Hemoperitoneum secondary to ruptured ovarian cyst: a tricky diagnosis.

A 41-years-old female with no significant medical history presented with syncopal episode following spontaneous mild lower quadrants pain. On admission, physical exam and laboratory test were unremarkable. She developed abdominal tenderness, with increased pain with sitting, hypotension and an acute drop of hemoglobin within 4 hours. An abdominal US was performed, showing a large amount of free intraperitoneal fluid with echogenic structures suggestive of blood clots in Douglas pouch. Due to abdominal bleeding suspicion, a triphasic abdominal CT scan was performed, confirming the hemoperitoneum with clots around the uterus in the non-contrast phase. A focus of contrast extravasation was found in the left pelvis in the arterial phase, which grew in the venous phase, indicative of arterial active bleeding. These finding were consistent with active hemorrhage from an ectopic pregnancy or an ovarian cyst rupture. As the BhCG determination was negative, the first one was excluded. An emergency laparotomy was performed. Hemoperitoneum was drained and a ruptured bleeding follicular cyst in the left ovary was detected and electrocoagulated.

A ruptured functional ovarian cyst is a relatively frequent cause of acute pelvic pain, most likely to occur in women of reproductive age. The disease course varies from minor symptoms (most frequent, usually with sudden onset unilateral lower abdominal pain) to severe peritoneal irritation and shock (very rare). Conservative management is usually performed, but the presence of a large hemoperitoneum and/or active bleeding are indications of surgery treatment. A combination of an ovarian cyst and pelvic blood or fluid in US makes the diagnosis of bleeding rupture cyst highly likely if no other causes are found. CT could be made to exclude other etiologies and determine the need for surgical treatment. The cyst may collapse after the rupture, disappearing (although a sentinel clot may be present sometimes) or may show strong wall enhacement (because of peripheral hypervascularization, described as “ring of fire” sign on Doppler US that can be seen in corpus luteal cysts and ectopic pregnancies).Ectopic pregnancy is the main diagnosis to exclude and should be suspected with positive B-HCG and absent intrauterine pregnancy in US.

A young female with hemodynamic instability and anemization should prompt imaging evaluation, which usually starts with a pelvic US. With hemoperitoneum and a negative B-hCG a ruptured cyst should also be suspected. A contrast CT could determine the cause, if possible, and the need for surgical treatment (large hemoperitoneum and/or active bleeding).

- Lee MS, Moon MH, Woo H, Sung CK, Jeon HW, Lee TS. Ruptured corpus Luteal cyst: prediction of clinical outcomes with CT. Korean J Radiol. 2017,18(4):607–14. - Howard MD.Evaluation and management of ruptured ovarian cyst.Post TW, ed. UpToDate. Waltham, M