Evaluation and management of ruptured ovarian cyst
- Howard T Sharp, MD
Howard T Sharp, MD
- Section Editor — Gynecologic Surgery
- Professor and Vice Chair for Clinical Activities
- Department of Obstetrics and Gynecology
- University of Utah Health Sciences Center
Rupture of an ovarian cyst is a common occurrence in women of reproductive age . Physiologic cysts, such as a follicular cyst or corpus luteal cyst, or pathologic cysts may rupture (endometriomas, cystic components of benign or malignant neoplasms). In the normal menstrual cycle, the physiologic rupture of small follicular cysts that occurs with every ovulatory cycle is not typically clinically significant. This cyclic event is generally asymptomatic or associated with mild mid-cycle pain (also referred to as mittelschmerz).
Ovarian cyst rupture results in release of cyst fluid or blood that may irritate the peritoneal cavity. Dermoid cysts contain sebaceous fluid, hair, fat, bone, or cartilage, and rupture of these cysts results in severe peritoneal irritation. Surgical management is usually required for rupture of a dermoid cyst.
Most women with a ruptured ovarian cyst may be managed with observation, analgesics, and rest, but some women require surgery. Decisions regarding management are based upon patient characteristics, including the severity of symptoms, presence or ongoing bleeding and/hemodynamic instability, and the presumptive histologic diagnosis.
Diagnosis and management of women with a ruptured ovarian cyst are reviewed here. The diagnosis and management of adnexal masses that are not ruptured is discussed separately. (See "Approach to the patient with an adnexal mass" and "Differential diagnosis of the adnexal mass" and "Ultrasound differentiation of benign versus malignant adnexal masses".)
EPIDEMIOLOGY AND RISK FACTORS
The incidence of ruptured ovarian cysts is uncertain.
- Bottomley C, Bourne T. Diagnosis and management of ovarian cyst accidents. Best Pract Res Clin Obstet Gynaecol 2009; 23:711.
- Westhoff C, Clark CJ. Benign ovarian cysts in England and Wales and in the United States. Br J Obstet Gynaecol 1992; 99:329.
- Raziel A, Ron-El R, Pansky M, et al. Current management of ruptured corpus luteum. Eur J Obstet Gynecol Reprod Biol 1993; 50:77.
- Milsom I, Korver T. Ovulation incidence with oral contraceptives: a literature review. J Fam Plann Reprod Health Care 2008; 34:237.
- Kim JH, Lee SM, Lee JH, et al. Successful conservative management of ruptured ovarian cysts with hemoperitoneum in healthy women. PLoS One 2014; 9:e91171.
- Yian MT, Chen HJ, Chu TY, Yin CS. Postcoital hemoperitoneum without identifiable bleeding source: a case report. Zhonghua Yi Xue Za Zhi (Taipei) 1996; 58:291.
- Mandato VD, Pirillo D, Ciarlini G, et al. Postcoital haemperitoneum without vaginal injury, a clinical challenge. Aust N Z J Obstet Gynaecol 2010; 50:580.
- McColgin SW, Williams LM, Sorrells TL, Morrison JC. Hemoperitoneum as a result of coital injury without associated vaginal injury. Am J Obstet Gynecol 1990; 163:1503.
- Abduljabbar HS, Bukhari YA, Al Hachim EG, et al. Review of 244 cases of ovarian cysts. Saudi Med J 2015; 36:834.
- Dafopoulos K, Galazios G, Georgadakis G, et al. Two episodes of hemoperitoneum from luteal cysts rupture in a patient with congenital factor X deficiency. Gynecol Obstet Invest 2003; 55:114.
- Müller CH, Zimmermann K, Bettex HJ, et al. Near-fatal intra-abdominal bleeding from a ruptured follicle during thrombolytic therapy. Lancet 1996; 347:1697.
- Gupta N, Dadhwal V, Deka D, et al. Corpus luteum hemorrhage: rare complication of congenital and acquired coagulation abnormalities. J Obstet Gynaecol Res 2007; 33:376.
