Rupture of the ovary or medical terminology "apoplexia" (apoplexia ovarii) is defined as a sudden onset of hemorrhage into an organ when the vessels of the graafian vesicle, ovarian stroma, follicular cyst or corpus luteum cyst rupture, accompanied by a violation of the integrity of the ovarian tissue and bleeding into the abdominal cavity.

Most often, ovarian ruptures occur between the ages of 14 and 40, usually between the ages of 20 and 35. However, there are cases of hemorrhage in young girls and adolescents. Its frequency among gynecological pathology is 1-3%, relapse in the absence of adequate rehabilitation reaches 40-70%.

HOW OVARIAN APOPLEXIA ARISES

In the ovaries of a sexually mature woman, follicles grow, the ovum matures in them, that is, preparation for the upcoming pregnancy. From the beginning of the menstrual cycle, a dominant follicle begins to grow, which by the middle of the menstrual cycle reaches its maximum size - about 20 mm. Then the follicle membrane ruptures, releasing a mature egg from itself - ovulation occurs. In place of the bursting follicle, a temporary formation is formed - the corpus luteum, which produces certain hormones that prepare the woman's body for pregnancy. This is the normal course of the ovarian cycle.

With dystrophic and sclerotic changes in ovarian tissue, which occur in acute and chronic inflammatory processes in the uterine appendages, with polycystic ovary syndrome, adhesions and some other diseases, as well as with drug stimulation of ovulation, certain disorders occur in the process of ovulation and the formation of the corpus luteum. As a result, the blood vessels at the site of the rupture of the ovary are poorly contracted, intra-abdominal bleeding continues and intensifies, and in the corpus luteum, due to the fragility of the vessels, a hemorrhage forms - a hematoma. All this is accompanied by pain, weakness, dizziness, nausea, vomiting, pallor of the skin, fainting. Without proper treatment, internal bleeding from a ruptured ovary can increase, posing a real threat to the health and life of a woman.

CAUSES OF OVARY RUPTURE

Most doctors identify "critical moments" for ovarian damage. So, in 90-95% of patients, ovarian apoplexy occurs in the middle and in the second phase of the menstrual cycle. This is due to the peculiarities of the ovarian tissue, in particular, with increased vascular permeability and an increase in their blood supply during ovulation and before menstruation.

Apoplexy of the right ovary occurs 2-4 times more often than the left, which is explained by its more abundant blood circulation, since the right ovarian artery departs directly from the aorta, and the left - from the renal artery.

In women, inflammatory processes of the pelvic organs are primarily predisposed to rupture of the ovary, leading to the adhesions and, as a consequence, to sclerotic changes both in the ovarian tissue (stromal sclerosis, fibrosis of epithelial elements, perioophoritis) and in its vessels (sclerosis, hyalinosis ), as well as congestive hyperemia and varicose veins of the pelvic organs.

Ovarian apoplexy can be promoted by blood diseases and prolonged use of anticoagulants, leading to disruption of the blood coagulation system.

Other causes include abdominal trauma, physical stress, violent or interrupted intercourse, horse riding, douching, vaginal examination, etc. They can be incorrect position of the uterus, mechanical compression of blood vessels, adhesions in the small pelvis, etc. Sometimes occurs for no apparent reason at rest or during sleep.

The leading role in the development of this condition is currently assigned to hormonal disorders. One of the main causes of ovarian rupture is considered an excessive increase in the amount and change in the ratio of gonadotropic hormones of the pituitary gland (FSH, LH, prolactin), which contributes to hyperemia of ovarian tissue.

MAIN FORMS OF APOPLEXIA IN THE OVARY

Allocate painful, anemic and mixed forms of ovarian apoplexy. Currently, the most commonly used classification (Savelyeva G.M.), taking into account the severity of intra-abdominal blood loss:

1. Painful form.

2. Hemorrhagic form:

I degree - mild (intra-abdominal blood loss does not exceed 150 ml);
... II degree - medium (blood loss 150-500 ml);
... III degree - severe (intra-abdominal blood loss of more than 500 ml).

Symptoms of Ruptured Ovary

The main complaint of a ruptured ovary in women is sudden pain in the lower abdomen. The pain is associated with irritation of the receptor field of the ovarian tissue and the effect on the peritoneum of the outflowing blood, as well as with spasm in the basin of the ovarian artery. Signs such as weakness, dizziness, nausea, vomiting, fainting are associated with intra-abdominal blood loss.

