterine appendages, torsion of the pedicle of an ovarian cyst. It should also be taken into account that in some women the process of ovulation is accompanied by the appearance of pain in the middle of the menstrual cycle, but there are no signs of internal bleeding. When differentially diagnosing these forms of pathology, it is necessary to take into account indications in the anamnesis of the recurrence of ovulatory pain, which is absent in ovarian apoplexy.

Emergency care for ovarian apoplexy

If bleeding from the ovary is suspected, hospitalization is necessary, since during the diagnostic process other diseases (see above) that have similar symptoms are excluded. Before transportation, the administration of painkillers is contraindicated. In a hospital setting, the question of the nature of treatment is decided. If the diagnosis of ovarian apoplexy and minor internal bleeding is confirmed, conservative therapy under strict medical supervision is possible. If there is significant internal bleeding, surgery (ovarian resection) is indicated.

doctor-v.ru

Emergency care for ovarian apoplexy.

Apoplexy is a sudden hemorrhage of the ovary due to rupture of the follicle vessels, testicular stroma, follicle cysts, corpus luteum cysts. Most often, ovarian apoplexy occurs when a mature follicle ruptures (days 12-14 of the normal menstrual cycle) or during vascularization of the corpus luteum (days 20-22 of the cycle). Usually there is apoplexy of one ovary, most often the right one. Symptoms The pain is acute, localized in the lower abdomen, radiating to the leg, external genitalia and rectum. Nausea and often vomiting occur. the pain is accompanied by symptoms of internal bleeding (pallor, cold sweat, increased heart rate, decreased blood pressure, etc.). According to the characteristics of the clinical picture, three forms of ovarian apoplexy are distinguished: painful (a picture of appendicitis), anemic (with the manifestation of an interrupted ectopic pregnancy) and mixed. The pulse increases, blood pressure decreases. When palpating the abdomen, tension in the muscles of the anterior abdominal wall and pain on the affected side are determined. Peritoneal phenomena are absent or mild. On vaginal examination, pain is noted when the cervix is displaced. The uterus is enlarged, dense, the vaginal vaults are painful on the affected side. The uterine appendages are somewhat enlarged on one side and are painful on palpation. In wedge analyses: decreased HB, insignificant lecocytosis without shift. Ultrasound: significant amount of fluid in the breast with pages of irregular shape (blood clots). Puncture of the posterior arch; Laparoscopy - ovulation stigma (raised spot, covered with a blood clot, or as a rupture of the uterus, signs of bleeding. Help: Conservative applied in the station under round-the-clock observation (if there is little bleeding, 150 ml) - rest, ice on the lower abdomen (vasospasm), hemostatics (ethamsilate ), antispasmodics, vitamins, PT (microwave, electrophoresis with CaCl). If there is a recurrence of an attack of pain, deterioration of the condition, unstable hemodin, increased blood in the br half-operation intervention. Laparoscopy with blood more than 150 ml, ineffective conster 1-3 days, - coagulation of the rupture site, opening or puncture of the cyst, laparotomy (bleeding with hemodynamic disturbance, hemorrhage shock) - lower medium or Pfannenstiel, blood reinf is possible.

Emergency care for a ruptured ectopic pregnancy. | Emergency care for preeclampsia. | Technique for taking a superficial scraping from the cervix for oncocytological examination. | Emergency care for gynecological peritonitis. | Technique for manual examination of the walls of the uterine cavity. | Write a prescription: contraception for a woman of advanced reproductive age | Write a prescription: vaginal hormonal contraception | Technique of simple and extended colposcopy. | Emergency care in case of uterine rupture. | Write a prescription: a drug to prevent infection with the human papillomavirus??? |

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Emergency conditions in gynecology

“Acute abdomen” in gynecology is a syndrome that develops as a result of acute pathology in the abdominal cavity and is manifested by sudden pain in any part of the abdomen, peritoneal symptoms and pronounced changes in the patient’s condition.

Acute pain in the lower abdomen in women with severe peritoneal symptoms is possible:

with intra-abdominal bleeding (ectopic pregnancy, ovarian apoplexy);
torsion of the pedicle of an ovarian cyst (cystoma);
perforation of purulent formations of the appendages;
pelvioperitonitis.

