How long does it take for the ovary to heal after ovarian apoplexy? The mechanism of ovarian apoplexy when surgery is required

In classical gynecology, ovarian apoplexy is a partial or complete rupture of an organ under the influence of internal or external traumatic factors. Violation of the integrity of the parenchyma usually occurs suddenly. If an ovary bursts, a woman requires emergency surgical care, since there is a high probability of death due to painful shock and large blood loss.

Ovarian apoplexy and its typical symptoms are discussed in the proposed material; you can also learn about the causes and methods of treating rupture. In 100% of diagnosed cases, an emergency operation is performed, the consequences of which depend on the scale of the internal catastrophe that has occurred. Long-term rehabilitation is required in the postoperative period. Symptoms of ovarian rupture and forms of treatment can be determined based on the diagnostic data obtained from ultrasound and laparoscopy.

It must be remembered that after surgery, in the short term, there may be a recurrence of the pathology, so the first signs of ovarian apoplexy should be known and taken into account when any pain syndrome occurs in the abdominal cavity. The structure of ovarian tissue is such that it is constantly restored.

Ovarian apoplexy is a dangerous condition

External and internal causes of ovarian rupture

The causes of apoplexy or ovarian rupture in a woman may include external and internal pathogenetic influence factors. For a general understanding, it is necessary to first talk about the physiological processes occurring in these organs.

Their structure is follicular, adapted for the constant reproduction and maturation of eggs released by a certain date of the menstrual cycle. As the egg develops, it reaches a diameter of up to 2 cm, after which the follicle bursts and the process of ovulation begins (preparation for fertilization and movement of the egg to the entrance to the uterine cavity. The follicle does not resolve, but continues to develop with the formation of the corpus luteum. This is a formation capable of producing estrogens in large quantities. In the absence of internal pathologies, the woman does not experience any discomfort and the cycle ends with menstruation or pregnancy. Ovarian apoplexy occurs only in the presence of pathological changes in the tissue.

However, if there are degenerative changes in the follicular and parenchymal tissue, cycle disturbances may occur. The egg either cannot leave the follicle and continues to develop inside the ovary, rupturing it, or leaves behind a hematoma that gradually increases in size.

The main causes of apoplexy or ovarian rupture in a woman may include:

1. adhesions;
2. inflammatory diseases of the pelvic organs;
3. polycystic disease and other neoplasms;
4. sclerosis and dystrophy of the choroid;
5. pharmacological intervention in the ovulation process;
6. injuries to the previous abdominal wall and falls from a height;
7. improper use of oral contraceptives;
8. venereal infections in the chronic phase of their course.

For the purpose of prevention, you should undergo regular examinations, have a moderate sex life, protect yourself from falls, blows, and unusual physical activity involving the abdominal muscles.

Forms of apoplexy of the left and right ovary

The most common forms of ovarian apoplexy are pain, anemia due to blood loss and a mixed complex of symptoms. The safest form for life is the painful form, in which there is no bleeding. It can be treated conservatively without surgery.

The mixed form of ovarian apoplexy is a case that is difficult to diagnose. Many acute pathologies in the pelvic cavity can manifest similar signs. So, in particular, apoplexy of the right ovary often gives reason to suspect acute appendicitis. And apoplexy of the left ovary can be masked as sigmoiditis, the consequences of prolonged constipation, or rupture of a tube during an ectopic pregnancy.

The anemic type of pathology development is determined by a number of specific signs indicating constant blood loss. There may not be any allocations. Pain with apoplexy of this type is present to a moderate degree.

In clinical diagnosis, it is important to determine the status of the patient’s condition and the extent of damage to the burst organ. The condition is classically categorized as mild, moderate and severe.

Clinical signs and symptoms

The development of this gynecological pathology is usually acute and sudden. Clinical signs of ovarian apoplexy can manifest as severe pain in the lower abdomen from the affected organ. Bilateral forms of ruptures are an extremely rare phenomenon and practically never occur in modern gynecology.

The characteristics of the pain syndrome with ovarian apoplexy include the following parameters:

• occurs approximately on the 14th day from the beginning of the menstrual cycle;
• intensifies gradually with increasing amplitude;
• localized on one side;
• radiates to the rectal area (may cause difficulty in defecation);
• causes aches and pains in the lumbosacral spine.

Symptoms of ovarian apoplexy, accompanied by internal bleeding, can be characterized as follows:

• a sharp or gradual decrease in blood pressure as the severity of blood loss increases;
• tachycardia with an increase in heart rate to 100 - 110 beats per minute;
• there is severe thirst and dry mouth;
• body temperature may rise to subfebrile levels;
• dizziness, nausea, vomiting, chills are present.

Upon examination, pallor of the skin, dry mucous membranes, shortness of breath, and increased heartbeat are noted. The patient may complain of bloody discharge during periods between menstruation. The history, shortly before the onset of such signs, may include physical exertion, nervous shock, falls and blows, and sexual intercourse.

Differential diagnosis is of great importance. According to medical statistics of surgical interventions, making a correct diagnosis for this pathology occurs only in 5% of women who come with characteristic complaints. This is due to the fact that the clinical picture of ovarian apoplexy is typical for many other acute pathologies. Differentiation is made between an attack of acute appendicitis and a developing ectopic pregnancy with rupture of the fallopian tube.

For diagnostic purposes, a puncture of the posterior vaginal vault is performed in order to obtain reliable information about the presence of intracavitary bleeding. A general blood test shows a sharp decrease in hemoglobin levels and the absence of eosinophilia. An ultrasound examination of the pelvic cavity reveals an enlarged corpus luteum and an accumulation of hemorrhagic effusion in the formed follicle cavity in the ovary.

To avoid negative consequences after this pathology...

Very often, after ovarian apoplexy, hormonal dysfunction and, in some cases, secondary infertility develop. The earlier the pathology is diagnosed, the higher the chances of complete restoration of a woman’s reproductive health.

In order to avoid negative consequences after this pathology, you must adhere to the following recommendations:

1. if a pain attack develops in the abdominal area, stop taking any painkillers (antispasmodics are especially dangerous, as they can significantly increase bleeding);
2. lie down in bed and do not make sudden movements;
3. call an ambulance immediately;
4. Before the doctor arrives, you can apply cold to the anterior abdominal wall, but you can keep it for no longer than 20 - 30 minutes.

The consequences of ovarian apoplexy can be minimized with the help of properly carried out comprehensive rehabilitation after surgery. It is important to engage in therapeutic exercises to prevent the development of adhesive disease. In some cases, correctional or hormone replacement therapy may be required.

Treatment of ovarian apoplexy is not always surgery

Surgery is not always required to eliminate the resulting pathology. If the rupture is small and the patient does not have a clinical picture of large blood loss, conservative therapy is possible. In this case, treatment of ovarian apoplexy begins with the appointment of strict bed rest. A laparoscopic examination of the pelvic cavity is performed. During its implementation, it is possible to eliminate the gap. This method is not advantageous, since secondary infertility, obstruction of the fallopian tubes and many other changes often develop.

By the way, such complications are not observed with laparoscopic intervention.

Surgery for ovarian apoplexy can be abdominal or laparoscopic. The second type of surgical intervention can be performed for any form of pathology and severity of damage to the appendages.

