Ovarian apoplexy

Ovarian apoplexy (apoplexia ovarii) is defined as the sudden bleeding into the ovary rupture of blood vessels Grafova of the bubble, the stroma of the ovary, follicular cysts or cyst of a yellow body, accompanied by violation of the integrity of its tissues and bleeding into the abdominal cavity.

Ovarian apoplexy occurs in age from 14 to 45 years, often in 20-35 years. However, the known cases of hemorrhage of the ovary in young girls. The frequency of apoplexy of the ovary among gynecologic pathology is 1-3. The recurrence of the disease reaches 42-69.

Apoplexy has a complex pathogenesis, due to physiological cyclic changes in blood supply to the pelvic organs. Most researchers distinguish "critical moments" for damage to the ovary. So, 90-94 patients with ovarian apoplexy occurs in the middle and in the second phase of the menstrual cycle. This is due to the ovarian tissue, in particular with increased vascular permeability and an increase in their blood during ovulation and before menstruation.

The right ovary apoplexy occurs 2-4 times more frequently than the left, due to more abundant circulation of the right ovary, since the right ovarian artery departs directly from the aorta, and the left - from the renal artery.

To the rupture of the ovary predispose inflammation of the pelvic organs, leading to sclerotic changes in ovarian tissue (sclerosis of stroma, fibrosis epithelial elements, perioophoritis), and its vessels (sclerosis, hyalinosis), as well as congestive redness and varicose ovarian veins. Bleeding from the ovary may contribute to diseases of the blood and long-term use of anticoagulants, resulting in impairment of blood coagulation. These conditions create the background for exogenous and endogenous factors leading to apoplexy of the ovary. Among the exogenous factors distinguish abdominal trauma, physical stress, turbulent or interrupted intercourse, horseback riding, douching, a vaginal examination, etc. Endogenous causes can be improper position of the uterus, mechanical compression of the vessels that violate the blood flow in the ovary, the pressure on the ovarian tumor, adhesions in the pelvis, etc. In some patients the rupture of the ovary occurs for no apparent reason at rest or during sleep.

Lead role in the pathogenesis of apoplexy of the ovary is currently discharged to the disturbance of the hormonal status. One of the main causes of rupture of the ovary is considered excessive increase in the number and changing the ratio of gonadotropic pituitary hormones (FSH, LH, prolactin), which contributes to congestion of the ovarian tissue.

Important role in the occurrence of apoplexy ovarian dysfunction belongs higher divisions of the nervous system, recorded with EEG and REG. As a result of stressful situations, emotional lability, environmental factors, living conditions.

Ovarian apoplexy is not only a complex of serious violations of the reproductive system, but also a disease of the whole organism involving the various levels of the nervous system.

Classification.

Secrete pain, anemic and mixed forms of apoplexy of the ovary. Clinic staff, G. M. Savelyeva was a classification that takes into account the severity of intra-abdominal blood loss:

• Painful form.
• Hemorrhagic form:
  • Grade I - mild (intra-abdominal blood loss does not exceed 150 ml)-
  • Grade II - medium (blood loss 150-500 ml)-
  • III degree - the heavy (intra-abdominal blood loss more than 500 ml).

The main clinical symptom of apoplexy of the ovary is sudden pain in the lower abdomen. The pain associated with irritation of the receptive fields of the ovarian tissue and the impact on the peritoneum of extravasated blood, and with spasm in the pool of the ovarian artery.

Weakness, dizziness, nausea, vomiting, fainting associated with intra-abdominal blood loss.

Painful ovarian apoplexy occurs when hemorrhage into the tissue of the follicle or the corpus luteum without bleeding into the abdominal cavity. The disease manifests itself as an attack of lower abdominal pain without irradiation, sometimes with nausea and vomiting. Signs of intra-abdominal bleeding is not.

The clinical picture of pain and easy haemorrhagic form of apoplexy of the ovary are similar.

During the inspection of the skin and visible mucous regular color. Heart rate and blood pressure within normal limits. Tongue clean, moist. The abdomen was soft, although perhaps a slight muscle tension anterior abdominal wall in the lower divisions. Palpation tenderness in the iliac region, usually on the right, no peritoneal signs. Percussion free fluid in the abdominal cavity is not defined. On examination the uterus is normal size, the ovaries are enlarged and painful. The vaginal vault is deep, loose. Ultrasound of the pelvic organs almost never allows to visualize directly the rupture of the ovary, but it is possible to detect the accumulation of fluid in papadimitrou (dupacova) space. When the pain ovarian apoplexy is a small amount of fluid in dupacova space, it is hypoechoic with a finely dispersed suspension (follicular fluid mixed with blood). In clinical analysis of blood no pronounced changes, sometimes revealed a moderate leukocytosis without shift formula to the left.

The clinical picture is average and severe bleeding (anemia) forms of apoplexy of the ovary the main symptoms are associated with intra-abdominal bleeding. The disease begins acutely, often due to external causes (sexual intercourse, physical stress, trauma, etc.). Pain in the lower abdomen often radiating to the anus, leg, pelvis, external genitals, accompanied by weakness, dizziness, nausea, vomiting, fainting. The severity of symptoms depends on the amount of intra-abdominal blood loss.