- Peters WA 3rd, Thiagarajah S, Thornton WN Jr. Ovarian hemorrhage in patients receiving anticoagulant therapy. J Reprod Med 1979; 22:82.
- Somers MP, Spears M, Maynard AS, Syverud SA. Ruptured heterotopic pregnancy presenting with relative bradycardia in a woman not receiving reproductive assistance. Ann Emerg Med 2004; 43:382.
- Adams SL, Greene JS. Absence of a tachycardic response to intraperitoneal hemorrhage. J Emerg Med 1986; 4:383.
- Jansen RP. Relative bradycardia: a sign of acute intraperitoneal bleeding. Aust N Z J Obstet Gynaecol 1978; 18:206.
- Uharcek P, Mlyncek M, Ravinger J. Elevation of serum CA 125 and D-dimer levels associated with rupture of ovarian endometrioma. Int J Biol Markers 2007; 22:203.
- Lucey BC, Varghese JC, Anderson SW, Soto JA. Spontaneous hemoperitoneum: a bloody mess. Emerg Radiol 2007; 14:65.
- Barnes AD. Nonsurgical management of a large hemoperitoneum from a ruptured corpus luteum: A 15-year study. The Female Patient 2005; 30:29.
- Teng SW, Tseng JY, Chang CK, et al. Comparison of laparoscopy and laparotomy in managing hemodynamically stable patients with ruptured corpus luteum with hemoperitoneum. J Am Assoc Gynecol Laparosc 2003; 10:474.
- Koshiba H. Severe chemical peritonitis caused by spontaneous rupture of an ovarian mature cystic teratoma: a case report. J Reprod Med 2007; 52:965.
- Togami S, Kobayashi H, Haruyama M, et al. A very rare case of endometriosis presenting with massive hemoperitoneum. J Minim Invasive Gynecol 2015; 22:691.
- Ye M, Huang L, Wang Y. A massive haemorrhage caused by rupture of cystic cervical endometriosis. J Obstet Gynaecol 2012; 32:498.
- Reif P, Schöll W, Klaritsch P, Lang U. Rupture of endometriotic ovarian cyst causes acute hemoperitoneum in twin pregnancy. Fertil Steril 2011; 95:2125.e1.
- Tsai HJ. Suitable timing of surgical intervention for ruptured ovarian endometrioma. Taiwan J Obstet Gynecol 2015; 54:105.
- Kim JH, Jeong SY, Cho DH. Massive hemoperitoneum due to a ruptured corpus luteum cyst in a patient with congenital hypofibrinogenemia. Obstet Gynecol Sci 2015; 58:427.
- Terzic M, Likic I, Pilic I, et al. Conservative management of massive hematoperitoneum caused by ovulation in a patient with severe form of von Willebrand disease--a case report. Clin Exp Obstet Gynecol 2012; 39:537.
- Singh N, Tripathi R, Mala YM, et al. Massive spontaneous intraperitoneal hemorrhage in a young female with chronic immune thrombocytopenic purpura masquerading as ruptured ovarian cyst: successful nonsurgical management of this rare catastrophic event. Pediatr Emerg Care 2015; 31:284.
- Shamshirsaz AA, Shamshirsaz AA, Vibhakar JL, et al. Laparoscopic management of chemical peritonitis caused by dermoid cyst spillage. JSLS 2011; 15:403.
- Chen L, Ding J, Hua K. Comparative analysis of laparoscopy versus laparotomy in the management of ovarian cyst during pregnancy. J Obstet Gynaecol Res 2014; 40:763.
- EPIDEMIOLOGY AND RISK FACTORS
- CLINICAL PRESENTATION
- Pelvic or abdominal pain
- Physical examination
- Laboratory tests
- Imaging studies
- DIFFERENTIAL DIAGNOSIS
- Uncomplicated cyst rupture
- Heavy or ongoing blood loss
- - Surgical procedure
- Special clinical situations
- - Ruptured teratoma
- - Ruptured endometrioma
- - Bleeding diathesis
- - Infection
- - Suspected malignancy
- PREGNANT WOMEN
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS