ovarian apoplexy - is rapidly progressive spontaneous bleeding in the ovary, followed by the expiration of the blood beyond.Ovarian apoplexy is an acute gynecological pathology.Most bleeding occurs in the ovary during ovulation (mid-cycle), or at the stage of flowering yellow body in times of increased vascularization of tissues of the ovary.It occurs in 2.5% of patients who did not win the 35-year mark, and much less likely to be diagnosed in other age groups.
In the ovaries of young women is a lot of primordial follicles - "bubble" with a liquid content.Each developing egg.During the period, equal to one menstrual cycle, the ovarian ripen one egg.When it completes its development, the wall of the follicle is destroyed, and the egg is beyond the ovary, while maintaining the viability of not longer than two days.This process is in the middle of the menstrual cycle and is called ovulation.Maturing follicles stimulates the synthesis of estrogen in the ovary, the first phase
on the spot death of the follicle develops corpus luteum.In the absence of fertilization it is not live longer than two weeks.The second phase of the cycle is accompanied by a high content of the pituitary luteinizing hormone (LH).
source of bleeding vessels are apoplexy ovarian stroma, ovarian primordial follicle, follicular cysts and corpus luteum cysts.
If during ovulation and formation of the corpus luteum fails, the ovarian blood vessels become defective, badly cut and are easily damaged.During the break the wall of the follicle appears first as a result of hemorrhage hematoma - blood cavity, delimited by the surrounding tissues.Then the wall hematoma is destroyed, and blood poured into the abdominal cavity.The amount of blood loss can sometimes reach two liters.Abdominal bleeding is threatening condition and requires immediate surgery.Qualified first aid when ovarian apoplexy help save the life of the patient.
ovarian apoplexy can provoke any condition which leads to the pathological changes in the mechanisms of formation of the normal menstrual cycle.Its cause and external factors, such as excessive exercise, increase intra-abdominal pressure.Due to better blood supply apoplexy right ovary develops most.
ovarian apoplexy Symptoms depend on the stage and form of the disease.Sometimes the bleeding is minor, and the symptoms are not bright.However, most often the disease develops quickly and has the features of an acute surgical pathology.Therefore, the right ovary apoplexy disguised as acute appendicitis.The main symptom of the disease is characterized by acute pain on the affected side.
In rare situations, in patients with mild apoplexy clinic can be conducted conservative treatment, but in most cases it is a preparatory period for the subsequent operation.
As with any medical emergency diagnosis of ovarian apoplexy should take a little time.Laparoscopy allows simultaneous visual, up to 98%, to evaluate the nature of the defeat and eliminate the cause of the disease.
Laparoscopic surgery for ovarian apoplexy is less traumatization, takes less time, and shortens the period of post-operative recovery.
As far as possible during the surgical treatment of apoplexy surgeons try to preserve the ovary and eliminate only a portion of a hemorrhage.If ovarian tissue lesions are common, have to remove the ovary.
reasons ovarian apoplexy
At the heart of apoplexy of the ovary is an existing long-term violation of the integrity of one (rarely - a few) vessels of the ovary, which occurred after his break.Released from the blood vessel, passes through the stages of hematoma, poured into the abdominal cavity.
provoke such a state can be:
- Change the normal values abdominal pressure upward.Often ovarian rupture is preceded by excessive exercise (lifting weights or overload in the gym, horse riding and the like) or stormy sex.Especially dangerous physical overload before or during menstruation (in the middle).
- Pathological changes in blood vessels of the ovary in the form of sclerosis, thinning of the wall or varicose.Such conditions prevent normal circulating blood, it is "stagnant" in any portion of a blood vessel, the vascular wall expands and can cause it to break.
- abdominal injury.
- pelvic tumors.
- misplaced genitals.
- Incorrect vaginal studies, especially before or during menstruation.
- adhesions in the pelvic area.
- Pathological structural changes in ovarian tissue on a background of infectious-inflammatory process.When inflammation, ovarian tissue become loose and vulnerable.Inflammation of the ovaries is easily injured and can burst.
- The moment of ovulation (12 - 14 day cycle).During the break the wall of the follicle in the ovary surface is microtrauma, at this point in the course of incorrect ovulatory ovarian tissue ruptures.