Risk factors for developing ectopic pregnancy:

previous history of salpingoophoritis, endomyometritis, abortion;
violation of hormonal function of the ovaries;
genital infantilism;
endometriosis;
previous operations on the internal genital organs;
increased trophoblast activity.

In an ectopic pregnancy, the fertilized egg implants and develops outside the uterine cavity. Pregnancy can develop or be disrupted (by the type of tubal abortion and by the type of fallopian tube rupture).

During a tubal abortion, the fertilized egg, not having the appropriate conditions for development, peels off from the walls of the fallopian tube and is expelled into the abdominal cavity. Due to the rhythmic contraction of the fallopian tube, blood enters the abdominal cavity periodically.

When the fallopian tube ruptures (with a delay of menstruation by an average of 3-4 weeks) as a result of a violation of an ectopic pregnancy, the villi of the fertilized egg completely destroy the thin wall of the fallopian tube and blood from the damaged vessels pours into the abdominal cavity.

Ovarian apoplexy (ovarian rupture, ovarian infarction, ovarian hematoma) is an acute violation of the integrity of the ovary with hemorrhage into its stroma and subsequent bleeding into the abdominal cavity. Ovarian apoplexy most often occurs in women of reproductive age, but also occurs in adolescents, more often occurring during the period of ovulation and in the stage of vascularization and flowering of the corpus luteum.

Ovarian rupture occurs due to:

congestive hyperemia;
varicose or sclerotic vessels;
sclerotic changes in the stroma;
dysfunctions of the autonomic and endocrine systems.

A hematoma forms, which causes sharp pain due to an increase in intraovarian pressure, followed by rupture of the ovarian tissue.

Torsion of the pedicle of an ovarian cyst (cystoma) is a complication of an ovarian cyst or cystoma. The onset of the disease is often associated with the following factors:

sudden change in body position;
increased intra-abdominal pressure as a result of strong straining, prolonged coughing, heavy physical work;
impaired blood supply to the cyst.

When the cyst pedicle is torsed, the following is observed:

disturbance of blood supply;
swelling of the cyst;
hemorrhage and necrosis of the parenchyma.

With partial (gradual) torsion:

the leg changes its position by 90–180°;
arterial blood flow is maintained;
venous outflow is difficult due to vascular compression;
Venous congestion and swelling of the cyst wall occur.

In case of complete (sudden) torsion:

the leg changes its position by 360°;
arterial blood flow stops;
necrobiotic processes occur in the ovarian cyst;
peritoneal symptoms appear;
When the cyst becomes infected, peritonitis begins.

Provoking factors for the development of purulent formations of the appendages are:

microbial invasion;
weakening or changing the barrier properties of the uterus and genital tract:
– physiological (menstruation, childbirth);

– iatrogenic (abortion, intrauterine contraceptives, operations, hysteroscopy, in vitro fertilization).

The routes of infection of the appendages can be intracanalicular, ascending, hematogenous, lymphogenous.

The following ectopic pregnancies are distinguished: tubal, ovarian, cervical, in the rudimentary horn, abdominal.

Fallopian tube rupture occurs suddenly and causes:

bleeding, usually massive (intra-abdominal);
pain in the lower abdomen, radiating to the rectum;
dizziness;
weakness;
pale skin;
fainting state.

With continued bleeding, hemorrhagic shock and posthemorrhagic anemia begin. The severity of hemodynamic disorders is directly dependent on the deficit in circulating blood volume.

Ovarian apoplexy is accompanied by: intra-abdominal bleeding (anemic form of apoplexy); pain syndrome (pain form).

The disease begins acutely, with sudden pain in the lower abdomen, mainly on the affected side.

Torsion of the pedicle of an ovarian cyst (cystoma) causes:

pain in the lower abdomen from the side of the mass - gradually increasing or acute;
nausea, vomiting, flatulence;
intestinal paresis;
tension of the anterior abdominal wall;
symptoms of peritoneal irritation.

The clinical picture of inflammatory diseases of the female genital organs, in particular the uterine appendages, is often blurred and asymptomatic. Pyosalpinx, piovar, tubo-ovarian abscess cause:

constant pain in the lower abdomen, mainly due to inflammation;
chills, high fever;
weakness;
tachycardia;
nausea, stool retention, gas;
purulent discharge from the genital tract.