The painful form of apoplexy is observed with hemorrhage into the tissue of the ovary or corpus luteum without bleeding into the abdominal cavity. The disease is manifested by an attack of pain in the lower abdomen without irradiation, sometimes with nausea and vomiting. There are no signs of intra-abdominal bleeding. The clinical symptoms of painful and mild hemorrhagic forms are similar.

In the clinical picture of moderate and severe hemorrhagic (anemic) forms of ovarian apoplexy, the main symptoms are associated with intra-abdominal bleeding. The disease begins acutely, often associated with external causes (sexual intercourse, physical stress, trauma, etc.). Pain in the lower abdomen often radiates to the anus, leg, sacrum, external genitals, accompanied by weakness, dizziness, nausea, vomiting, and fainting. The severity of symptoms depends on the amount of intra-abdominal blood loss.

DIAGNOSTICS

With ultrasound of the small pelvis, a significant amount of free fine and medium-dispersed fluid is determined in the abdominal cavity with structures of irregular shape, increased echogenicity (blood clots). To diagnose ovarian apoplexy without pronounced disturbances in general well-being, puncture of the abdominal cavity is used through the posterior fornix of the vagina. However, diagnostic laparoscopy is the optimal method of choice.

TREATMENT OF OVARIAN APOPLEXIA

The approach to the treatment of patients with ovarian apoplexy depends on the form of the disease and the severity of intra-abdominal bleeding. With a painful form and insignificant intra-abdominal blood loss (less than 150 ml) without signs of increased bleeding, it is possible to carry out conservative therapy... Drug treatment for ovarian apoplexy includes rest, ice on the lower abdomen (promotes vasospasm), hemostatic drugs, antispasmodics, vitamins, physiotherapeutic procedures (electrophoresis with calcium chloride, microwave therapy), especially during the rehabilitation period.

Conservative therapy for ovarian ruptures is carried out in a hospital under round-the-clock supervision. With positive dynamics from conservative therapy, the patient is discharged under the supervision of an outpatient gynecologist for further treatment and prevention of relapses and complications.

With a hemorrhagic form, a repeated attack of pain, a deterioration in the general condition, instability of hemodynamics, an increase in the amount of blood in the abdominal cavity, clinically and with ultrasound of the small pelvis, indications appear for surgical intervention(laparoscopy, laparotomy). At the same time, it is necessary to compensate for blood loss (retransfusion, transfusion of donor blood, blood substitutes), if necessary, cardiovascular drugs are administered.

Ovarian apoplexy is rare, but its consequences and complications can remain with a woman for life. Therefore, an extremely important role in maintaining women's health and reproductive function, in particular, is assigned to the recovery stage and the prevention of relapse. Preventive measures are aimed at reducing the likelihood of re-rupture of the ovary. In order to prevent recurrence of the condition and restore the hormonal status, the patient is prescribed oral contraceptives. Gynecologists recommend that women and girls avoid the factors that provoke this condition, undergo examinations every six months and contact a specialist for help in time. Timely treatment of diseases of the uterus and its appendages contributes to the healthy functioning of the entire reproductive system.

I am sure that many, after reading the title of the article, will go to Google, because the definition of "ovarian apoplexy" is not one that is used in everyday life. One feels that something is not good, but what exactly is hidden behind this mysteriously threatening phrase, the normal average person in most cases does not know. Well, I will not torment with anticipation, especially since the feeling of anxiety in this case is justified: apoplexy is a sudden rupture. Just imagine - a rupture of an internal organ ... The case is, without a doubt, the most serious, requiring urgent treatment. It cannot be said that this is a common disease: among all "female" diseases, ovarian apoplexy accounts for only 2-3%. How to recognize ovarian apoplexy, how to treat it, is surgery always indicated - you will learn about all this from our article.

