Apoplexia of the ovary (apoplexia ovarii) is an acute gynecological disease that results in the rupture of vessels (this may be the vessels of both the ovary itself and the cyst formed), and a sudden hemorrhage develops into the ovarian tissue or into the abdominal cavity.
Anatomy and physiology of ovaries.
The ovaries are a paired organ located on either side of the uterus in a small pelvis. Their average length is 3 cm, the thickness is 1 cm, and the width is 2 cm. But these dimensions are not constant, and vary throughout the month, depending on the phase of the menstrual cycle. Ovaries are female sex glands, they produce sex hormones (progesterone and estrogens), and every month an egg is formed that can give life to a new organism. Ovaries have their own ligaments, with which they attach to the uterus.
The prevalence of the disease.
Apoplexy of the ovary occurs at any age, but most often the gap occurs in women of childbearing period (from 18 to 45 years), because it is at this age that the ovaries are actively working. Among all gynecological diseases, ovarian apoplexy is about 1-3%. And if there was a rupture of the ovary, then the probability of recurrence of the disease is very high – up to 70%. In this case, apoplexy of the right ovary is observed 3 times more often than the left one. This is due to the fact that the right ovary has many more blood vessels.
I. Inflammatory diseases of the pelvic organs (the ovaries themselves, the uterus, the fallopian tubes). As a result of inflammation, the tissue of the ovary and the blood vessels that feed it change, which can cause their rupture. II. Varicose enlargement of ovarian (ovarian) veins and their change in various diseases. III. Violations of blood clotting (with congenital and acquired blood diseases, for example, in hemophilia) or taking medications that cause blood thinning. IV. Violation of the balance of sex hormones in the body. V. Diseases of the nervous system, stress. Nerve overstrain.
Against the background of these reasons, there are external and internal factors that can provoke ovarian apoplexy.
Spikes in the small pelvis.
Pressure on the ovary located next to the tumor (this may be uterine fibroids or tumors that are not related to the female genital organs.
Disturbance of blood flow in the ovary and vessels feeding it.
Incorrect position of the uterus.
Excessive physical overvoltage.
Injury of the abdomen.
Sexual intercourse (especially in the middle of the menstrual cycle.
Act of defecation.
Examination of the gynecologist with the help of mirrors.
However, as a rule, the provoking factor can not be identified; in such situations, ovarian apoplexy occurs at night, during a restful sleep.
The main symptoms.
The most important symptom of ovarian apoplexy is a sharp acute pain. The disease develops so suddenly that the patient can, with an accuracy of minutes, name the time of the onset of pain. Painful syndrome with apoplexy is associated with the ingress of blood into the abdominal cavity and irritation of the peritoneum covering the internal organs. In addition to pain, the patient will be disturbed by weakness, dizziness. Nausea and vomiting may occur. And in case of severe internal bleeding, a loss of consciousness may occur.
Forms of the disease.
The manifestations of ovarian apoplexy depend on the clinical form of the disease. Painful form of apoplexy of the ovary is observed when the hemorrhage occurs inside the ovary (when the egg leaves). The disease begins with a sharp pain in the lower abdomen, sometimes can be accompanied by nausea and vomiting, but signs of internal bleeding (weakness, decreased pressure, fainting) is not observed.
Hemorrhagic, or anemic form. The disease develops sharply, and is often associated with external provoking factors – sexual intercourse, physical activity, trauma. The main symptoms associated with this form of apoplexy are associated with intra-abdominal hemorrhage. Pain is felt in the lower abdomen, often in the leg, rectum, external genitalia, sacrum and back. Almost always there is weakness, dizziness, nausea, vomiting. With severe internal bleeding, the heart rate increases, the pressure decreases and the loss of consciousness.
Mixed form. Signs of apoplexy of the ovary with this form begin with a pain syndrome, but with abundant bleeding the manifestations of an anemic version of apoplexy are added.
The diagnosis of ovarian apoplexy is based on the consistent study of complaints, medical history, examination of the patient, the results of the analyzes and additional instrumental methods of examination.
I. Complaints: pain, nausea, vomiting, signs of internal bleeding.
II. History of the disease. In 90-95% of women, ovarian apoplexy occurs in the middle or in the second phase of the menstrual cycle (14-21 days after the onset of menstruation). These are the so-called “critical moments”, since during the period of ovulation (release of the egg) and before the monthly blood vessels become more permeable and crowded, which contributes to their rupture.
III. Examination of the patient. The general condition will depend on the form of apoplexy. With a painful form, the general condition will be satisfactory. The skin of the usual color, pulse and pressure will be within the normal range. The abdomen remains soft, painful above the pubis, often on the right. With the hemorrhagic form of ovarian apoplexy, the pallor of the skin and mucous membranes will be observed, maybe a cold sticky sweat. Arterial pressure in the patient will be lowered, and the pulse is increased. There is abdominal swelling and sharp soreness in the lower parts.