The pain radiates to the lower extremities and lumbar region. The abdomen is soft and may be moderately swollen.

With perforation of purulent formations, mild symptoms of peritonitis appear already in the first hours, which overlap with the clinical picture of a severe inflammatory process and include:

pain is intense, sometimes aching, of unclear localization;
chills, fever, tachycardia;
painful urination;
loose stools;
bloating;
local symptoms of peritoneal irritation.

Possible complications include intra-abdominal bleeding and pelvioperitonitis or peritonitis.

Diagnostics

Symptoms of ectopic pregnancy:

amenorrhea 4–8 weeks, probable signs of pregnancy;
positive immunological reactions to pregnancy;
the size of the uterus is less than the expected pregnancy;
spotting bloody discharge from the genital tract;
unilateral cramping or constant pain;
pain when the cervix is displaced;
unilateral adnextumor;
general disorders (deterioration of general condition, nausea, diarrhea, flatulence).

When the fallopian tube ruptures, the abdomen participates in the act of breathing to a limited extent, is painful on palpation and percussion, symptoms of peritoneal irritation are positive, and upon percussion there is dullness in the sloping areas of the abdomen.

In case of ovarian apoplexy, during examination the following is determined:

in the painful form - pain in the lower abdomen, symptoms of peritoneal irritation are mild;
in the anemic form - signs of intra-abdominal bleeding.

During an objective examination, general signs include behavior, gait, position in the gynecological chair and reaction to pain with facial expressions; color of skin and mucous membranes.

The respiratory rate can be more than 20 beats/min - with peritonitis, acute blood loss.

Tachycardia is always present in “acute abdomen” of any origin, as it is characteristic of fever, hypovolemia, and acute blood loss.

“Acute abdomen” is not accompanied by hypertension. Hypotension is caused either by a septic condition or by hypovolemia due to acute blood loss (tubal rupture, cyst rupture, ovarian apoplexy).

A general objective examination reveals signs of pregnancy: enlargement (engorgement) of the mammary glands, pigmentation of the nipples, and the release of colostrum.

A coated, dry tongue indicates inflammatory processes in the genitals, appendicitis, intestinal obstruction, and peritonitis.

An increase in abdominal volume is observed with large tumors, ascites, intestinal obstruction, peritonitis, intra-abdominal bleeding; lag of the abdominal wall from respiratory excursions - for all causes of “acute abdomen”.

Palpation of the abdomen during peritonitis reveals tension and pain in the abdominal wall, Shchetkin-Blumberg symptom; with bleeding into the abdominal cavity (ovarian apoplexy, rupture of the fallopian tube, rupture of the spleen) - Kulenkampff's symptom, pain and symptoms of irritation of the peritoneum without tension in the abdominal wall.

With intra-abdominal bleeding, inflammatory effusion, ascites, percussion of the abdomen shows dullness in sloping areas (iliac regions), which moves when the body changes to one side.

In a general blood test, leukocytosis, a shift in the leukocyte formula to the left, and an accelerated ESR indicate inflammatory diseases of the genitals; a decrease in hemoglobin level indicates intra-abdominal bleeding.

Puncture of the abdominal cavity through the posterior vaginal fornix reveals the nature of the liquid contents in the abdominal cavity (pus, serous effusion, blood).

An ultrasound is performed to clarify the size of the uterus, identify pathological formations in the uterus and appendages, and the presence of effusion.

Differential diagnosis of fallopian tube rupture is carried out with the following conditions:

ectopic pregnancy (delayed menstruation, subjective signs of pregnancy, bleeding from the genital tract);
acute pancreatitis (girdle pain, intense, poor diet, chronic diseases of the digestive system);
perforated ulcer of the stomach and duodenum;
acute appendicitis;
torsion of the pedicle of an ovarian cyst, etc.

Torsion of the cyst stalk (cystoma) and ovarian apoplexy are differentiated from acute appendicitis and impaired ectopic pregnancy.