When performing a surgical intervention, the doctor is always faced with the primary task of preserving the reproductive function of the woman’s body. To this end, it is necessary, as far as possible, to preserve the ovary by eliminating its rupture and preventing further blood loss.

After the operation, rehabilitation and restorative therapy is carried out. Physiotherapy is prescribed: electrophoresis and magnetic field, ultrasound and laser. It is important to properly organize your diet and regularly do special gymnastics under the guidance of an instructor. This will prevent the development of complications. It is recommended to plan pregnancy after ovarian apoplexy no earlier than after 6 menstrual cycles.

In the ovaries of a sexually mature woman, follicles grow and the eggs in them mature, that is, preparation for the upcoming pregnancy. From the beginning of the menstrual cycle, the dominant follicle begins to grow, which by the middle of the menstrual cycle reaches its maximum size - about 20 mm. Then the follicle membrane ruptures, releasing a mature egg - ovulation occurs. In place of the burst follicle, a temporary formation is formed - the corpus luteum, which produces certain hormones that prepare the woman’s body for pregnancy. This is the normal course of the ovarian cycle.

With dystrophic and sclerotic changes in ovarian tissue, which occur during acute and chronic inflammatory processes in the uterine appendages, with polycystic ovary syndrome and some other diseases, as well as with drug stimulation of ovulation, certain disturbances occur in the process of ovulation and the formation of the corpus luteum. As a result, the blood vessels at the site of the ovarian rupture contract poorly, intra-abdominal bleeding continues and intensifies, and in the corpus luteum, due to the fragility of the vessels, a hemorrhage is formed - a hematoma. All this is accompanied by pain, weakness, dizziness, nausea, vomiting, pale skin, and fainting. Without appropriate treatment, internal bleeding can intensify, creating a real threat to the health and life of a woman. Factors that provoke ovarian rupture also include excessive physical stress, violent sexual intercourse, horse riding, etc.

Frequency and forms of ovarian apoplexy

Ovarian apoplexy (ovarian rupture) is a sudden rupture (violation of the integrity) of ovarian tissue, accompanied by bleeding into the abdominal cavity and pain.

Among the causes of intra-abdominal bleeding, 0.5-2.5% are due to apoplexy of the ovary.

There are 3 forms apoplexy of the ovary depending on the prevailing symptoms:

1. Painful form, when there is severe pain, but there are no signs of intra-abdominal bleeding.
2. Anemic form, when the symptoms of internal (intra-abdominal) bleeding come first.
3. The mixed form combines the signs of painful and anemic forms of ovarian apoplexy.

However, according to modern data, this classification is considered inferior, since ovarian rupture without bleeding is impossible.

Therefore, this pathology is currently divided into several degrees of severity: mild, moderate and severe (depending on the amount of blood loss).

Symptoms of ovarian apoplexy

Clinical symptoms of apoplexy are associated with the main mechanism of development of this pathology:

1. Pain syndrome that occurs primarily in the middle of the cycle or after a slight delay in menstruation (when a corpus luteum cyst ruptures, for example). The pain is most often localized in the lower abdomen. Sometimes pain can radiate to the rectum, lumbar or umbilical region.
2. Bleeding into the abdominal cavity, which may be accompanied by:

• decrease in pressure,
• increased heart rate,
• weakness and dizziness,
• syncope,
• chills, increased body temperature up to 38°C,
• one-time vomiting,
• dry mouth.

Sometimes you may experience intermenstrual bleeding or bleeding after a missed period.

Quite often, ovarian apoplexy occurs after sexual intercourse or exercise in the gym, that is, under certain conditions when the pressure in the abdominal cavity increases and the integrity of the ovarian tissue is possible. However, ovarian rupture can occur even against the background of complete health.

Causes of ovarian apoplexy

Causes contributing to the occurrence of ovarian apoplexy:

1. Pathological changes in blood vessels (varicose veins, sclerosis).
2. Preceding inflammatory processes in ovarian tissue.
3. The moment of ovulation.
4. Stage of vascularization of the corpus luteum (middle and second phase of the cycle).

Risk factors contributing to the occurrence of ovarian apoplexy:

1. Injury.
2. Lifting weights or strenuous physical activity.
3. Violent sexual intercourse.

Diagnosis of ovarian apoplexy

According to the literature, the correct clinical diagnosis of ovarian apoplexy is only 4-5%.

Diagnostic errors are explained, first of all, by the fact that the clinical picture of this disease does not have a characteristic picture and develops like another acute pathology in the abdominal cavity and pelvis.

The patient is brought to the hospital with a diagnosis of “Acute abdomen”. The cause is determined in the hospital.

As a rule, in the case of an “acute abdomen” clinic, consultation with related specialists (surgeons, urologists) is also necessary.

Since ovarian apoplexy is an acute surgical pathology, the diagnosis must be made very quickly, since increasing the time before surgery leads to an increase in blood loss and can be a life-threatening condition!

The most informative research methods are:

1. Characteristic complaints are acute, appearing in the middle or second half of the menstrual cycle.
2. On examination, severe pain is noted on the affected ovary, and symptoms of peritoneal irritation also become positive.
3. A decrease in hemoglobin levels may be observed (with anemic and mixed forms of ovarian apoplexy)
4. Puncture of the posterior fornix, which allows you to confirm or refute the presence of intra-abdominal bleeding.
5. An ultrasound examination that allows you to see a large corpus luteum in the affected ovary with signs of hemorrhage into it and/or free fluid (blood) in the abdomen.
6. Laparoscopy, which allows not only to establish a 100% diagnosis, but also to correct any pathology.

The final diagnosis of ovarian apoplexy is almost always made during surgery.

What to do if you have apoplexy:

1. Immediately assume a horizontal position.
2. Urgently call an ambulance for hospitalization in a surgical or gynecological hospital.

Treatment of ovarian apoplexy

1. Conservative treatment is possible only in cases of mild form apoplexy of the ovary, which is accompanied by minor bleeding into the abdominal cavity.

Patients with a mild form of apoplexy complain primarily of pain in the lower abdomen.

However, data from many researchers prove that with conservative management of such patients, adhesions form in the pelvis in 85.7% of cases, and infertility is recorded in 42.8% of cases.

Almost every 2nd woman after conservative management may experience a relapse (repeated apoplexy of the ovary). This is because blood and clots that accumulate in the abdominal cavity after an ovarian rupture ( apoplexy of the ovary), are not washed out, as during laparoscopy, they remain in the abdominal cavity, where they organize and contribute to the formation of adhesions in the pelvis.

As a rule, the cyst capsule is removed, coagulation or suturing of the ovary is performed. In rare cases, massive hemorrhage may require removal of the ovary.

During the operation, it is necessary to thoroughly rinse the abdominal cavity, remove clots and blood, to prevent the formation of adhesions and infertility.

Rehabilitation measures for ovarian apoplexy

Rehabilitation measures after an ectopic pregnancy should be aimed at restoring reproductive function after surgery. These include: prevention of adhesions; contraception; normalization of hormonal changes in the body. To prevent adhesions, physiotherapeutic methods are widely used:

During the course of anti-inflammatory therapy and for another 1 month after completion, contraception is recommended, and the issue of its duration is decided individually, depending on the age of the patient and the characteristics of her reproductive function. Of course, a woman’s desire to preserve reproductive function should be taken into account. The duration of hormonal contraception is also highly individual, but usually it should not be less than 6 months after surgery.