Apoplexy (rupture) of the ovary: where does that come from

A symptom of ovarian apoplexy is a sharp spontaneous pain in the lower abdomen. Probably, before proceeding to the description of the symptoms, it will be useful to understand the very nature of this pathology. The fact that the female body is different from the male, like "Cayenne" from "Priora", is the "secret of Opening". That is, from a structural and technical point of view, it is a more highly organized biological unit, the functioning of which during a certain period of its life - reproductive - is strictly cyclical. All this time, the female ovaries are suppliers of vesicular tissue formations - follicles, which serve as a receptacle for a maturing egg. In the initial phase of each menstrual cycle, in some way unknown to modern science, the only dominant follicle is selected: this time the egg will mature in it. By the middle of the cycle, the follicle that has reached 20 mm by this time ruptures, and the egg comes out. This is called ovulation. The place of the bursting ex-follicle is not empty for a long time: a new tissue structure is formed here - the corpus luteum, the role of which is in the secretion of the female sex hormone progesterone, which prepares a woman for pregnancy.
Ideally, this is the case, but not always. Sometimes in this system that works like a clock, any unfavorable factors interfere, under the influence of which the ovarian tissue undergoes sclerotic and dystrophic degeneration, which negatively affects the formation of the corpus luteum. Because of this, in the area of ​​the bursting follicle, blood circulation is locally disturbed, and the ovary begins to bleed (i.e., its perforation occurs) into the abdominal cavity with the formation of a hematoma in the corpus luteum.

Causes of ovarian apoplexy

Among the causes of ovarian apoplexy are the following:

• sclerotic changes in the inner walls of the vessels of the ovary and the tissue forming it due to previous inflammatory diseases;
• long-term use of drugs that prevent blood clotting;
• external mechanical factors, which, together with the above reasons, contribute to an increased risk of ovarian apoplexy (abdominal trauma, rough sexual contact, horseback riding, gynecological manipulations).

Symptoms of ovarian apoplexy

The first thing that suggests ovarian apoplexy is a sharp spontaneous pain in the lower abdomen, “shooting” into the lumbar region, navel or lower extremities. Pain syndrome is associated with irritation of pain receptors of the ovary and peritoneum with opened bleeding and spasm of the ovarian artery. The time of manifestation is after a delay in menstruation or in the middle of the menstrual cycle.

If we really delve into the essence of the issue, then it should be mentioned about the existence of two forms of ovarian apoplexy: painful and hemorrhagic. In the first case, there is a distinct pain without obvious signs of bleeding, in the second, on the contrary. But if you think sensibly, then if there is no bleeding, then there is no apoplexy, therefore, each of the forms cannot exist in a single distilled genus. In this regard, it would be appropriate to highlight not the forms of apoplexy, but different degrees of severity, depending on the amount of blood loss. Therefore, the onset of the disease is characterized by pain symptoms, and as blood loss increases, hemorrhagic (anemic) symptoms appear. What symptoms are inextricably linked to blood loss? Dizziness, weakness, nausea with vomiting, decreased blood pressure, tachycardia, dry mouth, possible fainting.

Diagnosis of ovarian apoplexy

The peculiarity of the diagnosis of ovarian apoplexy is the required promptness of the correct diagnosis due to the acute nature of this pathology. The algorithm for diagnosing ovarian apoplexy includes an initial examination, during which the doctor observes in the patient a distinct painful sensation caused by a ruptured ovary. In a laboratory study of blood, hemoglobin reduced due to blood loss is determined. A puncture of the posterior vaginal fornix is ​​done to confirm intraperitoneal bleeding. Blood in the abdominal cavity and hematoma of the corpus luteum are visible on ultrasound. The final confirmation of the correctness of the diagnosis is provided by a laparoscopic examination.

Ovarian apoplexy treatment

Conservative

Apoplexy of the right ovary In the initial stage, with insignificant non-progressive blood loss, it is possible to do without surgery. Conservative treatment methods include taking hemostatic ( etamsylate, dicinone) antispasmodic (no-spa, papaverine) drugs, vitamins (B1, B6, B12), physiotherapy (electrophoresis of calcium chloride solution, microwave therapy). However, as practice shows, conservative treatment is not the best choice due to possible relapses of the disease as a result. In 50% of cases, after conservative treatment, ovarian apoplexy occurs again... The blood does not go anywhere from the abdominal cavity, and in the future, against this background, the adhesion process starts. And the consequences of recurrent ovarian apoplexy are. Conclusion: conservative treatment of ovarian apoplexy is indicated only for mild forms of the disease and only for those women who do not plan offspring.

Surgical

In other cases, as well as with direct indications for surgery (the presence of more than 150 ml of blood in the abdominal cavity, repeated bouts of pain, deterioration of the general condition) is shown surgery... It must be extremely careful in order to preserve the ovary (except in cases where this is no longer possible - with profuse hemorrhages). Coagulation of the rupture site or suturing of the ovary is performed, removal of the capsule contents after puncture of the ovarian cyst using suction. The abdominal cavity is washed from blood clots to avoid adhesions.