Main directions of therapy

In case of intra-abdominal bleeding - administration of blood-substituting solutions (dextrans, starch preparations) up to hospitalization.
Broad-spectrum and long-acting antibiotics (ceftriaxone 1–2 g intravenously or intramuscularly in combination with metronidazole 100 ml intravenously and amoxicillin 2–4 g intravenously in combination with metronidazole 100 ml intravenously).

In case of torsion of the pedicle of the cyst (cystoma) of the ovary, treatment is not carried out at the prehospital stage.

The algorithm for dealing with bleeding in the event of an ectopic pregnancy is presented in the figure.

Clinical pharmacology of individual drugs

Reopolyglucin is a 10% solution of low molecular weight dextran dissolved in an isotonic sodium chloride solution. It has a detoxifying effect, prevents and eliminates the aggregation of blood cells and reduces its viscosity, helps restore blood flow in small vessels. Available in bottles of 200 and 400 ml. Administer intravenously in streams and drips of 400–1000 ml (up to 1500 ml).

Polyglucin (dextran) is a synthetic colloidal plasma substitute that has a colloid-osmotic and hemodynamic effect. Produced in bottles of 200 and 400 ml of 6% solution. Administer intravenously in streams and drips of 400–1200 ml (up to 2000 ml).

Common errors in therapy are: administration of analgesics and delay in hospitalization.

Analysis of clinical cases. The ambulance team was called to the home of a 24-year-old patient who complained of weakness, dizziness, dry mouth, and pain in the lower abdomen radiating to the rectum. The patient became acutely ill 2 hours ago, when the above complaints suddenly arose after coitus.

From the anamnesis, it was possible to find out that the patient’s menstruation began at the age of 12, 6–7 days after 30 days, moderate, painless. The last menstruation began 14 days ago, came on time, and went as usual. Contraception was carried out with the combined oral contraceptive Logest for 4 months.

On examination: the patient's condition is moderate. The skin is pale. The tongue is dry, covered with a white coating. Blood pressure - 90/60 mm Hg. Art., pulse - 92 beats/min, rhythmic. Heart sounds are clear and rhythmic. The abdomen evenly participates in the act of breathing, is somewhat swollen, sharply painful on palpation in the lower parts. The Shchetkin–Blumberg sign is positive in the lower sections.

Probable diagnosis: ovarian apoplexy, intra-abdominal bleeding.

Emergency hospitalization to a gynecological hospital is indicated and, taking into account the presence of intra-abdominal bleeding, the administration of blood replacement solutions (dextrans, starch preparations) is indicated at the pre-hospital stage.

The ambulance team was called to the home of a 20-year-old patient who complained of pain in the left lower abdomen, nausea, vomiting, flatulence, gradually increasing or acute; I fell ill 3 days ago, when, after physical activity, pain first appeared in the lower abdomen, more on the left, which gradually intensified.

From the anamnesis: the patient’s menstruation from 15 years of age was 4–5 days every 30 days, moderate, painless. The last menstruation began 10 days ago, came on time, and went as usual. Sexual life from the age of 17, without contraception. The only pregnancy ended in an induced abortion at 5 weeks, without complications. 2 months ago, during a routine examination, a gynecologist discovered a cyst on the right ovary. No treatment was given.

Objectively: the patient’s condition is of moderate severity. The skin is pale. The tongue is clean and moist. Blood pressure - 110/75 mm Hg. Art., pulse - 78 beats/min, rhythmic. Heart sounds are clear and rhythmic.

The abdomen evenly participates in the act of breathing, is not distended, there is pronounced tension in the muscles of the anterior abdominal wall, symptoms of peritoneal irritation are positive.

Presumable diagnosis: torsion of the pedicle of the right ovarian cyst. The patient is indicated for urgent hospitalization in a hospital. If the pedicle of an ovarian cyst is torsed, no treatment is carried out at the prehospital stage.

Let's give other examples.

The ambulance station received a call from patient E., 34 years old, who 5 hours ago developed intense aching pain of unclear localization, chills, fever, painful urination, loose stools, and bloating. 10 days ago, the patient underwent an ultrasound-guided medical abortion at 8 weeks of pregnancy and removal of an intrauterine contraceptive inserted 7 years ago. After 7 days, cloudy, purulent discharge from the genital tract with an unpleasant odor appeared.