- following the ovulation stage of formation and vascularization of the corpus luteum (20 - 22 day cycle), when due to fragility of vessels it begins to form a hematoma.
- Long-term use of anticoagulants - drugs that reduce blood clotting.
apoplexy ovary during pregnancy is associated with rupture of the corpus luteum and flows similar to that of non-pregnant patients.
relative frequency of rupture of the ovary, followed by bleeding due to the peculiarities of blood supply to the body.The mature follicle and corpus luteum braided large number of full-blooded branching blood vessels.
ovarian apoplexy associated with disorders of the neuroendocrine regulation - namely, increased secretion of the pituitary luteinizing hormone, which causes bleeding in the development of ovarian tissue.
The largest number of registered cases of ovarian apoplexy in the second half of the cycle, because in the first half of mature follicles poor blood vessels.
Province left the uterus has fewer blood vessels so apoplexy left ovary develops less right.
Unfortunately, the exact cause of ovarian apoplexy is not always possible.Sometimes the rupture of ovarian tissue occurs in perfectly healthy patients in a period of complete rest, or even during sleep.
Symptoms and signs of ovarian apoplexy
source of bleeding in apoplexy ovarian corpus luteum is formed or a cyst in his place.The process of formation of the corpus luteum cyst starts immediately after ovulation.
In healthy women, the corpus luteum performs temporary hormonal function: it synthesizes the hormone progesterone is necessary for the proper development of a potential pregnancy.In the absence of fertilization, the corpus luteum destroyed a few days after ovulation.
Under the influence of external provoking factors (hypothermia or overheating, stress, physical stress, and the like), or under the influence of internal negative reasons (inflammation, hormonal dysfunction, etc.) the corpus luteum is formed correctly, and instead of the reverse development begins to accumulate fluid, followed by the formation of cysts.Accumulating fluid pressure on the inner wall of the cyst and damages are receptacles therein.As a result, developing a hemorrhage in a cystic cavity, the subsequent break its shell and the flow of blood outside of the ovary.
clinical picture of apoplexy is always accompanied by two major symptoms - pain and bleeding.Depending on the dominance of one of the symptoms of the conditional release:
- painful form with signs of acute appendicitis and leading symptom - pain.
- anemic shape resembling the flow interrupted tubal pregnancy.
- mixed form, having signs of the previous two.
This division ovarian apoplexy of its forms is not entirely reliable because the severity of the disease and its consequences depend primarily on the amount of blood loss.Therefore, a more reliable determination of the form in accordance with ovarian apoplexy largest volume of lost blood, such as:
- light (100 ml);
- average (500 ml);
- heavy (over 500 ml).
primary diagnosis of ovarian apoplexy often carried out by doctors "ambulance", and the patient hospitalized in a surgical hospital with a diagnosis of "acute abdomen".Unfortunately, the primary diagnosis is correct only 4 - 5%.
diagnostic errors due to the fact that the clinical signs of ovarian apoplexy are similar to those in many other acute emergencies.A similar clinic are:
- acute appendicitis;
- interrupted for the type of rupture of the fallopian tube ectopic pregnancy;
- torsion (malnutrition) legs ovarian cyst;
- piosalpinks gap;
- acute pancreatitis;
- intestinal obstruction;
- perforation of stomach ulcers.
sometimes apoplexy left ovary clinically similar to the left-sided renal colic.
The disease often begins acutely in the middle or the second half of the cycle.Suddenly, there are pronounced abdominal pain, often - in one of the iliac regions corresponding to the localization of apoplexy.Pain radiating to the external genitals, back, anus and even foot.
sharp pain accompanied by severe nausea and even vomiting, heart palpitations.Then, there are signs of internal bleeding: pale skin, rapid pulse, low blood pressure, the appearance of a cold sweat, weakness and dizziness.When a large blood loss may occur hemorrhagic shock.
Sometimes patients may appear the short-term bleeding.Because of this, it is difficult to differentiate ovarian apoplexy with interrupted ectopic pregnancy.
During the inspection indicated a sharp pain in the lower abdomen or on the side of the ruptured ovary.Positive symptoms of peritoneal irritation indicate the presence of abundant internal bleeding.
