Author Information
Ansari MF*, Parulekar
SV**
(* Assistant Professor,
** Professor and Head of Department
Department of Obstetrics
and Gynaecology, Seth G.S. Medical College and K.E.M Hospital, Mumbai, India.)
Abstract
Corpus luteum
haematoma is known to develop after ovulation, especially in patients
with bleeding disorders (like thrombocytopenia , pancytopenia ) and those on
long term anticoagulant therapy. We report two cases of hemoperitoneum secondary to ruptured corpus luteum haematoma, one
due to
thrombocytopenia in a case of aplastic
anaemia, and the other due to warfarin toxicity. Both were managed successfully by
conservative management.
Introduction
Hemoperitoneum secondary to ruptured corpus luteum haematoma
can happen in patients with underlying blood
dyscrasias like thrombocytopenia , von
Willebrand disease , Glanzmann’s thromboasthenia , other platelet disorders
(qualitative/quantitative), pancytopenia
as in aplastic anaemia and also in those patients who are on long term
anticoagulant therapy. In these patients coagulation mechanism is inefficient to
control slight bleeding that
happens normally at the time of ovulation,
which progresses to the formation of corpus luteum hematoma and its rupture
leading to a hemoperitoneum.
Case 1
A 25 years old nulligravida , married for 4 years, a known case of aplastic anemia came to our hospital casualty with severe pain in abdomen for 2 days. She also had intermittent fever episodes not associated with rigor. On inquiry the patient had neither any gastrointestinal complaints like nausea, vomiting, diarrhea nor bleeding from any site. She was not sure of her last menstrual period. She had recent complaint of menorrhagia for which she was prescribed tablet Danazol 200 mg q8h and with that her complaint was relieved. On clinical examination, the patient had severe pallor , bilateral pedal edema grade 2, pulse rate of 110 beats per minute , and BP of 100/60 mm Hg. There was no icterus , cyanosis nor bleeding from any sites, ecchymoses or petechiae. On abdominal examination, tenderness and guarding were present in the right iliac fossa. There was no rigidity. Systemic examination revealed normal findings. On vaginal examination, the uterus was anteverted, smooth, firm, and mobile. Its size could not be assessed due to hemoperitoneum. There was tenderness and fullness in the right lateral and posterior fornices. The left fornix felt free and non –tender. Urine pregnancy test was negative. Ultrasonography of the abdomen and pelvis done showed a hemoperitonium and a ruptured corpus luteum haematoma on the right side. Her Hb was 5.8gm%, white cell count 3800/cmm, platelet count below 10000/cmm, liver and renal function tests within normal limits. The patient was transfused two units of packed red cells, 4 units of platelets, and intravenous antibiotics. She was monitored by recording her vital parameters, abdominal girth, input (iv fluid+ oral intake) and urine output at frequent intervals. She remained hemodynamically stable and there was no further intraperitoneal hemorrhage. She was discharged after 3 days of treatment, with advice to continue treatment of aplastic anemia and oral contraceptive pills to prevent ovulation and recurrence of formation of corpus luteum hematoma.
Case
2
A 38 years old woman, second para, presented with acute pain in the abdomen for one day. There were no symptoms suggestive of bowel dysfunction in any way. She had had menstrual flow four weeks ago. She was on oral warfarin therapy for deep vein thrombosis, as prescribed by a surgeon at another center. However she had continued the treatment without any monitoring of the prothrombin time and INR. She had been treated by a laparotomy, intestinal resection and anastomosis, and antituberculous therapy for abdominal tuberculosis 4 years ago. On examination, her general condition was fair and vital parameters were within normal limits. Systemic examination was normal. There was a 15 cm long midline abdominal scar, equal length above and below the umbilicus, going around its left. There was tenderness and guarding over the entire abdomen, but no rigidity. Free fluid was present in the abdomen. Peristaltic sounds were normal. Her Hb was 8.5 g/dl, white cell count 6400/cmm, platelet count 234000/cmm, random plasma sugar 108 mg/dl, serum creatinine 1 mg/dl, SGPT and SGOT 12 and 18 U/l, prothrombin time 30 sec and INR 4.3. Her D-dimer level was 0.25 µg/mL. Abdominopelvic ultrasonography showed a moderate-sized hemoperitoneum and right sided corpus luteum hematoma. A diagnosis of overdose of warfarin induced coagulopathy, and hemoperitoneum secondary to a rupture of a corpus luteum hematoma was made. The patient was transfused six units of fresh frozen plasma and two units of packed red cells. Warfarin administration was stopped. Her vital parameters, abdominal girth, and urine output were closely monitored. She remained hemodynamically stable. Her abdominal girth did not increase and urine output was adequate. She made an uneventful recovery after 7 days, when her INR became 2.0. She was discharged after starting warfarin therapy again, with instructions to get prothrombin time and INR monitored as advised.
Discussion
After ovulation mature graafian follicle is transformed to
corpus luteum. The basement membrane of corpus luteum degenerates so that blood
vessels can grow into it in response to various angiogenic factors.[1] The slight bleeding that occurs as a result of
this at the time of ovulation is
efficiently controlled by fibrin formation in women with normal clotting
system. Therefore rupture of
corpus luteum hematoma is rare in healthy women in reproductive age group. But
it is not so uncommon in women with congenital or acquired bleeding disorders
or those on anticoagulant therapy. Corpus luteum hematoma rupture is one of the
differential diagnoses of “acute abdomen” in women of reproductive age. Although
it can occur at any time of life, it is likely to develop in the early period
after menarche.[2] It is described
more from the right ovary as it is believed that the recto-sigmoid colon
helps protect the left ovary from trauma,[3] or it is due to a
higher intraluminal pressure on the right side because of the differences in
ovarian vein architecture.[4] In both of our cases, the patients had
right corpus luteum hematoma rupture. Women with coagulation disorders can have
varied hemorrhagic manifestations ranging from mild mucocutaneous bleeds to
potentially life-threatening internal bleeding. Purpura, epistaxis, gingival
bleeding, and menorrhagia are the most common clinical features. Female
patients in particular are prone to
continuous gynecological and obstetric bleeding challenges, menorrhagia being the most common. Menorrhagia has been reported in 10–70% of
women with bleeding disorder.[5]
Hemorrhagic ovarian cysts are less commonly described in coagulation disorders.
Various studies have described it in conditions such as von-Willierand disease, afibrinogenemia , and deficiencies
in factors X and XIII.[3,6-9] The principle of management
is correction of
underlying coagulation defect to
secure hemostasis. In the past, a
surgical intervention has been the mainstay of therapy - either laproscopy or
laparotomy - resulting in lutectomy (corpus luteum cystectomy), wedge excision
or oophorectomy. But the coagulopathy has to be corrected prior to any surgical
intervention. Conservative management of hemoperitoneum includes
transfusion of blood and blood products to correct the coagulopathy.
It not only avoids unnecessary surgery, but also conserves ovarian function. To
prevent recurrences, combined oral contraceptive pill should be prescribed safely in women
with bleeding disorders but with caution in those who are on anticoagulant. World Health Organization states that combined contraceptives are
deemed unsuitable for use in women who are currently anticoagulated.[10]
Progestin-only methods are all effective contraceptives, though they
are not effective ovulation inhibitors. Progestin-only pill like oral
desogestrel consistently inhibits
ovulation, whereas norethindrone acetate of
0.35 mg inhibits ovulation
only in about 30% of the times.[11]
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