Author Information
Pandey Nihita*, Gupta AS**
(* Second Year Resident, ** Professor.Department of Obstetrics and Gynecology,
Seth G.S.
Medical College
and K.E.M Hospital,
Mumbai, India.)
Abstract
Surgical and conservative approaches to manage
the same patient of ruptured corpus luteal hematoma in non consecutive
menstrual cycles indicate that conservative management is a practical alternative
to surgery in patients on chronic anticoagulation.
Case Report
A 35 year old multiparous woman, on oral
warfarin therapy for prosthetic mitral valve, presented to the emergency room with
acute abdominal pain and an INR of greater than 10.0. She had inadvertently
doubled her warfarin dose (from 5 to 10mg daily) due to change in the brand for
the past 2 weeks.
She had undergone an exploratory laparotomy
for expanding hemoperitoneum due to ruptured corpus luteum hematoma 7 months
back. The INR at that time was 5.8. Presently, the patient was pale. Her pulse
was 110 /min, regular and blood pressure was 100/60 mm of Hg. On CVS
auscultation a click was heard. Respiratory system was normal. Scars of midline
sternotomy and a midline vertical infraumblical laparotomy were noted. Abdominal distension, tenderness and guarding
were present. On vaginal examination the
uterus was anteverted and normal sized, There was a left sided minimally tender
cyst of 5x8 cm. Culdocentesis yielded 5
cc of altered blood that failed to clot. Her Hb was 6.9gm%, INR >10.0,
aPTT 90 sec test and 30 sec control; electrocardiogram
showed a RBBB pattern, Ultrasonography (USG) of the abdomen and pelvis showed
signs of hemoperitoneum with loculated pocket of 20 ml in the left iliac fossa
and free fluid in the remaining abdomen. A loculated, 5 cm x 7 cm cyst in the left
ovary was reported.
Figure 1: Ultrasonographic scan showing hemoperitoneum. Arrow marks
the free fluid.
Figure 2: Ultrasonographic scan showing corpus Luteum Hematoma (mass
in pouch of Douglas)
β HCG levels were 1.2mg/dl. Liver, renal
function tests, serum electrolytes were normal. The coagulopathy was corrected
with fresh frozen plasma transfusion (15ml/kg body weight). Warfarin was
stopped; INR was closely monitored until target INR of 2.5 to 3.5 was achieved.
Subcutaneous Heparin 5000 U 6 hourly with warfarin 5 mg/day orally overlap was
started to maintain the INR between 2.5 and 3.5. She was under close
observation for 10 days. As her condition stabilized she was discharged on 5 mg
oral warfarin and instructions for regular follow up. On follow up over the
next 4 months resolution of the hemoperitoneum and the corpus luteum hematoma
was confirmed clinically and by pelvic USG.
Discussion
Normally the corpus luteum basement
membrane degenerates and blood vessels grow into it due to various angiogenic
factors.[1] With normal hemostatic mechanisms, fibrin formation
stops any bleeding.[2] In coagulopathies the bleeding continues and
a hematoma forms. Hematoma ruptures due to mounting intra-cystic pressures
causing hemoperitoneum. Patients on chronic anti-coagulant therapy (warfarin)
are at risk of recurrent vascular accidents like corpus luteal hematoma in
every ovulatory cycle.[3] However, as a hematoma does not form in
every cycle, there is probably a threshold INR level above which these vascular
accidents occur. This patient presented with a hematoma once with an INR of
5.87 and the next time with an INR of > 10.
Conservative management should be the preferred mode of the treatment in
hemodynamically stable patients where the collection is small[4].
Careful monitoring, achieving target anticoagulation, serial USG for resolution
of the hematoma are recommended. Conservative approach is recommended as
repeated surgery and anesthesia increases the morbidity in an already moribund
and high risk patient. Repeated wedge resection of the ovary for hematomas will
eventually leave no ovarian tissue causing early menopause.
Surgery is reserved for large
hemoperitoneums, vascular instability or collapsed patients.[4, 5, 6]
Surgery consists of wedge resection of the ovary (hematoma), drainage of the
hemoperitoneum. Prompt transfusion of
plasma fractions, reversal of anti-coagulation with vitamin K or protamine
sulfate and optimizing the INR levels to the target level (2.5-3.5) is
mandatory. Ovulation suppression with oral contraceptive pills cannot be
recommended in patients with valvular heart disease. Patient education and
regular quarterly monitoring of INR levels can reduce risk of recurrent
vascular accidents.
Conclusion
A determined effort resulting in optimal
correction of the coagulation mechanisms can stop the ongoing bleeding and tilt
the management option in favor of a conservative approach to a ruptured corpus
luteum hematoma. However, this judgment is based on meticulous examination, monitoring,
prompt corrections and round the clock facilities for an emergency exploration.
References
1. Olive DL, Palter SF. Reproductive
Physiology. In Berek and Novak’s Gynecology,
Wolters Kluwer Health – Lippincott Williams & Wilkins, 14th edition,
pg 181.
2. Wong KP, Gillett PG. Recurrent
hemorrhage from corpus luteum during anticoagulant therapy. Can Med Assoc J. 1977;116(4):
388–390.
3. Tresch DD, Halverson G, Blick M, Keelan
MH Jr. Ovarian (Corpus Luteum) Hemorrhage During Anticoagulation Therapy. Ann
Intern Med 1978; 88(5):642-646.
4. A Raziel A, Ron-El R, Pansky M, Arieli S,
et al. Current management of ruptured corpus luteum. Eur J Obstet & Gynecol
and Reprod Biol 1993; 50(1):77-81.
5. Takeda A, Sakai K, Mitsui T, Nakamura H.
Management of ruptured corpus luteum cyst of pregnancy occurring in a
15-year-old girl by laparoscopic surgery with intraoperative autologous blood
transfusion. J Ped Adol Gynecol. 2007; 20(2):97-100.
6. Webb N, Lucidi RS. Ovarian Cyst Rupture
Treatment & Management. Available at
http://emedicine.medscape.com/article/253620-overview#showall.
Citation
Pandey N, Gupta AS.
Conservative Management of Corpus Luteum Hematoma and Hemoperitoneum Due to
Warfarin Toxicity: An Alternative Treatment Modality. JPGO Volume 1 Issue 2,
February 2014, available at:http://www.jpgo.org/2014/02/conservative-management-of-corpus.html