Patients in whom treatment for apoplexy was started in the early, painful phase, even before massive blood loss, as a rule, tolerate the disease without serious consequences. If the treatment began too late, when blood loss reached 50% of the total circulating blood volume, a fatal outcome is possible.

Apoplexy of the ovary is a sharp hemorrhage due to a rupture, for example, a cyst located there. In addition, a ruptured vesicle, a follicle containing an egg, or a rupture of the connective tissue of an organ, the stroma, can also lead to apoplexy. Any internal bleeding is dangerous for the body and ovarian apoplexy is no exception.

Causes of the disease

Ovarian apoplexy in most cases is observed in adolescent girls and women of childbearing age (14–45 years). This age range can be explained by the constant active maturation of follicles in a woman's body, which contain an egg. Most often, the disease affects patients aged 20 to 35 years. In very rare cases, such hemorrhages occur in girls who have not yet reached puberty. The disease has a complex mechanism of development and, unfortunately, is characterized by frequent relapses.

As you know, the female reproductive system works cyclically: first, an egg matures in the graafian ovarian bubble, then the follicle ruptures, and the mature cell is sent to a possible meeting with the sperm. If such a "date" did not happen, she dies over a certain period of time, and menstruation sets in, renewing the uterine lining, which has not yet received a fertilized egg. In this monthly recurring process, there are certain periods of increased risk of damage to the ovary - this is the middle and second half of the menstrual cycle. It is during this period that the vessels feeding the uterine appendages become the most permeable, they are overwhelmed with blood.

Hemorrhage in the right ovary occurs several times more often than in the left, but there is no mystery here - just in the right appendage, blood circulation occurs more intensively due to the fact that the artery feeding it branches out directly from the aorta, and the bloodstream of the left appendage originates from the renal artery.

Ovarian apoplexy can occur for the following reasons:

• acute and especially chronic inflammation of the internal organs of the female genital area;
• improper position of the uterus, usually congenital;
• the presence of tumors that put pressure on the ovary;
• due to postoperative adhesions in the small pelvis;
• varicose veins of the ovary;
• blood clotting disorders (thrombocytopenia) due to taking anticoagulant drugs or a number of diseases.

Able to provoke hemorrhage:

• mechanical damage to the pelvic organs, for example, trauma;
• physical strain, too intense or rough sex;
• inept douching, rough examination by a gynecologist;
• horseback riding.

Forms and signs of ovarian apoplexy

Gynecologists use several options for classifying ovarian apoplexy, the most popular of which is the division of the disease into two forms - painful (without intra-abdominal bleeding) and hemorrhagic (with intra-abdominal bleeding). The hemorrhagic form, in turn, is divided into three degrees, depending on the volume of internal blood loss. With a painful form, hemorrhage also occurs, but it is limited to the ingress of blood into the tissues of the ovary - corpus luteum or follicle, blood does not enter the abdominal cavity.

Symptoms

Both forms of ovarian apoplexy have similar symptoms. The main symptom can be considered a sharp, unexpected pain in the lower abdomen. Then the feeling of pain is joined by nausea and weakness, which are the result of blood loss.

The main symptom of ovarian apoplexy is a sharp, sudden pain

In the hemorrhagic form of the disease, if blood loss increases, these symptoms may be joined by signs indicating intra-abdominal bleeding:

• vomit;
• loss of consciousness;
• pallor of mucous membranes and skin;
• clammy sweat;
• cardiopalmus;
• lowering blood pressure.

On examination, the doctor detects tension in the anterior abdominal wall and bloating. Touching the abdomen is extremely painful for the patient.

Basic diagnostic methods

Ovarian apoplexy is an insidious disease that can disguise itself as an ectopic pregnancy, which in many cases leads to an incorrect diagnosis. Sometimes it happens that an accurate diagnosis of the disease occurs only on the operating table, when providing emergency care.

In order to differentiate ovarian apoplexy and ectopic pregnancy, the following differences must be considered:

In addition, with ovarian apoplexy, extreme soreness is noted during a two-handed vaginal examination.

To clarify the diagnosis, the following are usually used:

• a blood test showing a decrease in hemoglobin levels;
• examination using ultrasound, which allows you to detect the accumulation of fluid;
• puncture of the abdominal cavity, which is performed through the vagina.