During the inspection of the skin and visible mucous membranes pale, the skin cold clammy sweat. Blood pressure decreased, tachycardia. Tongue dry, abdomen tense, perhaps minor swelling. On palpation determined sharp pain in one of the iliac regions, or the entire hypogastrium. Peritoneal symptoms are most pronounced in the lower divisions. Percussion to identify free fluid in the sloping areas of the abdomen (right, left side channels).

During gynecological examination vaginal mucosa normal color or pale. Bimanual examination may be difficult because of severe tenderness of the anterior abdominal wall. Uterus normal in size, painful, side apoplexy palpable painful, slightly enlarged ovary. The vaginal vault hanging, traction past the cervix sharply painful.

In clinical analysis of blood marked decrease in hemoglobin, but in acute blood loss in the first hours may increase the level of hemoglobin as a result of thickening of blood. Some patients have noted a slight increase in leukocytes without shift formula to the left.

When ultrasound examination of internal genitalia is determined by a considerable number of free small and medium (fluid in the abdominal cavity with the structures of irregular shape, increased echogenicity (blood clots).

To diagnose the disease without obvious violations of hemodynamic parameters used puncture of abdominal cavity through posterior vaginal fornix. However, the method of choice in the diagnosis of apoplexy of the ovary has become laparoscopy. Apoplexy of the ovary during a laparoscopy looks like the stigma of ovulation (elevated above the surface of a small spot diameter of 0.2-0.5 cm with signs of bleeding or covered by a blood clot), in the form of a cyst of a yellow body in "collapsed" state or in the form of the yellow body with a line break or a rounded defect tissue with signs of bleeding with or without them.

Treatment of patients with ovarian apoplexy depends on the form of the disease and the severity of intra-abdominal bleeding. When pain form and minor intra-abdominal blood loss (150 ml) with no signs of increase bleeding can be performed conservative therapy. It includes rest, ice on the lower abdomen (promotes spasm of blood vessels), preparations haemostatic action (etamzilat), antispasmodics (papaverine, no-Spa), vitamins (thiamin, pyridoxine, cyanocobalamin), physiotherapy (electrophoresis with calcium chloride, SHF-therapy).

Conservative therapy is carried out in a hospital under constant supervision. With repeated attack of pain, deterioration of General condition, hemodynamic instability, increasing the amount of blood in the abdominal cavity clinically and on ultrasound scan appear the indication to surgery (laparoscopy, laparotomy).

Indications for laparoscopy:

• more than 150 ml of blood in the abdominal cavity, as confirmed by physical examination and ultrasound, with stable hemodynamic and satisfactory condition of the patient-
• the ineffectiveness of conservative therapy within 1 to 3 days, signs of ongoing intra-abdominal bleeding, confirmed by ultrasound
• differential diagnosis of acute gynecological and acute surgical pathology.

Surgery if apoplexy of the ovary should be as sparing: coagulation of a rupture, opening or puncture of the cyst and removal of the contents by using acupuntura-suction, resection of the ovary. For large lesions and the absence of the possibility of preservation of the ovary is removed.

Indications for laparotomy:

• signs of intra-abdominal bleeding leading to hemodynamic instability with severe condition of the patient (hemorrhagic shock)-
• the inability laparoscopy (due to adhesions, enhance bleeding from damaged blood vessels of the ovary).

Surgery perform Nizhneserginsk access or a suprapubic Pfannenstiel incision. The scope of the intervention does not differ from the laparoscopic. Laparotomy for possible reinfusion of blood extravasated into the peritoneal cavity.

In patients with painful ovarian apoplexy CNS disorders, hormonal profile and blood circulation in the ovary reversible, in connection with which specific preventive measures required. Patients who have undergone hemorrhagic ovarian apoplexy, dysfunction of the higher divisions of the Central nervous system, changes hormonal status and violations of the ovarian blood flow is usually persistent. These patients demonstrate the complex drug therapy, tearing pathogenetic vicious circle. Within 3 months of therapy, corrective activity of brain structures: prescribe nootropics to improve metabolic processes in the Central nervous system, drugs that improve cerebral perfusion (Cavinton, tanakan, Vinpocetine), tranquilizers, with intracranial hypertension - diuretics. To suppress ovulation and correcting the hormonal profile within 3-6 months of use combined estrogen-progestin monophasic low and microdose available oral contraceptive pill (marvelon, regulon, Janine, femoden, select, novinet, mercilon, LOGEST).

Forecast. When the pain ovarian apoplexy forecast favorable for life. In patients with hemorrhagic form the prognosis depends on the timeliness of diagnostic and therapeutic interventions. Fatal rupture of the ovary may result decompensated irreversible hemorrhagic shock, occurs when blood loss is more than 50 BCC.

Preventive measures help to reduce the frequency of relapses.

Gynecologist