After completing rehabilitation measures, before recommending that the patient plan the next pregnancy, it is advisable to perform diagnostic laparoscopy, which allows assessing the condition of the fallopian tube and other pelvic organs. If control laparoscopy does not reveal pathological changes, then the patient is allowed to plan a pregnancy in the next menstrual cycle.

Ovarian apoplexy invades a woman’s life unexpectedly. Many people have heard that modern techniques make it possible to do this without surgery. Is this really so, what are the symptoms of ovarian apoplexy and what treatment method allows us to avoid complications with this disease, we will look into it below.

The ovaries are paired reproductive organs. With the help of ligaments they are attached to the pelvis. Their weight is only 5-10 grams. Externally, the ovaries resemble peach pits, covered with grooves - traces of multiple ovulations and corpus luteum. The main role of the ovaries is to contain eggs capable of fertilization.

Ovarian apoplexy is considered an acute gynecological pathology. In this condition, there is a sudden rupture of the blood vessels of the ovary and hemorrhage in its tissue. Then the blood from the ovary goes beyond its boundaries.

With ovarian apoplexy, a woman needs urgent medical attention, because serious blood loss can result: in some cases, up to 2 liters of blood can leak into the abdominal cavity, which is extremely life-threatening.

Most often, the disease can occur in the middle of the cycle or at the stage of maturation of the corpus luteum, when the ovary is maximally permeated with loose blood vessels. Typically, apoplexy occurs in women at the age of maximum ovarian function (18–40 years).

While a woman retains the ability to become pregnant, an egg matures in her ovaries. At the end of the cycle (ovulation period), the eggs are released into the abdominal cavity. Instead of a follicle, a corpus luteum appears in the ovary, which lives up to two weeks without fertilization.

Bleeding during apoplexy can be observed from:

• ovarian vessels;
• follicles and their cysts;
• Corpus luteum cysts.

Most often, a failure occurs at some phase of the ovarian cycle, then the vessels become damaged, defective, lose their ability to contract and are easily damaged. Rupture of the follicle walls results in the appearance of a cavity with blood (hematoma). First, the blood accumulates in it, and then flows into the abdominal cavity.

Ovarian hemorrhage may occur repeatedly.

Typically, ovarian apoplexy occurs in the second half of the cycle. It is during this period that the follicle and corpus luteum are maximally entwined with the vascular network. In this case, the luteinizing hormone of the pituitary gland, produced during the ovulation period, plays an important function. Apoplexy is sometimes possible in the first trimester of pregnancy.

Mechanism of apoplexy

In order for this disease to appear, the body must have serious neuroendocrine disruptions and inflammation in the ovaries. These pathological changes entail stagnation of blood in these organs with their expansion and sclerosis. The consequence of such disorders is the appearance of varicose veins of the ovarian veins. The ovarian tissue itself becomes inflamed, and the walls of their vessels become excessively permeable, forming many small cysts. The development of a hematoma with the release of blood from the affected vessels contributes to a “jump” in pressure in the ovary. With such a complex of problems, it is elementary to provoke rupture of blood vessels. The right ovary, which is almost always better supplied with blood, is especially often ruptured.

Causes

Ovarian apoplexy is provoked by complex vascular disorders. In addition, a number of internal (endogenous) or external (exogenous) reasons can contribute to the development of this pathology in the body.

The following factors may serve as internal impulses responsible for the development of ovarian apoplexy:

• abnormalities of the genital organs (incorrectly positioned uterus);
• the appearance of varicose veins of the ovaries (due to hormonal contraceptives, frequent pregnancies, heavy physical activity, excess estrogen);
• compression of the ovary by a tumor or constriction by adhesions;
• blood clotting pathologies;
• ovarian sclerocystosis (when there is a load on the ovary due to the density of its membrane).

Ovarian apoplexy can occur due to:

• injuries to the abdominal area (fall, blow);
• lifting weights or sudden movements of the body (jumping, running, turning, bending);
• rough sex;
• active douching;
• interrupted sexual intercourse (due to increased blood flow and increased pressure in the vessels of the genital organs);
• side effects of certain hormonal drugs (clomiphene, which stimulates ovulation, but also promotes the formation of cysts, long-term use of anticoagulants);
• a rough examination by a gynecologist (with speculum at the time of ovulation);
• the appearance of constipation (due to increased intra-abdominal pressure);
• after riding (due to shaking);
• visiting a sauna or steam bath.

In some cases, ovarian apoplexy occurs without any provoking factors, against the background of delayed menstruation or simultaneously with the development of appendicitis.

Symptoms

Ovarian rupture is an acute condition. That is, it can occur suddenly and, if treated incorrectly or untimely, threaten the reproductive function or even the life of a woman.

Ovarian apoplexy is manifested by two main symptoms:

• abdominal pain;
• symptoms of internal bleeding.

Pain in this condition is characterized by:

• manifestations in the lower abdomen;
• sharpness and suddenness;
• variety of character: paroxysmal or constant, cramping or stabbing;
• recoil to the navel, lower back, perineum, rectum;
• lasting from half an hour to several hours, stopping and returning during the day.

Internal bleeding may occur:

• dizziness;
• weakness;
• weakening and increased heart rate;
• pale face;
• decrease in pressure;
• dry mouth;
• chills;
• vomiting;
• frequent urination and the urge to urinate;
• against the background of delayed menstruation in the form of discharge (bloody) from the genital tract.

Ovarian apoplexy by degree

Without emergency measures, internal bleeding intensifies, threatening the woman’s life.

A mild degree of apoplexy (with blood loss up to 150 ml) manifests itself:

• nausea;
• rapidly passing pain attacks;
• the absence of peritonitis and shock.

The average degree of this disease (blood loss up to 500 ml) is characterized by symptoms:

• pain in the abdomen is severe;
• vomiting;
• dry mouth;
• general weakness;
• temperature;
• fainting;
• phenomena of peritonitis (severe "dagger-like" pain in the abdomen);
• shock 1st degree.

Severe apoplexy (blood loss of more than 500 ml) is characterized by the appearance of:

• constant abdominal pain;
• vomiting;
• bloating;
• tachycardia;
• temperature, chills;
• cold sweat;
• collapse;
• sharp pain in the lower abdomen;
• shock of 2-3 degrees with slowing of the pulse and loss of consciousness;
• decrease in hemoglobin in the analysis by 50%.

The classic form of apoplexy is easier to identify, as it has clearer manifestations.

Often, ovarian apoplexy can manifest only as pain without signs of bleeding (painful form), or, conversely, be limited to symptoms of bleeding without pain (hemorrhagic form).

There are also combinations of ovarian apoplexy with ectopic pregnancy or acute appendicitis.

Diagnostics

Due to the fact that ovarian apoplexy does not have specific manifestations, this diagnosis is established immediately in no more than 5% of cases.

When diagnosing apoplexy, it is difficult to immediately correctly diagnose. This disease does not have a clear characteristic picture and can often occur under the mask of other similar conditions:

• appendicitis;
• torsion of ovarian cyst;
• perforated stomach ulcer;
• pyosalpinx;
• acute pancreatitis;
• intestinal obstruction;
• renal colic;
• acute peritonitis.

