Ruptured ovarian cyst

Dr Varun Babu and Dr Matt A. Morgan et al.

Ruptured ovarian cysts are one of the most common causes of acute pelvic pain in premenopausal women. The sonographic appearance depends on whether a simple or haemorrhagic ovarian cyst ruptures, and whether the cyst has completely collapsed. The most important differential consideration is a ruptured ectopic pregnancy.

Ruptured ovarian cysts and haemorrhagic ovarian cysts are the most common causes of acute pelvic pain in an afebrile, premenopausal woman presenting to the emergency room 1.

Cysts may rupture during pregnancy (if a very early pregnancy, this may cause diagnostic confusion with ectopic pregnancy).

Rebound tenderness from the pain is possible and the haemorrhage from a cyst can rarely be severe enough to cause shock 2.

Although rupture of an ovarian follicle is a physiologic event (mittelschmerz (German for 'middle pain’)), rupture of an ovarian cyst (>3 cm) may cause more dramatic clinical symptoms.

The pain from a ruptured ovarian cyst may come from stretching the capsule of the ovary, torquing of the ovarian pedicle, or leakage of cyst contents (serous fluid/blood) which can cause peritoneal irritation 2.

It is a common cause of physiological pelvic intraperitoneal fluid.

Ruptured ovarian cysts can have a variety of appearances depending on when the rupture took place, and whether the cyst is haemorrhagic or not. If a candidate is found, it should fulfil the criteria for a cyst:

  • thin wall
    • if haemorrhagic, clot may adhere to cyst wall mimicking a nodule, but has no blood flow on Doppler imaging
  • posterior acoustic enhancement
    • may be less noticeable if harmonics or compound imaging is used
  • there should not be any internal blood flow
    • circumferential blood flow in the cyst wall is possible

If a hemorrhagic cyst ruptures, then low-level echo haemoperitoneum may be present in the pouch of Douglas, Morison's pouch, or in the left upper quadrant.

Treated conservatively in a premenopausal woman unless evidence of hypovolaemic shock (tachycardia and postural drop in blood pressure).

A ruptured haemorrhagic cyst in a perimenopausal woman should be viewed more suspiciously and followed up appropriately. A haemorrhagic cyst or ruptured cyst in a postmenopausal woman deserves surgical evaluation.

Differential considerations on ultrasound include:

Ultrasound - gynaecology
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Article information

rID: 33379
System: Gynaecology
Synonyms or Alternate Spellings:
  • Ovarian cyst rupture
  • Mittelschmerz

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Cases and figures

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    Case 1: with large volume haemoperitoneum
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    Case 2
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