It should be noted that if a patient shows signs of cavity bleeding, she in any case needs an urgent surgical operation, regardless of what caused this bleeding. Differential diagnostics are not important here.

Apoplexy of the right ovary can simulate an attack of appendicitis, however, with apoplexy, pain radiates to the anus and right leg, while with appendicitis, pain is concentrated in the midline of the abdomen above the navel. For differential diagnosis, it is important to take into account the fact that with appendicitis, examinations through the rectum are especially painful for the patient, and with apoplexy, severe pain is caused by the effect on the uterus.

Ovarian apoplexy should also be differentiated from such diseases:

• adnexitis (inflammation of the uterine appendage);
• torsion of the legs of the ovarian cyst;
• intestinal obstruction;
• perforated stomach ulcer;
• an attack of pancreatitis and colic - hepatic and renal.

How is ovarian apoplexy treated?

The method of treatment will be chosen by the doctor depending on the form of the disease and the patient's condition.

Operation

When a large amount of blood (more than 150 ml) is poured into the abdominal cavity, an urgent (urgent) surgical operation is performed.

Surgical intervention can be carried out both in the traditional way - by making an incision with a scalpel in the suprapubic or lower median region, or in a more gentle way - laparoscopic, using special surgical instruments introduced into the abdominal cavity through small punctures. Both methods allow to carry out the necessary amount of surgical intervention - to coagulate the rupture site, remove or puncture the cyst, remove the blood that has entered the abdominal cavity, and even remove the damaged ovary, if necessary. The choice of the method of performing a surgical operation depends on a number of factors - the presence of adhesions, the degree of bleeding intensity, the severity of the patient's condition.

Operation by laparoscopic method

In what cases is conservative treatment prescribed?

In the absence of bleeding (painful form of apoplexy), or with minor bleeding, it is possible to use conservative treatment, which consists in the following:

• a hot water bottle with ice on the lower abdomen;
• hemostatic drugs (Vikasol, Etamsilat, etc.);
• antispasmodics (No-shpa);
• vitamins B1, B6, B12;
• electrophoresis with calcium chloride or microwave physiotherapy.

Conservative therapy is possible only in a hospital setting and under the supervision of a doctor... If the patient's condition worsens, there may be indications for surgery.

Conservative therapy has a number of significant drawbacks that determine the use of this type of treatment in relation to women who, in the future, no longer plan to have children, since such therapy often provokes infertility. After it, as a rule, adhesions are formed due to the impossibility of removing blood residues, and there is a high risk of recurrence of the disease. If the patient is planning a pregnancy, she will most likely be offered surgery.

Folk remedies

Traditional medicine also has treatments for ovarian apoplexy. However, it should be emphasized here that such self-medication is possible only with a mild painful form of the disease and with a well-established diagnosis. When resorting to popular recommendations, a woman should be aware of the high risk of such self-medication.... Here are some recipes:

1. Wrap the flax seed (20 g) in several layers of cheesecloth and dip in boiling water to steam. Then squeeze the bundle with the seed and apply overnight to the ovary area.
2. Prepare a decoction of burdock root (10 g), pouring a glass of boiling water over it and insist for 12 hours. You need to take the broth three times a day half an hour before eating.
3. In a similar way, you can steam a rape (10 g) with a glass of boiling water, insist and take in the same way.
4. You can try taking one tablespoon of freshly squeezed aloe juice half an hour before meals with a little water.

How to behave after healing

The main thing that a woman needs to strive for is the restoration of reproductive function, and this requires measures to prevent the formation of adhesions and establish hormonal metabolism. Most likely, the patient will be offered a course of anti-inflammatory therapy, and to optimize the hormonal balance and suppress the ovulation process, combined low-dose (Regulon, Femoden) or micro-dose contraceptives (Mersilon, Novinet) are usually prescribed, which must be taken for at least six months. The decision on the duration of their use is made by the attending physician on an individual basis.

For the most effective rehabilitation of the patient, physiotherapeutic methods can also be used - ultrasound, laser therapy, ultratonotherapy, electrophoresis.

Menstruation can recover within a month or a month and a half after the operation, but pregnancy can be planned only after the end of rehabilitation measures, the completion of hormonal drugs, a detailed examination and consultation with a gynecologist. As for the resumption of sexual activity, a doctor's consultation is also necessary, since it depends on the severity of the cured ailment, the form of treatment and the objective condition of the woman.