For any severe abdominal pain and suspicion of internal blood loss, urgent delivery of the woman to the hospital is necessary. As a rule, in such conditions a general diagnosis of “acute abdomen” is made. And the cause of this condition is clarified in the hospital.

Usually, ovarian rupture must be distinguished from two diseases that are most similar in symptoms - ectopic pregnancy and appendicitis. Therefore, the patient also needs to be examined by several specialists in related specialties: a gynecologist, a urologist, a surgeon. However, there are differences when one of these acute conditions is suspected:

With this pathology, it is important to make a diagnosis as quickly as possible. Otherwise, delay in diagnosis will cause an increase in blood loss with the risk of death of the patient.

Data to clarify the diagnosis of ovarian apoplexy

1. complaints of acute abdominal pain associated with ovulation or the second half of the cycle;
2. phenomena of severe pain at the site of the affected ovary with symptoms of peritoneal irritation (indicates peritonitis);
3. gynecological examination with a characteristic normal or pale color of the vagina, normal size of the uterus and a slightly enlarged and painful ovary at the site of the lesion;
4. difficulties in conducting manual research due to pain in the anterior abdominal wall;
5. low indicator, excluding ectopic pregnancy;
6. a decrease in hemoglobin in the general blood test (with a sharp blood loss, hemoglobin may even increase due to blood viscosity) and a frequent increase in leukocytes;
7. the presence of blood during puncture of the posterior vaginal fornix (under anesthesia), confirming the suspicion of intra-abdominal bleeding;
8. ultrasound data with a conclusion about the presence in the affected ovary of a corpus luteum with hemorrhages or accumulations of blood with clots (fine or medium dispersed liquid) in the abdominal cavity;
9. laparoscopy data allowing to definitively confirm this diagnosis.

Regardless of all diagnostic methods, most often the final diagnosis of apoplexy is confirmed at the time of surgery.

Treatment of ovarian apoplexy

The main actions of the patient in case of suspected ovarian apoplexy should be:

1. lie down immediately;
2. call an ambulance.

Two methods of treating apoplexy are still used:

• conservative;
• surgical.

Conservative method

A conservative method in medicine is used only in cases of mild apoplexy, when the ovary is slightly damaged, with minimal bleeding into the abdominal cavity. In this case, the patient feels only minor abdominal pain without symptoms of internal bleeding.

Conservative treatment of apoplexy includes the use of:

• bed rest and complete rest;
• ice on the lower abdomen;
• antispasmodics to relieve tone, pain and oxygen supply to tissues (No-shpa, Buscopan, Papaverine);
• hemostatics to reduce bleeding and accelerate blood clotting (Etamzilat, Ambien, Tranexam);
• vitamins for quickly restoring the body’s defenses and the functioning of various organs (usually C and group B);
• iron supplements to prevent anemia (Fenuls, Sorbifer);
• douching with disinfectant solutions (with iodine solution);
• suppositories (Papaverine, Antipyrine);
• physiotherapy (diathermy, electrophoresis, Bernard currents).

When choosing a conservative method of treating ovarian apoplexy, a woman should know that the results of such therapy are rarely successful. After conservative treatment, cases of adhesive disease (in 85%) and subsequent infertility (in 42%) are common.

Every second patient, after conservative treatment of apoplexy, experiences a relapse in the form of repeated ovarian rupture. This is explained by the fact that the accumulation of blood clots and fluid remains in the ovary affected by the rupture (since laparoscopy was not performed to wash out the clots) and contributes to aseptic inflammation with the development of relapse

Therefore, such conservative treatment is not performed on young women or women planning to have children in the future.

If a patient is diagnosed with a mild degree of apoplexy, but the woman is still of reproductive age, the choice of treatment method should be in favor of laparoscopy.

Surgery

The method of surgical treatment is the main one for ovarian rupture. This method has advantages:

• final confirmation of the diagnosis;
• carrying out full treatment;
• preventing relapses in the future.

Surgery for apoplexy can be performed using two methods:

• laparoscopic (through a small hole in the abdominal wall);
• laparotomy (with an incision in the abdominal wall).

Laparotomy

It is performed in case of serious consequences after ovarian rupture. It covers those situations in which a more gentle type of surgical treatment (laparoscopy) cannot be used. A similar technique is used for very large blood loss in a patient with hemorrhagic shock or adhesive disease.

During laparotomy, a mandatory examination of the abdominal cavity (revision) is performed with the removal of all blood clots. During the operation, the ovary is truncated or completely removed. If ruptured vessels are found, they are sutured. Antibiotics, analgesics, and anti-inflammatory drugs are used in postoperative treatment.

Laparoscopy

Gradually, the innovative method of laparoscopy is replacing the traditional classical method of laparotomy. And this is understandable. Indeed, among the advantages of laparoscopy we can note:

1. Performed using a gentle method.
2. Absence of severe pain and vulgar marks from the operation.
3. Minimizing the risk of adhesions and complications after the intervention.
4. Minimal pain relief during and after surgery.
5. The ability to perfectly clean the abdominal cavity from the accumulation of clots, blood clots and blood.
6. The ability to preserve the ovaries for future childbearing.
7. If necessary, intervention can be performed even during pregnancy, while preserving the life of the fetus and continuing its gestation.
8. Minimal recovery period.
9. Maintaining psychological comfort for the patient.

Currently, removal of the entire ovary during apoplexy is performed only if the woman’s life is threatened due to enormous blood loss and the inability to preserve the function of damaged vessels and tissues.

Despite the low invasiveness of laparoscopy, the operation is not used if the patient has:

• myocardial infarction;
• severe hypertension;
• stroke;
• severe renal and hepatic pathology;
• bronchial asthma;
• high degree of obesity;
• large tumors (more than 10 cm in diameter);
• abdominal hernia;
• acute purulent processes of the abdominal cavity (peritonitis);
• bleeding disorders;
• allergies to medications used;
• large blood loss;
• general severe exhaustion and weakening.

It is also not advisable to perform laparoscopy in the second half of pregnancy.

If laparoscopy is not possible, laparothymic surgery is often used. With this technique, an incision of about 10 cm is made above the pubis. In the postoperative period after laparotomy, complex antibacterial therapy is used.

Postoperative period

After any surgical treatment of ovarian apoplexy, the patient will usually need 2-3 months to regain her health.

A mandatory conservative type of treatment after surgery for ovarian rupture is physiotherapy (electrophoresis, ultrasound, UHF, magnetic therapy). This type of therapy using medications (lidase, aloe, magnesium sulfate) avoids the formation of adhesions. A woman after surgery should not neglect this type of therapy. In this case, physical therapy is an affordable way to avoid the occurrence of many serious complications in the future.

If a woman has undergone laparotomy, then she needs to wear a bandage for at least 2 months. All this time, the patient is prohibited from having sex in order to avoid re-traumatization of the ovary. A woman after ovarian apoplexy is also prohibited from becoming pregnant for 6 months after surgery.

After laparotomy, patients must wear special compression garments or a bandage for two months. Sexual activity should be completely excluded throughout the recovery period.

5-7 days after the intervention, the woman should begin her period. The discharge is more often than usual or less abundant than usual.

