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Ovarian Cyst Rupture Workup

  • Author: Nathan Webb, MD; Chief Editor: Richard Scott Lucidi, MD, FACOG  more...
 
Updated: Nov 15, 2015
 

Approach Considerations

Perform a urine pregnancy test. If the pregnancy test is positive, make sure to rule out an ectopic pregnancy. Evaluate for ovarian torsion before discharge. If a diagnosis of bleeding ruptured ovarian cyst is considered, make sure the hemoglobin level is stable before discharging the patient. It is appropriate to admit the patient for observation and pain control.

Perform a diagnostic laparoscopy and/or laparotomy if the patient is hemodynamically unstable or if a specific diagnosis is unclear, yet a definitive diagnosis is necessary.

A study by Shiota et al indicated that C-reactive protein (CRP) levels can be used preoperatively to differentiate a ruptured ovarian cyst from ovarian torsion. In a retrospective evaluation of 98 patients diagnosed with a benign ovarian cyst, it was found that 21 patients with a ruptured cyst and 77 patients with ovarian torsion had mean preoperative CRP levels of 6.6 and 0.9 mg/dL, respectively; the mean size of the ovarian cysts also differed significantly between the two groups (6.7 cm and 9.7 cm, respectively). The investigators mentioned another study, however, that indicated that patients with ovarian torsion who present over 10 hours after the onset of acute abdomen with elevated CRP levels are at risk of necrosis. They suggested, therefore, that by taking into account imaging findings, CRP levels, and time of acute abdomen onset, clinicians can preoperatively differentiate ovarian cyst rupture from ovarian torsion.[8]

Tanaka et al suggest that plasma D-dimer levels may be markers for endometriotic ovarian cyst rupture.[9] In their study of 6 patients with emergent endometriotic cyst rupture and 16 control patients with unruptured endometriotic cysts, significantly elevated plasma D-dimer levels were seen in the group with the ruptured cysts. The investigators also noted that differences in white blood cell count and serum CRP levels between the two groups were statistically significant.[9]

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Lab Studies

Serum or urine pregnancy testing should be performed. In the case of a positive result, the patient should be evaluated for ectopic pregnancy. If concerned regarding possible hemorrhage, monitor the hematocrit (serially, if necessary) to ensure there is no continued bleeding.

If the diagnosis is unclear, urinalysis should be performed to identify a possible urinary tract infection or renal or bladder stones. Blood, urine, and cervical cultures may also be indicated rule out pelvic inflammatory disease or urinary tract infections.

Blood type and cross-match are indicated in patients with significant peritoneal signs or hemodynamic instability, because such patients may require surgical intervention or blood transfusion.

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Imaging Studies

Ultrasonography is the preferred imaging modality for assessing gynecologic structures, given its low cost, availability, and sensitivity in recognizing adnexal cysts and hemoperitoneum.[10, 11] Despite this, there remain instances in which the ultrasound findings are nonspecific, particularly after rupture and decompression of a cyst in the setting of apparent physiologic levels of fluid in the pelvis.

If ultrasound yields ambiguous results in a patient with significant pain, computed tomography (CT) of the pelvis with contrast should be performed. CT features of corpus luteum cysts have been previously described.[12, 13]

Although commonly performed in the past, culdocentesis has been largely abandoned in favor of ultrasonography and CT scanning, as both can readily identify fluid collections in the cul-de-sac. Culdocentesis is still acceptable, however, in locations where imaging is not available.

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Contributor Information and Disclosures
Author

Nathan Webb, MD Resident Physician, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center

Nathan Webb, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, AAGL

Disclosure: Nothing to disclose.

Coauthor(s)

David Chelmow, MD Leo J Dunn Professor and Chair, Department of Obstetrics and Gynecology, Virginia Commonwealth University Medical Center

David Chelmow, MD is a member of the following medical societies: Phi Beta Kappa, Sigma Xi, American College of Obstetricians and Gynecologists, American Society for Colposcopy and Cervical Pathology, Council of University Chairs of Obstetrics and Gynecology, Society for Academic Specialists in General Obstetrics and Gynecology, American Medical Association, Association of Professors of Gynecology and Obstetrics, Society for Reproductive Investigation, Society for Medical Decision Making

Disclosure: Nothing to disclose.

Specialty Editor Board

Nicole W Karjane, MD Associate Professor, Department of Obstetrics and Gynecology, Virginia Commonwealth University Medical Center

Nicole W Karjane, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Professors of Gynecology and Obstetrics, North American Society for Pediatric and Adolescent Gynecology

Disclosure: Nothing to disclose.

Chief Editor

Richard Scott Lucidi, MD, FACOG Associate Professor of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine

Richard Scott Lucidi, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Charles J Ascher-Walsh, MD Director of Gynecology, Female Pelvic Medicine and Reconstructive Surgery, Mt Sinai School of Medicine; Clinical Assistant Professor, Department of Obstetrics and Gynecology, Mt Sinai Medical Center

Charles J Ascher-Walsh, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Obstetricians and Gynecologists, American Medical Association, and Medical Society of the State of New York

Disclosure: Nothing to disclose.

Richard S Legro, MD Professor, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, Pennsylvania State University College of Medicine; Consulting Staff, Milton S Hershey Medical Center

Richard S Legro, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, Endocrine Society, Phi Beta Kappa, and Society of Reproductive Surgeons

Disclosure: Korea National Institute of Health and National Institute of Health (Bethesda, MD) Honoraria Speaking and teaching; Greater Toronto Area Reproductive Medicine Society (Toronto, ON, CA) Honoraria Speaking and teaching; American College of Obstetrics and Gynecologists (Washington, DC) Honoraria Speaking and teaching; National Institute of Child Health and Human Development Pediatric and Adolescent Gynecology Research Think Tank Panel (Bethesda, MD) Honoraria Speaking and teaching; University of Illinois (Chicago, IL) Honoraria Speaking and teaching; Georgetown University Hospital (Washington, DC) Honoraria Speaking and teaching; Heilongjiang University (Harbin, China) Speaking and teaching; New England Fertility Society (Nashua, NJ) Honoraria Speaking and teaching; William Beaumont Hospital Division of Reproductive Endocrinology and Infertility (Detroit, MI) Honoraria Speaking and teaching; Wayne State University School of Medicine (Detroit MI) Honoraria Speaking and teaching

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
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  16. Odejinmi F, Sangrithi M, Olowu O. Operative laparoscopy as the mainstay method in management of hemodynamically unstable patients with ectopic pregnancy. J Minim Invasive Gynecol. 2011 Mar-Apr. 18(2):179-83. [Medline].

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