IV. General clinical tests. In the general analysis of blood, the hemoglobin index decreases (but in acute severe blood loss due to blood thickening it can remain normal), the level of leukocytes (inflammation cells may be increased.
V. Instrumental research. On ultrasound with apoplexy of the ovary fluid (blood) in the abdominal cavity will be determined. To accurately diagnose the nature of the fluid, medical manipulation is performed – puncture (puncture) of the abdominal cavity through the vagina. This intervention is performed under anesthesia. If this study did not help diagnose, an operation is performed – diagnostic laparoscopy.
The tactics of treatment will depend on the form of the disease and the severity of the patient’s condition. Conservative (non-surgical) treatment of ovarian apoplexy can be carried out with painful form, when the patient feels satisfactory, and there are no signs of internal bleeding. Conservative treatment includes: 1. Complete rest. 2. Cold on the bottom of the abdomen (this helps reduce pain and narrow the blood vessels). 3. Hemostatic drugs (sodium etamzilate, etc.). 4. Drugs that relieve spasms (no-sppa, papaverine, etc.). 5. Vitaminotherapy: Vitamins B 1 are prescribed. In 6 and in 12. 6. Physiotherapeutic procedures: Microwave treatment, electrophoresis with calcium chloride.
Treatment should be carried out only in a hospital, under round-the-clock supervision of medical personnel. In the case of a recurrence of a painful attack, if the general condition and analysis parameters deteriorate, the question of conducting an operation is considered.
Operation with apoplexy of the ovary can be carried out in two ways: laparotomically (through the incision) and laparoscopically (through the punctures of the abdominal wall). Indications for laparoscopy with ovarian apoplexy.
Absence of effect from non-operative treatment during 1-3 days.
Continuing internal bleeding, confirmed by ultrasound.
Differential diagnosis of ovarian apoplexy and other acute gynecological or surgical pathology.
With a satisfactory condition of the patient, normal test values and presence in the abdominal cavity no more than 150 ml of blood.
Indications for laparotomy.
If for any reason it is impossible to perform laparoscopy (adhesions in the abdominal cavity, excessive bleeding from the vessels that are on the surface of the ovary.
Emergency care for apoplexy of the ovary with severe internal bleeding with a violation of the general condition (low pressure, leading to a shock state with loss of consciousness.
With laparotomy, a small incision is made above the pubis (as in cesarean section surgery), and laparoscopic surgery is performed through 3 small punctures on the front surface of the abdomen. Operative intervention, regardless of access, should be as gentle as possible: cauterization of the rupture site to stop bleeding, or ligation of the bleeding vessel; When a cyst is present, it is opened and deleted. Then, abnormal ovarian tissue is removed. And only with large damages, when it is not possible to save the ovary, it is completely removed.
Differential diagnosis with ovarian apoplexy.
Differential diagnosis with apoplexy is carried out with the following diseases: 1. Gynecological: rupture of the tube with ectopic pregnancy. purulent formation of the uterine tube, torsion of the ovarian cyst leg. 2. Surgical: appendicitis. acute intestinal obstruction. pancreatitis. intestinal colic. stomach ulcer.
Pregnancy after apoplexy of the ovary.
The rupture of the ovary itself does not affect the further possibility of conception, tk. During the operation, partial removal of the ovary is performed. But even if the ovary tissue is completely removed, the egg can ripen in a second, healthy ovary.
Difficulties with conception can arise when forming adhesions in the abdominal cavity. To minimize the effects of ovarian apoplexy, it is necessary to follow all the doctor’s recommendations in the rehabilitation (recovery) period.
Carry out a course of anti-inflammatory treatment (with mandatory prescription of antibiotics) and physiotherapy sessions (low-frequency ultrasound, laser therapy, electrophoresis with lidase and zinc.
Prevention of pregnancy for 4-6 months.
The use of hormonal tablets (novine regulon logistic yarina, etc.) to prevent the formation of adhesions and restore the hormonal background.
Very rarely apoplexy of the cyst (yellow body) of the ovary occurs during an already existing pregnancy. In this case, according to the indications, an operation is performed by laparotomy (incision). Pregnancy is preserved, although the risk of miscarriage increases.
Prevention of recurrent disease.
After the surgery for apoplexy of the ovary, the need for prevention is determined by the form of the disease. If there was a painful form of apoplexy, special preventive measures to prevent re-apoplexy are not required, since all changes in the level of hormones and blood supply in the ovary soon on their own come back to normal.
Prevention is necessary for those patients who have suffered the hemorrhagic form of apoplexy, because they have persistent violations of the hormonal background and the work of the central nervous system. In such a situation, a set of measures is appointed, which includes application.
Drugs that improve the activity of the nervous system (so-called nootropic drugs – piracetam., Nootropil.
Preparations that improve cerebral circulation (tanakan, cavinton, vinpocetine).
Diuretics with increased intracranial pressure.
Drugs that normalize the hormonal status of the body (contraceptives).
Before use, consult a specialist.