Probable diagnosis: acute bilateral salpingoophoritis, endomyometritis; pelvioperitonitis.

The patient requires emergency hospitalization in a gynecological hospital. At the prehospital stage, infusion, antibacterial, and anti-inflammatory therapy is indicated.

The ambulance station received a call from patient D., 28 years old, who 3 hours ago, after lifting weights, developed pain in the lower abdomen, which gradually intensified, as well as nausea, vomiting, and dry mouth. From the medical history, it was possible to find out that the patient’s last normal menstruation was 3 weeks ago, came on time, and was more scanty. It is necessary to make a differential diagnosis between acute appendicitis, torsion of the pedicle of an ovarian cyst, and impaired tubal pregnancy.

The patient is indicated for urgent hospitalization in a gynecological hospital.

Taking into account the possibility that the patient had a torsion of the pedicle of the ovarian cyst, no treatment was carried out at the prehospital stage.

A. Z. Khashukoeva, Doctor of Medical Sciences, Professor Z. Z. Khashukoeva RGMU, Moscow

www.lvrach.ru

2018 Blog about women's health.

- an emergency condition in gynecology, characterized by a sudden violation of the integrity (rupture) of ovarian tissue. With ovarian apoplexy, hemorrhage occurs in the ovarian tissue, bleeding of varying severity into the abdominal cavity and acute pain syndrome. Diagnosis is based on general examination methods, results of puncture of the posterior vaginal vault, pelvic ultrasound, and laparoscopy. Treatment of ovarian apoplexy is often emergency surgical – organ-preserving or radical. With timely assistance and the absence of complications (peritonitis, adhesions), the prognosis for life and subsequent pregnancy is favorable.

General information

Synonyms apoplexy of the ovary serve as hematoma, heart attack, ovarian rupture. Ovarian apoplexy occurs in 1-3% of all women with gynecological pathology, most often at the age of 20-35 years. Apoplexy of the right ovary develops more often, which is associated with its richer blood supply from the right ovarian artery, which arises directly from the aorta. The right ovary is characterized by larger size, weight and a more developed lymphatic system. The blood supply to the left ovary is provided by the left ovarian artery, which branches off from the renal artery.

Based on clinical and morphological characteristics, hemorrhages from follicular ovarian cysts, mature follicles during ovulation, ovarian stroma, corpus luteum cysts, and dysfunctional ovaries are distinguished. Ovarian apoplexy causes intra-abdominal bleeding in 0.5-2.5% of patients.

Causes of ovarian apoplexy

The development of ovarian apoplexy is pathogenetically related to the specifics of ovarian tissue. Predisposing factors are the peculiarities of blood supply to the pelvic organs, changes in the permeability of the ovarian vessels in different phases of the ovarian menstrual cycle. If there are changes in the vascular walls as a result of expansion and blood filling of the vessels, their permeability may increase until their integrity is damaged.

The background against which ovarian apoplexy occurs can be dystrophic and sclerotic changes in the ovarian tissue due to polycystic ovary disease, varicose veins of the ovary, oophoritis, inflammation of the appendages, miscarriage, etc. The likelihood of ovarian apoplexy increases due to drug stimulation of ovulation, which can lead to disturbances in the processes of ovulation and the formation of the corpus luteum. Some authors cite neuroendocrine disorders, accompanied by changes in the properties of the vessels of ovarian tissue, as well as the use of anticoagulants, as the causes of ovarian apoplexy.

Ovarian apoplexy can be provoked by abdominal trauma, physical overexertion, horse riding, sports activities, violent or interrupted sexual intercourse and other moments associated with increased intra-abdominal pressure. However, ovarian apoplexy is also observed in the absence of provoking factors. Often, ovarian rupture correlates with the development of appendicitis. Ovarian apoplexy can occur at any phase of the menstrual cycle, but more often it happens during ovulation or on the eve of menstruation, when the content of gonadotropic hormones reaches its peak. It is also possible that ovarian apoplexy may occur due to delayed menstruation.

Classification of forms of ovarian apoplexy

Taking into account the prevailing symptoms, the following forms of ovarian apoplexy are distinguished: anemic or hemorrhagic form with a predominance of symptoms of bleeding into the abdominal cavity; painful form, in which there is severe pain without signs of internal bleeding; mixed form, combining the symptoms of anemic and painful forms of ovarian apoplexy.

