Presentation
Severe abdominal pain 2 days post-OPU (ovum pick-up).
Patient Data
Replacing both ovaries are several multilocular cysts with enhancing walls and septations, some intensely. The largest cyst is on the right and measures 15.0 x 9.6 x 17.0 cm. There is omental fat stranding.
Multiloculated cystic structure in the hepatic caudate lobe (segment I) measuring 3.7 x 2.9 x 4.1 cm altogether. Small hypodense focus in segment II and another one in segment V, both too small to characterize.
Small amount of free intraperitoneal fluid, most of which is perihepatic.
Case Discussion
The patient had undergone OPU, in which none of the harvested follicles contained an ovum. Pertinent history of excision of a large endometrioma.
Physical: Lower abdominal tenderness.
TVUS: Right ovary enlarged due to a large cystic structure containing echogenic fluid. At its periphery ovarian tissue with vascular flow was demonstrated. Several large follicles noted in the ovary. Left ovary with several corpora lutea measuring up to 32 mm, ovarian tissue rich in vascular flow, status post-OPU.
Post-admission, the patient developed leukocytosis with a left shift. Antibiotic treatment was initiated. Additionally, she received preventive enoxaparin (Clexane) due to obesity and hormonal stimulation.
In light of the intraperitoneal fluid and a clinical picture suspicious for sepsis, and with a differential of perforated bowel vs endometrioma which had become infected during OPU, diagnostic laparoscopy was undertaken (the day after the CT was done), which showed:
- a large amount of turbid brown fluid filling the entire abdomen, with many loculations
- a large cyst taking up considerable space, identified as arising from the right ovary
- numerous adhesions between bowels and said cyst, between bowels and the pelvic wall. Omentum adhering to bowels and cyst. Entire pelvis obstructed by adhesions
During the course of the operation, the large cyst ruptured when its mobilization was attempted, releasing a copious amount of turbid fluid. Conversion to diagnostic-therapeutic laparotomy:
- the cyst was drained, then separated from the ovary
- wide excision of most of the omentum, which appeared inflamed, infected, and full of endometriotic foci
- exposure and rupture of numerous intra-abdominal fluid loculations
- multiple irrigations
Histopathology:
- Macro: Torn cyst measuring ~10 cm in diameter, wall thickness 0.8-1.0 cm, outer surface a shiny grey; inner surface greenish-brown, slightly bumpy; no papillae noted.
Micro: Diagnosis: Compatible with ruptured endometriotic cyst. - Macro: Fragment of irregular torn cystic tissue measuring 3X4X6 cm, bumpy, greenish-brown.
Micro: Diagnosis: Fragment of inflamed fibrotic tissue showing areas of endometriosis and wall of endometriotic cyst with foci of necrosis. - Macro: Greenish-brown omentum measuring 2X14X18 cm.
Micro: Diagnosis: Fragment of omental tissue showing extensive hemorrhage, fibrosis, multiple areas of acute and chronic inflammation and small foci of endometriosis.
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