Gynecological examination accompanied by tenderness on the affected side, in the case of a large loss of blood spilled pain may acquire character.Visually determined pale shade of the vaginal mucosa, the presence of a small amount of bloody discharge.If the pelvic cavity accumulates a lot of blood, it flows into the region, bordering on the rear or lateral vaginal vault.In this situation, during the inspection, you can find them bulging (overhang) in the vaginal cavity.On palpation determined by the increase in the size of the painful ovary.When you try to move the cervix toward the pain appears.The uterus is a normal size, firm and painless.
distinctive clinical symptoms of ovarian apoplexy during pregnancy has not.However, pregnancy complicates the situation need to preserve the fruit.
Diagnosing ovarian apoplexy
success treating ovarian apoplexy depends on how quickly and correctly diagnosed, because the growing internal bleeding exacerbates the condition of the patient, and sometimes life-threatening.
on admission of any type is required joint consultation surgeons and gynecologists, to make a differential diagnosis of the disease with the same emergency pathologies.
In the primary stage of a study of complaints and external pelvic examination.Laboratory diagnosis includes:
- blood count to determine the degree of anemia;
- the study of blood coagulation;
- definition of hCG in the blood of suspected ectopic pregnancy interrupted;
definite diagnosis of apoplexy of the ovary can not be put without special instrumental methods of examination, because the symptoms are similar to those for all emergency situations.
during scans if there is a suspicion of the presence of pelvic free fluid (overhanging arches of the vagina), is performed posterior vaginal fornix puncture when using a special needle connected to a syringe made a puncture of the vaginal wall and the subsequent "suctioning" of liquid present.The presence of blood in the resulting fluid indicates bleeding, and its absence - on infectious and inflammatory nature of the disease.
Ultrasound scans can detect in the affected ovary great education (cyst) with signs of bleeding in the cavity.When significant bleeding has echoes signs of blood in the abdomen.
the most reliable diagnosis of apoplexy is only when his laparoscopic confirmation.Laparoscopic surgery for ovarian apoplexy combines the features of diagnostic and therapeutic procedures.
During direct examination often found:
- availability of free blood (sometimes with clots);
- unchanged the appearance and size of the uterus;
- the possible inflammatory changes in the fallopian tubes (thickening, the change in length and / or adhesions);
- in the pelvic cavity can be visualized expressed adhesive process.
damaged ovary is of normal size, but can be increased if the cyst (follicular or corpus luteum) large.When you break an ovarian cyst is painted in crimson.On the surface of the ovaries can be seen a small gap, he may bleed or be closed by blood clots (thrombi).
In some cases, laparoscopic picture is not to determine the cause of the rupture of the ovary, but only sets its presence.
contraindications to laparoscopy are expressed chronic adhesive process and a lot of bleeding (hemorrhagic shock and loss of consciousness).If any one has to resort to standard treatment and diagnostic methods - laparotomy.
small number of blood loss can sometimes be accompanied by small signs, whereas the initial diagnosis is carried out without hospitalization of the patient, but in the end of ovarian apoplexy in any form requires surgical invasion.
Treatment of ovarian apoplexy
primary emergency care at an apoplexy of the ovary is usually emergency doctors "on site" before the arrival of the patient to the hospital.Do not attempt self-treatment may be as spontaneous medication can worsen and complicate subsequent diagnosis.For example, the independent use of painkillers or anti-inflammatory drugs leads to a false temporary "improve" health, but does not eliminate internal bleeding.
Patients with mild ovarian apoplexy, do not always agree on the surgery, since the disease correlated with the severity of his symptoms - slightly severe abdominal pain.
Regardless of the chosen method of treatment of a patient hospitalized in the hospital for constant observation.If the background of conservative methods of treatment marked increase in symptoms, and there are signs of internal bleeding, immediate surgery is performed.
Conservative therapy ovarian apoplexy may include:
- complete rest;
- cold on lower abdomen to increase the spasm of blood vessels and reduce bleeding;
- Hemostatic agents;
- antispasmodics to decrease smooth muscle spasm and pain relief;
- antianemic means.
Conservative treatment of mild apoplexy possible, but does not guarantee the absence of complications.Almost 86% of patients with conservative therapy appears adhesions, and in 43% of registered infertility.In addition, conservative therapy increases the risk of recurrence of ovarian apoplexy every second the treated patients.
- Ectopic pregnancy.