Prophylaxis

Unfortunately, often in patients who have undergone ovarian apoplexy, relapses of the disease are observed. You should be careful about your health and take medications that your doctor will prescribe depending on the cause of the disease (for example, hormones, nootropics, tranquilizers, etc.), and also avoid excessive physical exertion and lifting weights.

A regular visit to a gynecologist is an effective method for the prevention of diseases of the pelvic organs

It is necessary not to forget to visit the gynecologist twice a year, as well as timely treat infectious and inflammatory diseases of the pelvic organs.

Ovarian apoplexy is a serious disease that has a high risk of dangerous complications and can lead to tragic health consequences. The disease must be accurately diagnosed and treated only within the walls of a medical institution. Self-diagnosis and self-medication are highly undesirable in this case.

The site provides background information for informational purposes only. Diagnosis and treatment of diseases must be carried out under the supervision of a specialist. All drugs have contraindications. A specialist consultation is required!

Ovarian apoplexy(apoplexia ovarii) is an acute gynecological disease, as a result of which a rupture of blood vessels occurs (these can be the vessels of both the ovary itself and the formed cyst), and a sudden hemorrhage develops into the ovarian tissue or into the abdominal cavity.

Anatomy and physiology of the ovaries

The ovaries are a paired organ located on either side of the uterus in the small pelvis. Their average length is 3 cm, thickness is 1 cm, and width is 2 cm. But these dimensions are not constant, and change throughout the month depending on the phase of the menstrual cycle. The ovaries are the female sex glands, they produce sex hormones (progesterone and estrogens), and every month an egg is formed, which can give life to a new organism. The ovaries have their own ligaments through which they attach to the uterus.

Prevalence of the disease

Ovarian apoplexy occurs at any age, but most often rupture occurs in women of childbearing period (from 18 to 45 years), since it is at this age that the ovaries are actively working. Among all gynecological diseases, ovarian apoplexy is about 1-3%. And if there is a rupture of the ovary, then the likelihood of a recurrence of the disease is very high - up to 70%. In this case, apoplexy of the right ovary is observed 3 times more often than the left. This is due to the fact that the right ovary has many more blood vessels.

Causes

I. Inflammatory diseases of the pelvic organs (the ovaries themselves, uterus, fallopian tubes). As a result of inflammation, the tissue of the ovary and the blood vessels feeding it are modified, which can cause them to rupture.
II. Varicose enlargement of the ovarian (ovarian) veins and their changes in various diseases.
III. Blood clotting disorders (with congenital and acquired blood diseases, such as hemophilia) or taking medications that cause blood thinning.
IV. Violation of the balance of sex hormones in the body.
V. Diseases of the nervous system, stress, nervous strain.

Against the background of these reasons, there are external and internal factors that can provoke ovarian apoplexy.

Internal factors:

• Adhesions in the small pelvis.
• Pressure on the ovary from a nearby tumor (this can be uterine fibroids or tumors other than female genital organs).
• Violation of blood flow in the ovary and the vessels feeding it.
• Incorrect position of the uterus.

External factors:

• Excessive physical stress.
• Abdominal trauma.
• Sexual intercourse (especially in the middle of the menstrual cycle).
• The act of defecation.
• Horseback riding.
• Examination by a gynecologist using mirrors.

However, as a rule, the provoking factor is never identified; in such situations, ovarian apoplexy occurs at night, during restful sleep.

The main symptoms

The most important symptom of ovarian apoplexy is a sharp, sharp pain that appears. The disease develops so suddenly that the patient, with an accuracy of minutes, can name the time of the onset of pain.
Pain syndrome with apoplexy is associated with the ingress of blood into the abdominal cavity and irritation of the peritoneum covering the internal organs.
In addition to pain, the patient will be disturbed by weakness, dizziness. Nausea and vomiting may occur. And in the case of severe internal bleeding, loss of consciousness may occur.

Forms of the disease

The manifestations of ovarian apoplexy depend on the clinical form of the disease.
The painful form of ovarian apoplexy is observed when hemorrhage occurs inside the ovary itself (when the egg is released). The disease begins with a sharp pain in the lower abdomen, sometimes accompanied by nausea and vomiting, but there are no signs of internal bleeding (weakness, decreased pressure, fainting).