However, since in reality ovarian apoplexy is always accompanied by bleeding of varying severity, it is now customary to divide the pathology into degrees of severity. Taking into account the amount of bleeding, mild, moderate and severe degrees of ovarian apoplexy are distinguished.

Symptoms of ovarian apoplexy

The main manifestations of ovarian apoplexy are pain and signs of internal bleeding.

Pain syndrome during ovarian apoplexy occurs acutely and is localized in the lower abdomen; There may be irradiation of pain to the umbilical or lumbar region, rectum, perineum. The pain can be of a different nature - constant or paroxysmal, stabbing or cramping. The painful attack lasts from half an hour to several hours, periodically returning during the day.

The development of bleeding during ovarian apoplexy is accompanied by a decrease in blood pressure, increased and weakened pulse, pallor of the skin, general weakness, dizziness, fainting, chills, dry mouth, vomiting, frequent urination, and the urge to defecate. After a delay in menstruation, bloody discharge from the genital tract is often observed. Without emergency measures, intra-abdominal bleeding can progress and pose a serious threat to the patient's life.

A mild degree of ovarian apoplexy is characterized by spontaneous short-term pain attacks, nausea, absence of peritoneal phenomena and shock. Ovarian apoplexy of moderate severity occurs with severe pain, general weakness, vomiting, fainting, mild peritoneal phenomena, and first-degree shock. In severe ovarian apoplexy, severe constant pain, bloating, vomiting, collapse, cold sweat, tachycardia, stage II-III shock, severe peritoneal symptoms, and a decrease in hemoglobin by more than 50% of normal are noted. The clinic of ovarian apoplexy can grow under the guise of ectopic pregnancy, acute appendicitis, uterine pregnancy, torsion of ovarian cyst, renal colic, acute pancreatitis, peritonitis, which requires careful differential diagnosis.

Diagnosis of ovarian apoplexy

Typically, patients with ovarian apoplexy are hospitalized with a diagnosis of “acute abdomen”. To clarify the causes of the pathology, surgeons, gynecologists, and urologists are involved in the diagnosis. Ovarian apoplexy requires quick and accurate recognition, since increasing bleeding aggravates the condition and can threaten the woman’s life. For the differential diagnosis of ovarian apoplexy, it is important to conduct a gynecological examination on a chair, measure hemoglobin, perform a puncture of the posterior vaginal vault, pelvic ultrasound, and laparoscopy.

Characteristic signs of ovarian apoplexy are complaints of acute abdominal pain in the middle of the menstrual cycle or its second half. During general examination and palpation, attention is drawn to pain on the side of the involved ovary, abdominal distension, and positive peritoneal symptoms. In a general blood test for ovarian apoplexy, a noticeable decrease in hemoglobin and leukocytosis are noted. To exclude ectopic pregnancy, blood is tested for hCG.

During a vaginal examination, the gynecological nature of the pathology is clarified: sharp pain in the lateral and posterior vaults, pulsation of the vessels of the vaults are revealed, and in the case of massive hemorrhage, bulging of the posterior vault. When the cervix moves to the sides, severe pain occurs. The size of the uterus is usually unchanged, sometimes slightly enlarged, and the consistency is dense. The affected appendage is painful, enlarged to the size of a chicken egg, has an elastic consistency and limited mobility. With ovarian apoplexy, blood discharge from the genital tract is possible.

During puncture of the posterior vaginal fornix for ovarian apoplexy, blood or serous-bloody fluid is obtained. The ultrasound picture of ovarian apoplexy is characterized by the presence of free fluid in the abdomen, signs of hemorrhage into the ovarian tissue on the affected side. For the final diagnosis of ovarian apoplexy and elimination of bleeding, laparoscopy is indicated.

Treatment of ovarian apoplexy

Conservative tactics are possible only in mild cases of ovarian apoplexy in the absence of obvious signs of internal bleeding. Conservative measures for ovarian apoplexy include the appointment of strict rest, cold on the stomach, suppositories with belladonna, antispasmodics, vitamins, and hemostatic drugs. After the acute period subsides, diathermy, electrophoresis with calcium chloride, and Bernard currents are performed. If signs of increased bleeding appear, immediate surgery is indicated.

Prevention of ovarian apoplexy

In order to prevent the occurrence or recurrence of ovarian apoplexy, it is necessary to treat existing gynecological diseases (adnexitis, oophoritis, PCOS, STDs, etc.), exclude provocative factors, and observe a gynecologist. If ovarian apoplexy is suspected, it is necessary to provide the patient with rest, place her in a horizontal position, put cold on her stomach and call an ambulance.

Symptoms of Ovarian Apoplexy

Diagnosis of Ovarian Apoplexy

Differential diagnosis for ovarian apoplexy

Emergency care for ovarian apoplexy

Bleeding from the ovary can occur in women
at any age, but more often it occurs in the reproductive period, sometimes -
in girls who are not sexually active. In most cases it is impossible
It is impossible to determine the exact cause of bleeding from the ovary. More often
In total, ovarian apoplexy occurs when a mature follicle ruptures
(12-14th day of the normal menstrual cycle) or during vascular
tion of the corpus luteum (20-22nd day of the cycle). Apoplexy usually occurs
one ovary, usually the right one.
Symptoms The picture of the disease depends on the severity and speed of
cessation of internal bleeding. The pain is acute, localized in the lower
parts of the abdomen, radiates to the leg, external genitalia and straight
gut. Due to irritation of the peritoneum by the spilled blood, nausea occurs.
and often vomiting. Subsequently, the pain is accompanied by symptoms of internal
bleeding (pallor, cold sweat, increased heart rate, decreased
blood pressure, etc.). According to the characteristics of the clinical picture, different
There are three forms of ovarian apoplexy: painful, anemic and mixed.
The painful form has many similarities with the picture of acute appendicitis, and
anemic - with the manifestation of an interrupted ectopic pregnancy. At
mixed form is a combination of pain and anemic syndrome.
In patients with ovarian apoplexy, the pulse is increased, blood pressure
with significant internal bleeding it decreases. When palpating the abdomen
tension in the muscles of the anterior abdominal wall and pain in the
side of the lesion. Peritoneal phenomena are absent or mildly expressed
bo. Vaginal examination reveals pain when displaced
cervix. The uterus is not enlarged, dense, vaginal vaults are painful
on the losing side. The uterine appendages are slightly enlarged on one side
us, painful on palpation. In the presence of peritoneal phenomena, palpation
tion of the uterine appendages can be difficult. Sometimes from the genital tract appears
there is bleeding (endometrial response to hormonal
changes), which resembles the symptoms of a disturbed ectopic pregnancy
ness.
The diagnosis of ovarian apoplexy in most cases is made in
time of surgery (often the operation is performed due to suspected abnormalities
suspected ectopic pregnancy). However, in a number of cases, the correct diagnosis
Nose can be diagnosed before surgery if the doctor pays attention to the
absence of signs of pregnancy (no delay in menstruation, cyanosis of mucous membranes)
zous membranes of the vagina and cervix, enlargement and softening of the uterus
etc.), coincidence of the onset of the disease with the middle or second half
menstrual cycle.
Differential diagnosis of ovarian apoplexy is carried out with impaired
ectopic pregnancy, acute appendicitis, inflammation of the appendages
uterus, torsion of the pedunculated ovarian cyst. It should also be taken into account that
For some women, the ovulation process is accompanied by the appearance in the middle
menstrual cycle pain syndrome, but signs of internal bleeding
there are no implications. In the differential diagnosis of these forms
pathology, it is necessary to take into account indications in the anamnesis of the recurrence of ovu-
latory pain, which is absent with ovarian apoplexy.
Emergency care and hospitalization. If you suspect bleeding from
ovary requires hospitalization, since the diagnostic process excludes
There are other diseases (see above) that have similar symptoms. Before
During transportation, the administration of painkillers is contraindicated. IN
hospital conditions decide the nature of treatment. Upon confirmation
diagnosis of ovarian apoplexy and minor internal bleeding is possible
conservative therapy under strict medical supervision. If
In cases of internal bleeding, surgery (ovarian resection) is indicated.