If menstruation does not occur at this time, the woman should contact her gynecologist. This must be done to prevent the development of complications.

The woman should be in the hospital for at least a week after the operation. Then the gynecologist at the antenatal clinic registers the patient with a dispensary for a year. At the same time, every 3 months she should be shown to a gynecologist for an examination.

Postoperative complications

Surgery for apoplexy does not belong to the category of lungs. If it is delayed, it can result in hemorrhagic shock or even the death of the patient. Therefore, unauthorized treatment with traditional methods or self-medication using painkillers is strictly contraindicated if ovarian apoplexy is suspected.

Patients often find it difficult to tolerate laparotomy surgery. But a gentle laparoscopy technique can also lead to serious consequences. Complications after surgical treatment of apoplexy can be early and late. Any early complications are associated with disturbances in the process of treatment and early rehabilitation.

Often, early complications occur due to a woman’s late seeking of qualified help. Similar complications can arise with accession:

• peritonitis;
• sepsis;
• genitourinary infections;
• infertility due to loss of both ovaries.

Late complications appear some time after treatment.

After suffering ovarian apoplexy, patients may experience the following phenomena:

1. Formation of adhesions in the pelvic organs (fusion of internal organs with each other) due to retention of blood and blood clots in the abdominal cavity. Adhesions can form in the pelvis when surgical treatment is replaced with conservative treatment.
2. Ectopic pregnancy. This complication is a consequence of adhesions, when the fertilized egg is not able to enter the uterus, but is fixed in the fallopian tube.
3. Risk of recurrent apoplexy. It occurs more often after conservative treatment or behavioral disturbances in the patient during the recovery period, with hormonal imbalance in the female body.
4. . It especially often occurs as a consequence of adhesive disease or hormonal disorder. It is also a consequence of removal of the ovary after it was impossible to save it.

Traditional methods of treatment

Treatment of such a serious illness as ovarian apoplexy should be carried out in a hospital under the supervision of a doctor.

Traditional methods of treatment for this pathology can only be used as an auxiliary type of therapy at the stage of rehabilitation treatment.

Here are examples of the most effective folk methods of treatment after ovarian rupture.

upland uterus

The most popular means of treating the consequences of apoplexy are drugs. This plant has a complex of healing properties for gynecological ailments: absorbent, cleansing, stimulating immunity, antimicrobial, antitumor, diuretic, increasing estrogen levels.

The forms of using the boron uterus are:

1. Water tincture. To do this, pour 2 tablespoons of dry uterus herb with 2 cups of boiling water and leave for 2 hours. The infusion for douching is used in doses so as not to provoke vaginal dysbiosis.
2. Alcohol tincture of hogweed and red brush. This ready-made pharmaceutical drug has a complex effect, helping to restore the mucous membrane after apoplexy and prevent bleeding. The product is often sold under the name “Femofit”. Most often, this tincture is used three times a day before meals, 30 drops in half a glass of water.

Red brush

Preparations from it are most useful for apoplexy, as they can normalize hormonal balance, eliminate congestion in the genitals and help the rapid healing of postoperative wounds.

It is most convenient to use a ready-made pharmacy tincture of red brush for one month, three times a day, 30 drops in a tablespoon of water. The break between courses is at least 2 weeks.

Another way to use red brush is to use it in parallel with sage. In the first half of the cycle (before ovulation), a glass of sage infusion is prescribed (a teaspoon of sage herb is poured with boiling water and infused) with a parallel intake of 20 drops of red brush in a tablespoon of water. In the second half of the cycle, sage is excluded, but red brush is drunk 40 drops three times a day. The course lasts 3 months, then a break of 2 weeks is needed.

Although traditional methods cannot replace official methods of treating ovarian apoplexy, with their help it is possible to thoroughly restore many impaired functions of the female body.

There is no need to panic if the patient is faced with surgery for apoplexy. Even after surgery, female reproductive function is usually preserved. It is very important for a woman to carefully follow all the rules of conduct after surgery and to protect herself from pregnancy for six months. Although apoplexy is a serious condition, in the case of timely qualified assistance, any woman can count on a complete cure and the preservation of her ability to become a mother. Take care of your women's health!

Ovarian apoplexy is a sharp hemorrhage that occurred due to a rupture, for example, of a cyst located there. In addition, a ruptured Graafian vesicle - a follicle containing an egg, or a rupture of the connective tissue of an organ - the stroma, can also lead to apoplexy. Any internal bleeding is dangerous for the body and ovarian apoplexy is no exception.

Causes of the disease

Ovarian apoplexy in most cases occurs in adolescent girls and women of childbearing age (14–45 years). This age range can be explained by the constant active maturation in the woman’s body of the follicles that contain the egg. Most often, the disease affects patients aged 20 to 35 years. In very rare cases, such hemorrhages occur in girls who have not yet reached puberty. The disease has a complex development mechanism and, unfortunately, is characterized by frequent relapses.

As is known, the female reproductive system works cyclically: first, an egg matures in the Graafian vesicle of the ovary, then the follicle ruptures, and the mature cell is sent to a possible meeting with a sperm. If such a “date” does not happen, she dies over a certain time, and menstruation occurs, renewing the uterine mucosa, which never received the fertilized egg. In this monthly repeating process, there are certain periods of increased risk of ovarian damage - these are the middle and second half of the menstrual cycle. It is during this period that the vessels feeding the uterine appendages become most permeable and are filled with blood.

Hemorrhage in the right ovary occurs several times more often than in the left, but there is no mystery here - simply in the right appendage, blood circulation occurs more intensely due to the fact that the artery feeding it branches directly from the aorta, and the bloodstream of the left appendage originates from the renal artery.

Ovarian apoplexy can occur due to the following reasons:

• acute and especially chronic inflammation of the internal organs of the female genital area;
• abnormal position of the uterus, usually congenital;
• the presence of tumors putting pressure on the ovary;
• due to postoperative adhesions in the pelvis;
• varicose veins of the ovary;
• bleeding disorders (thrombocytopenia) due to taking anticoagulant drugs or a number of diseases.

The following can cause hemorrhage:

• mechanical damage to the pelvic organs, for example, trauma;
• physical strain, too intense or rough sex;
• inept douching, rough examination by a gynecologist;
• horseback riding.

Forms and signs of ovarian apoplexy

Gynecologists use several classification options for ovarian apoplexy, the most popular among which is the division of the disease into two forms - painful (without intra-abdominal bleeding) and hemorrhagic (with intra-abdominal bleeding). The hemorrhagic form, in turn, is divided into three degrees, depending on the amount of internal blood loss. In the painful form, hemorrhage also occurs, but it is limited to blood entering the ovarian tissue - the corpus luteum or follicle; blood does not enter the abdominal cavity.

Symptoms

Both forms of ovarian apoplexy have similar symptoms. The main symptom can be considered a sharp, unexpected pain in the lower abdomen. Then the feeling of pain is accompanied by nausea and weakness, which are a consequence of blood loss.

The main symptom of ovarian apoplexy is sharp, sudden pain.

In the hemorrhagic form of the disease, if blood loss increases, these symptoms may be accompanied by signs indicating intra-abdominal bleeding:

• vomit;
• loss of consciousness;
• pallor of the mucous membranes and skin;
• sticky sweat;
• cardiopalmus;
• decrease in blood pressure.

