Ruptured ovarian cyst

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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.

Clinical presentation

Ruptured ovarian cysts and haemorrhagic ovarian cysts are the most common causes of acute pelvic pain in 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.

Pathology

Although rupture of an ovarian follicle is a physiologic event (mittelschmerz (German for 'middle pain’)), the 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.

Radiographic features

Ultrasound

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 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
- maybe less noticeable if harmonics or or compound imaging is used
there should not be any internal blood flow
- circumferential blood flow in the cyst wall is possible

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

Treatment and prognosis

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 diagnosis

Differential considerations on ultrasoundinclude:

ectopic pregnancy: differentiate with a positivebeta-hCG level
haemoperitoneum or echogenic intraperitoneal free fluid from another aetiology
ruptured cystic ovarian tumour, with possible pseudomyxoma peritonei
ruptured ovarian dermoid

-<p><strong>Ruptured </strong><strong>ovarian cysts </strong>are one of the most common causes of <a href="/articles/acute-pelvic-pain">acute pelvic pain</a> in premenopausal women. The sonographic appearance depends on whether a <a href="/articles/ovarian-cyst-2">simple</a> or <a href="/articles/haemorrhagic-ovarian-cyst">haemorrhagic ovarian cyst</a> ruptures, and whether the cyst has completely collapsed. The most important differential consideration is a ruptured <a href="/articles/ectopic-pregnancy">ectopic pregnancy</a>.</p><h4>Clinical presentation</h4><p><a href="/articles/ruptured-ovarian-cyst">Ruptured </a>ovarian cysts and <a href="/articles/haemorrhagic-ovarian-cyst">haemorrhagic ovarian cysts</a> are the most common causes of <a href="/articles/acute-pelvic-pain">acute pelvic pain</a> in an afebrile, premenopausal woman presenting to the emergency room <sup>1</sup>.</p><p>Cysts may rupture during pregnancy (if a very early pregnancy, this may cause diagnostic confusion with <a href="/articles/ectopic-pregnancy">ectopic pregnancy</a>).</p><p>Rebound tenderness from the pain is possible and the haemorrhage from a cyst can rarely be severe enough to cause shock <sup>2</sup>.</p><h4>Pathology</h4><p>Although rupture of an ovarian follicle is a physiologic event (mittelschmerz (German for 'middle pain’)), the rupture of an <a href="/articles/ovarian-cyst-2">ovarian cyst</a> (>3 cm) may cause more dramatic clinical symptoms.</p><p>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 <sup>2</sup>.</p><p>It is a common cause of <a href="/articles/physiological-pelvic-intraperitoneal-fluid">physiological pelvic intraperitoneal fluid</a>.</p><h4>Radiographic features</h4><h5>Ultrasound</h5><p>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:</p><ul>
+<p><strong>Ruptured </strong><strong>ovarian cysts </strong>are one of the most common causes of <a href="/articles/acute-pelvic-pain">acute pelvic pain</a> in premenopausal women. The sonographic appearance depends on whether a <a href="/articles/ovarian-cyst-2">simple</a> or <a href="/articles/haemorrhagic-ovarian-cyst">haemorrhagic ovarian cyst</a> ruptures, and whether the cyst has completely collapsed. The most important differential consideration is a ruptured <a href="/articles/ectopic-pregnancy">ectopic pregnancy</a>.</p><h4>Clinical presentation</h4><p><a href="/articles/ruptured-ovarian-cyst">Ruptured </a>ovarian cysts and <a href="/articles/haemorrhagic-ovarian-cyst">haemorrhagic ovarian cysts</a> are the most common causes of <a href="/articles/acute-pelvic-pain">acute pelvic pain</a> in an afebrile, premenopausal woman presenting to the emergency room <sup>1</sup>.</p><p>Cysts may rupture during pregnancy (if a very early pregnancy, this may cause diagnostic confusion with <a href="/articles/ectopic-pregnancy">ectopic pregnancy</a>).</p><p>Rebound tenderness from the pain is possible and the haemorrhage from a cyst can rarely be severe enough to cause shock <sup>2</sup>.</p><h4>Pathology</h4><p>Although rupture of an ovarian follicle is a physiologic event (mittelschmerz (German for 'middle pain’)), the rupture of an <a href="/articles/ovarian-cyst-2">ovarian cyst</a> (>3 cm) may cause more dramatic clinical symptoms.</p><p>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 <sup>2</sup>.</p><p>It is a common cause of <a href="/articles/physiological-pelvic-intraperitoneal-fluid">physiological pelvic intraperitoneal fluid</a>.</p><h4>Radiographic features</h4><h5>Ultrasound</h5><p>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:</p><ul>
~~-<li>posterior acoustic enhancement<ul><li>maybe less noticeable if <a href="/articles/harmonic-imaging">harmonics</a> or compound imaging is used</li></ul>~~
+<li>posterior acoustic enhancement<ul><li>maybe less noticeable if <a href="/articles/harmonic-imaging">harmonics</a> or compound imaging is used</li></ul>
-</ul><p>If a haemorrhagic cyst ruptures, then low-level echo <a href="/articles/haemoperitoneum">haemoperitoneum</a> maybe present in the pouch of Douglas, <a href="/articles/posterior-right-subhepatic-space">Morison's pouch</a>, or in the left upper quadrant.</p><h4>Treatment and prognosis</h4><p>Treated conservatively in a premenopausal woman unless evidence of hypovolaemic shock (tachycardia and postural drop in blood pressure).</p><p>A ruptured <a href="/articles/haemorrhagic-ovarian-cyst">haemorrhagic cyst</a> 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.</p><h4>Differential diagnosis</h4><p>Differential considerations on ultrasound<strong> </strong>include:</p><ul>
+</ul><p>If a haemorrhagic cyst ruptures, then low-level echo <a href="/articles/haemoperitoneum">haemoperitoneum</a> maybe present in the pouch of Douglas, <a href="/articles/posterior-right-subhepatic-space">Morison's pouch</a>, or in the left upper quadrant.</p><h4>Treatment and prognosis</h4><p>Treated conservatively in a premenopausal woman unless evidence of hypovolaemic shock (tachycardia and postural drop in blood pressure).</p><p>A ruptured <a href="/articles/haemorrhagic-ovarian-cyst">haemorrhagic cyst</a> 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.</p><h4>Differential diagnosis</h4><p>Differential considerations on ultrasound<strong> </strong>include:</p><ul>

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Image 11 CT (C+ portal venous phase) ( create )

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case 11

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