Upon examination, the doctor detects tension in the anterior abdominal wall and bloating. Touching the abdomen is extremely painful for the patient.

Basic diagnostic methods

Ovarian apoplexy is an insidious disease that can masquerade as an ectopic pregnancy, which in many cases leads to incorrect diagnosis. Sometimes it happens that an accurate diagnosis of an illness occurs only on the operating table, during emergency care.

In order to differentiate ovarian apoplexy and ectopic pregnancy, the following differences must be taken into account:

In addition, with ovarian apoplexy, extreme pain is noted during vaginal two-handed examination.

To clarify the diagnosis, the following are usually used:

• a blood test showing a decrease in hemoglobin levels;
• an ultrasound examination to detect fluid accumulation;
• abdominal puncture, which is performed through the vagina.

It should be noted that if the patient has signs of abdominal bleeding, she will in any case need emergency surgery, regardless of what caused the bleeding. Here differential diagnosis is not of great importance.

Apoplexy of the right ovary can simulate an attack of appendicitis, however, with apoplexy, pain irradiates to the anus and right leg, while with appendicitis, pain is concentrated in the midline of the abdomen above the navel. For differential diagnosis, it is important to take into account the fact that with appendicitis, examinations through the rectum are especially painful for the patient, and with apoplexy, severe pain is caused by the impact on the uterus.

Ovarian apoplexy should also be differentiated from the following diseases:

• adnexitis (inflammation of the uterine appendage);
• torsion of the pedicle of an ovarian cyst;
• intestinal obstruction;
• perforated stomach ulcer;
• an attack of pancreatitis and colic - hepatic and renal.

How is ovarian apoplexy treated?

The treatment method will be chosen by the doctor depending on the form of the disease and the patient’s condition.

Operation

If a large amount of blood (more than 150 ml) leaks into the abdominal cavity, emergency surgery is performed.

Surgical intervention can be carried out either in a traditional way - using a scalpel incision in the suprapubic or inframedian region, or in a more gentle way - laparoscopic, using special surgical instruments inserted into the abdominal cavity through small punctures. Both methods allow you to carry out the required amount of surgical intervention - coagulate the rupture site, remove or puncture the cyst, remove blood that has entered the abdominal cavity, and even remove the damaged ovary, if necessary. The choice of surgical procedure depends on a number of factors - the presence of adhesions, the intensity of bleeding, and the severity of the patient’s condition.

Carrying out surgery using the laparoscopic method

In what cases is conservative treatment prescribed?

In the absence of bleeding (painful form of apoplexy), or in case of minor bleeding, it is possible to use conservative treatment, which consists of the following:

• a heating pad with ice on the lower abdomen;
• hemostatic drugs (Vikasol, Etamzilat, etc.);
• antispasmodics (No-shpa);
• vitamins B1, B6, B12;
• electrophoresis with calcium chloride or microwave physiotherapy.

Conservative therapy is possible only in a hospital setting and under the supervision of a doctor.. If the patient's condition worsens, indications for surgery may arise.

Conservative therapy has a number of significant disadvantages, which determine the use of this type of treatment in relation to women who no longer plan to have children in the future, since such therapy often provokes infertility. After it, as a rule, adhesions form due to the impossibility of removing residual blood, and a high risk of relapse of the disease remains. If the patient is planning a pregnancy, she will most likely be offered surgery.

Folk remedies

Traditional medicine also has remedies for treating ovarian apoplexy. However, it should be emphasized here that such self-medication is possible only with a mild painful form of the disease and with an accurately established diagnosis. When resorting to popular recommendations, a woman should be aware of the high risk of such self-medication. Here are a few recipes:

1. Wrap flax seed (20 g) in several layers of gauze and put it in boiling water to steam it. Then squeeze out the bundle with the seed and apply it to the ovarian area overnight.
2. Prepare a decoction of burdock root (10 g), pour a glass of boiling water over it and leave for 12 hours. You need to take the decoction three times a day, half an hour before meals.
3. In a similar way, you can steam colza (10 g) with a glass of boiling water, infuse it and take it in the same way.
4. You can try taking one tablespoon of freshly squeezed aloe juice half an hour before meals with a small amount of water.

How to behave after treatment

The main thing a woman needs to achieve is the restoration of reproductive function, and this requires measures to prevent the formation of adhesions and establish hormonal metabolism. Most likely, the patient will be offered a course of anti-inflammatory therapy, and to optimize hormonal balance and suppress the ovulation process, combined low-dose (Regulon, Femoden) or microdose contraceptives (Mersilon, Novinet) are usually prescribed, which must be taken for at least six months. The decision on the duration of their use is made by the attending physician on an individual basis.

For the most effective rehabilitation of the patient, physiotherapeutic methods can also be used - ultrasound, laser therapy, ultratonotherapy, electrophoresis.

Menstruation can be restored within a month and a half after the operation, but pregnancy can be planned only after the end of rehabilitation measures, the completion of hormonal drugs, a detailed examination and consultation with a gynecologist. As for the resumption of sexual activity, a doctor’s consultation is also necessary here, since this depends on the severity of the cured illness, the form of treatment and the objective condition of the woman.

Prevention

Unfortunately, patients who have suffered ovarian apoplexy often experience relapses of the disease. You should pay close attention to your health and take medications that your doctor will prescribe depending on the cause of the disease (for example, hormonal drugs, nootropics, tranquilizers, etc.), and also avoid excessively intense physical activity and heavy lifting.

Regular visits to the gynecologist are an effective method of preventing diseases of the pelvic organs

You must remember to visit a gynecologist twice a year, and also promptly treat infectious and inflammatory diseases of the pelvic organs.

Ovarian apoplexy is a serious disease that has a high risk of dangerous complications and can lead to tragic health consequences. The disease must be accurately diagnosed and treated only within the walls of a medical institution. Self-diagnosis and self-medication in this case are highly undesirable.

Update: October 2018

Ovarian apoplexy is an emergency condition and requires emergency medical care, often surgical intervention. Compared to other gynecological diseases, this pathology is quite common and accounts for 17% or 3rd place in the structure of female diseases. The causes of ovarian rupture are varied, and the consequences of untimely or inadequate treatment can be very sad (infertility as a result of a pronounced adhesive process).

Intra-abdominal bleeding, which occurs in a number of gynecological diseases, is caused in 0.5 - 2.5% by ovarian apoplexy. Symptoms of ovarian rupture are most often diagnosed in young women (20–35 years), but the occurrence of pathology is also possible in other age groups (14–45 years).

Ovaries: anatomy and functions

The ovaries are gonads (female gonads) and belong to paired organs. They are located in the small pelvis, in which they are attached by ligaments (mesentery and suspensory ligament of the ovary). One of the ends faces the fallopian tube (the egg released from the ovary immediately enters the tube). In appearance, the ovaries resemble peach pits and are furrowed with scars - traces of past ovulations, the formation and disappearance of the corpus luteum. The organs are small in size: 20–25 mm wide and up to 35 mm long. The weight of the ovaries reaches 5–10 grams. Blood enters the gonads from the ovarian arteries, and the right ovarian artery branches directly from the abdominal aorta, which is why its diameter is slightly larger, and the blood supply to the right organ is better. Accordingly, the right gland is larger in size compared to the left.

The functions of the reproductive gonads include the formation of estrogens and androgens (in small quantities), and most importantly, the production of an egg ready for fertilization.

Eggs are formed from follicles that were laid during the fetal development stage.

The female gonads consist of:

• germinal epithelium (covers the organ from above and delimits it from neighboring organs);
• tunica albuginea (consists of connective tissue and contains elastic fibers);
• parenchyma, which has 2 layers: outer (cortical) and inner (cerebral).

In the cortical layer of the gland there are immature and maturing follicles. Having reached a state of maturity (Graafian vesicle), the follicle protrudes somewhat above the surface of the gland and ruptures, from where the finished egg is released (ovulation phase). As the egg enters and moves through the tube, a corpus luteum is formed in place of the former burst follicle - the second stage of the cycle. The corpus luteum actively produces progesterone, which is necessary to support the onset of pregnancy. If conception does not occur, the corpus luteum undergoes a process of reverse development (involution) and becomes the white body (connective tissue), which eventually disappears completely.

The inner (brain) layer is located in the very depths of the glands and has a well-developed circulatory network and nerve endings.

Definition of pathology and classification

The term "ovarian apoplexy" means a hemorrhage into it, which happened suddenly against the background of a violation of the integrity (rupture) of the ovarian tissue. The disease is accompanied by progressive bleeding into the abdominal cavity and severe pain. Other names for the pathology are rupture of the ovary or hematoma, less often a heart attack. Hemorrhage into the gonad can occur when a cyst of the corpus luteum ruptures, at the time of damage to the vessels of the Graafian vesicle or stroma of the organ.

The disease is divided into:

On forms:

• pain form (it is also called pseudoappendicular) - characterized by a pronounced pain syndrome, which is accompanied by nausea and fever;
• anemic form (or hemorrhagic) - according to the clinic, it is similar to a pipe rupture during an ectopic pregnancy, intra-abdominal bleeding is a cardinal sign.
• mixed - the characteristics of both forms are combined.

Based on the amount of blood loss and the manifestation of clinical signs, the following degrees are distinguished:

• light (the volume of blood shed is 0.1 - 0.15 liters);
• average (blood loss is 0.15 - 0.5 liters);
• severe (free blood in the abdomen exceeds 0.5 liters).

Anemic and painful forms are diagnosed equally often.

Causes and mechanism of development

The mechanism of development of the disease lies in neuroendocrine disorders and inflammatory processes of the internal genital organs. As a result of these factors, sclerotic changes develop in the ovaries, and blood stagnation in the pelvic vessels, which leads to varicose veins of the ovarian veins. Due to various changes in the vessels of the genital gonads (their varicose veins, sclerosis of the vascular wall), hyperemia and inflammation of the ovarian tissue, the formation of many small cysts, the walls of the ovarian vessels become defective, 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 of increased pressure in the ovary. Then, due to excessive intraovarian pressure, the vessel/vessels burst, which leads to bleeding, often massive (even with a small rupture).

Ovarian apoplexy occurs in any phase of the cycle, but more often in the ovulatory and luteal (second) phases. During this period, blood flow to the gonads increases, the corpus luteum blossoms, and, possibly, the formation of a luteal cyst. The possibility of rupture of the corpus luteum in the first trimester of pregnancy cannot be ruled out.

It is characteristic that the right ovary ruptures more often, which is explained by its better blood supply compared to the left.

Causes

Reasons that create a favorable background for ovarian rupture (endogenous factors):

• inflammation of the ovaries/appendages;
• varicose veins of the ovary (provoked by heavy physical labor, repeated pregnancies, taking hormonal contraceptives, hyperestrogenism);
• anomalies in the location of the genital organs (retroflexion or bending of the uterus, compression of the ovary by a tumor of a neighboring organ);
• adhesions in the pelvis, especially when the ovary is constricted with adhesions;
• diseases of the blood coagulation system;
• sclerocystic ovary (the tunica albuginea becomes too dense, its rupture during ovulation “requires significant effort from the follicle”).

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

• violent sex or interrupted sexual intercourse (blood flow to the gonads increases and intraovarian pressure increases);
• heavy lifting, sudden movements (bending, turning) or heavy physical work);
• abdominal trauma (blow, fall on the stomach);
• drug stimulation of ovulation (one of the side effects of clomiphene, which stimulates ovulation, is the formation of luteal cysts, which is fraught with apoplexy of the ovarian cyst);
• defecation (increased intra-abdominal pressure);
• horse riding (shaking);
• rough gynecological examination;
• visiting a bathhouse, sauna;
• long-term use of anticoagulants.

Case Study

A young woman, 22 years old, was admitted to the gynecology department at night with signs of intra-abdominal bleeding. Preliminary diagnosis after examination and abdominal puncture through the posterior vaginal fornix: “Apoplexy of the left ovary, mixed form.” The patient had a history of sclerocystic ovary disease and no pregnancies within a year of regular sexual activity (the patient recently got married). She was put on a waiting list for a paid laparoscopic operation for ovarian sclerocystosis at a regional hospital (the operation was scheduled a week after admission to our hospital). During laparotomy, liquid blood with clots of up to 900 ml was found in the abdominal cavity, and a rupture of the right ovary of about 0.5 mm. Resection of both ovaries, sanitation of the abdominal cavity and layer-by-layer suturing of the wound were performed. The postoperative period was without complications, she was discharged in satisfactory condition.

The cause of ovarian rupture in this case was sclerocystic disease. The woman happened, one might say, the first independent ovulation in her life, which led to the rupture of the gland and bleeding. On the other hand, the patient did not have to go to a paid operation (resection of both ovaries was planned).

After 5 months, the woman was registered for pregnancy in our antenatal clinic.

Clinical picture

Signs of ovarian apoplexy depend on the intensity of bleeding and concomitant (background) gynecological pathology. In the clinical picture, the predominant symptoms of ovarian apoplexy are intra-abdominal bleeding and severe pain. In the case of a mixed form of pathology, signs of internal bleeding and pain syndrome are equally detected.

pain

In most cases, pain occurs suddenly, their nature is sharp, very intense, and often a painful attack is preceded by provoking factors (hypothermia, sudden movements, violent sex). It is also possible that pain may appear against the background of complete well-being, for example, during sleep. Occasionally, on the eve of an acute painful attack, a woman may notice a weak dull/aching pain or tingling in the left or right iliac region. Such aching pain is caused by small hemorrhages (hematoma formation) in the ovarian tissue, or by swelling or redness of the gland. The localization of the patient’s pain is often determined precisely, in the lower abdomen, right or left, and lower back pain is possible. Acute pain is explained by irritation of nerve receptors in the ovarian tissue, as well as blood spilling into the abdominal cavity and irritation of the peritoneum. Pain may radiate to the leg, under and above the collarbone, to the sacrum, anus or perineum.

Signs of internal bleeding

The severity of symptoms during intra-abdominal bleeding depends on the amount of blood spilled into the abdominal cavity, the intensity and duration of the bleeding. In moderate and severe cases (blood loss is more than 150 ml), signs of acute anemia come to the fore, and in severe cases, hemorrhagic shock. Blood pressure drops sharply, the patient feels severe weakness, and fainting is possible. The pulse quickens and weakens, the skin and mucous membranes become pale, nausea/vomiting appears, and signs of peritoneal irritation (peritoneal symptoms) appear. The patient complains of dry mouth, thirst, cold skin, with perspiration.

Other symptoms

Also typical for this pathology, but not always, is the appearance of minor intermenstrual bleeding or bleeding against the background of a delay in menstruation. The patient complains of frequent urination and the urge to defecate (irritation of the rectum due to gushing blood).

Gynecological and general examination

A general examination confirms the picture of internal bleeding (pale, cold and moist skin, tachycardia and low blood pressure, peritoneal symptoms, bloating).

A gynecological examination reveals: pallor of the mucous membranes of the vagina and cervix, a smoothed or overhanging posterior vaginal fornix (with large blood loss), a painful and enlarged right or left ovary. The uterus “floats” in the pelvis upon palpation, and displacement behind the cervix causes pain.

Diagnostics

Only in 4–5% is it possible to make a correct diagnosis, which is understandable. The signs of the disease are similar to the clinical picture of other pathological processes. Differential diagnosis is carried out with:

• interrupted ectopic pregnancy;
• acute adnexitis;
• rupture of an ovarian cyst;
• pyosalpinx and its rupture;
• appendicitis;
• renal colic;
• acute pancreatitis;
• perforation of a stomach ulcer;
• intestinal obstruction.

The patient's complaints are carefully collected and anamnesis is studied, a general and gynecological examination is performed, after which additional research methods are prescribed:

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

• Coagulogram
• pelvic ultrasound

Examination of the ovaries and determination of their size, taking into account the phase of the menstrual cycle and the condition of the other gland. The damaged ovary is somewhat larger in size; in its stroma, a hypoechoic or heterogeneous formation is detected - the corpus luteum. The diameter of the corpus luteum is not larger than the size of the maturing follicle, and the follicular apparatus of the gonad is normal (fluid inclusions up to 4–8 mm). Free fluid is visualized behind the uterus.

• Culdocentesis

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

• Laparoscopy

A minimally invasive intervention that allows not only to clarify the diagnosis, but also to carry out surgical treatment. During the inspection the following is revealed:

• blood poured into the abdominal cavity, without or with clots;
• an enlarged, purple ovary with a rupture that is either bleeding or blocked by a blood clot;
• normal sized uterus;
• inflammatory changes in the tubes (tortuosity, hyperemia, thickening, adhesions);
• pelvic adhesions.

In case of severe chronic adhesions or signs of hemorrhagic shock, laparoscopy is contraindicated and immediate therapeutic and diagnostic laparotomy is started.

Treatment

Treatment of the pathology is carried out in a hospital, since all patients are admitted with symptoms of “acute abdomen” and on an emergency basis. “Acute abdomen” requires not only careful diagnosis, but also monitoring of the patient’s condition. There are 2 options for treating the disease.

Conservative therapy

Conservative treatment is allowed for patients with minor blood loss (up to 0.15 liters) who have already achieved their reproductive function (they have children and are no longer planning to have children). The complex of treatment measures includes:

• Strict bed rest

The patient's movements can provoke and intensify subsided bleeding from the ovary, and also intensify the pain attack.

• Cold

All patients, immediately after diagnostic measures, are prescribed cold on the lower abdomen (rubber heating pad with ice), which causes vasospasm, stops bleeding and reduces pain.

• Hemostatic drugs

Also, to stop bleeding, hemostatic agents are administered: etamsylate, ascorbic acid, vikasol, vitamins B1, B6 and B12.

• Analgesics and antispasmodics

Baralgin, drotaverine, no-spa effectively relieve pain.

• Iron supplements

Prescribed for antianemic purposes (tardiferon, sorbifer, fenyuls).

Surgery

Surgery is performed either laparoscopically or laparotomically. Laparoscopic surgery is preferred, especially in the case of women who are planning a pregnancy in the future.
Advantages of laparoscopic access:

• psychological comfort (no rough scars in the abdominal area);
• quick recovery from anesthesia;
• early activation of the patient;
• short hospital stay;
• less use of pain medications after surgery for ovarian rupture;
• low risk of adhesions and preservation of reproductive function.

Laparotomy is performed when the patient is in serious condition (hemorrhagic shock) and if it is impossible to perform laparoscopy (lack of equipment, significant adhesions in the abdominal cavity).

Stages of surgery:

• stopping bleeding (hemostasis) from a damaged ovary (coagulation, suturing the rupture or wedge resection of the gland is possible);
• removal of blood and clots from the abdominal cavity;
• sanitation (rinsing) with antiseptic solutions (aqueous solution of chlorhexidine, saline solution).

Very rarely it is necessary to perform an oophorectomy - complete removal of the ovary (in case of massive hemorrhage into the ovarian tissue).

Rehabilitation

After surgery for ovarian apoplexy, the patient undergoes rehabilitation measures:

Prevention of adhesions formation

Physiotherapy procedures are actively prescribed (starting from 3–4 days of the postoperative period):

• low frequency ultrasound;
• low intensity laser therapy;
• electrical stimulation of the fallopian tubes;
• therapeutic electrophoresis (with zinc, lidase, hydrocortisone);

Restoration of hormonal levels

Dispensary registration

All women who have suffered ovarian apoplexy are subject to mandatory dispensary registration at the antenatal clinic for a year. The first examination is scheduled after a month, then after 3 and 6.

Consequences

The prognosis in most cases after ovarian rupture (especially in the case of conservative treatment) is favorable. But the consequences cannot be excluded:

Adhesive process

Conservative therapy or delaying the timing of surgery in 85% of cases leads to the formation of adhesions in the pelvis. This is facilitated by the presence of blood and clots in the abdominal cavity, which eventually organize and cause the formation of adhesions. In addition, the occurrence of adhesions is provoked by the duration of the operation, an open wound of the abdomen (during laparotomy), the presence of chronic inflammation of the appendages and a complicated course of the postoperative period.

Infertility

Infertility develops in 42% of patients, which is facilitated by intense adhesions, hormonal imbalance and chronic inflammatory diseases of the ovaries and appendages. But if after apoplexy and surgery one healthy ovary remains, the chances of becoming pregnant in the future are high.

Relapse of the disease

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

Ectopic pregnancy

The risk of ectopic pregnancy increases due to the formation of adhesions in the pelvis, torsion and kinking of the fallopian tubes.

Question answer

How long do you stay in the hospital after surgery?

As a rule, after surgery for ovarian apoplexy, patients stay in the hospital for 7–10 days. Early discharge is carried out after laparoscopic access and a smooth course of the postoperative period.

I underwent conservative treatment for 3 days in the hospital for a painful form of ovarian apoplexy. Laparoscopy was not performed, an ultrasound was performed and treated with hemostatic drugs. I was discharged with an improvement, but at home I again felt pain that radiated to the lower back and anus, plus the temperature rose to 37.5. What to do?

You need to urgently contact a gynecologist and possibly undergo laparoscopic surgery. All signs point to continued bleeding from the ovary and accompanying inflammation. In the event of an attack of acute pain, immediately call an ambulance.

When can you start having sex after surgery (ovarian rupture)?

In about a month.

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

In the absence of background gynecological diseases, taking COCs only for a month after surgery, ovulation and conception are possible already in the second menstrual cycle after surgical treatment.