Hemorrhagic, or anemic form. The disease develops sharply, and is often associated with external provoking factors - sexual intercourse, physical activity, trauma. The main symptoms in this form of apoplexy are associated with intra-abdominal bleeding. The pain is felt in the lower abdomen, often radiates to the leg, rectum, external genitalia, sacrum and back. There is almost always weakness, dizziness, nausea, and vomiting. With severe internal bleeding, there is an increase in heart rate, a decrease in pressure and loss of consciousness.

Mixed form. Signs of ovarian apoplexy in this form begin with pain, but with profuse bleeding, manifestations of the anemic variant of apoplexy are added.

Diagnostics

The diagnosis of ovarian apoplexy is made on the basis of a consistent study of complaints, medical history, examination of the patient, the results of the tests performed and additional instrumental examination methods.

I. Complaints: pain, nausea, vomiting, signs of internal bleeding.

II. History of the disease. In 90-95% of women, ovarian apoplexy occurs in the middle or in the second phase of the menstrual cycle (after 14-21 days from the beginning of menstruation). These are the so-called "critical moments" because during ovulation (release of the egg) and before menstruation, the blood vessels become more permeable and congested, which contributes to their rupture.

III. Examination of the patient. The general condition will depend on the form of apoplexy. With a painful form, the general condition will be satisfactory. Normal skin color, pulse and blood pressure will be within normal limits. The abdomen remains soft, painful above the pubis, often on the right. With the hemorrhagic form of ovarian apoplexy, pallor of the skin and mucous membranes will be observed, there may be cold clammy sweat. The patient's blood pressure will be lowered and the pulse quickened. There is bloating and severe soreness in the lower sections.

IV. General clinical analyzes. In the general analysis of blood, the hemoglobin index decreases (but in acute severe blood loss due to thickening of the blood, it can remain normal), the level of leukocytes (inflammatory cells) may be increased.

V. Instrumental research. On ultrasound with ovarian apoplexy, fluid (blood) in the abdominal cavity will be determined. For an accurate diagnosis of the nature of the fluid, medical manipulation is performed - a puncture (puncture) of the abdominal cavity through the vagina. This intervention is performed under general anesthesia. If this study did not help to make a diagnosis, an operation is performed - diagnostic laparoscopy.

Conservative treatment

The tactics of treatment will depend on the form of the disease and the severity of the patient's condition.
Conservative (non-surgical) treatment of ovarian apoplexy can be performed in painful form, when the patient feels satisfactory and there are no signs of internal bleeding.
Conservative treatment includes:
1. Complete rest.
2. Coldness on the lower abdomen (this helps to reduce pain and vasoconstriction).
3. Hemostatic drugs (sodium ethamsylate, etc.).
4. Drugs that relieve spasms (no-shpa, papaverine, etc.).
5. Vitamin therapy: vitamins B 1, B 6 and B 12 are prescribed.
6. Physiotherapy procedures: microwave treatment, electrophoresis with calcium chloride.

Treatment should be carried out only in a hospital, under the round-the-clock supervision of medical personnel. In the event of a recurrence of a painful attack, with a deterioration in the general condition and test indicators, the question of conducting an operation is considered.

Surgery

Operation for ovarian apoplexy can be performed in two ways: laparotomically (through an incision) and laparoscopically (through punctures of the abdominal wall).
Indications for laparoscopy for ovarian apoplexy:

• The lack of effect from the non-operative treatment carried out within 1-3 days.
• Continuous internal bleeding, confirmed by ultrasound.
• Differential diagnosis of ovarian apoplexy and other acute gynecological or surgical pathology.
• If the patient is in a satisfactory condition, normal test values ​​and the presence of no more than 150 ml of blood in the abdominal cavity.

Indications for laparotomy:

• If for some reason it is impossible to conduct laparoscopy (adhesions in the abdominal cavity, profuse bleeding from the vessels located on the surface of the ovary).
• Emergency care for ovarian apoplexy with severe internal bleeding with a violation of the general condition (low pressure, leading to a state of shock with loss of consciousness).

In a laparotomy, a small incision is made over the pubis (as in a caesarean section), and laparoscopic surgery is performed through 3 small punctures on the anterior surface of the abdomen. Surgical intervention, regardless of access, should be as careful as possible: cauterization of the rupture site is performed to stop bleeding, or bandaging of a bleeding vessel; in the presence of a cyst, it is opened and the contents removed. Then, the abnormal ovarian tissue is removed. And only in case of large damage, when it is not possible to preserve the ovary, it is completely removed.

Differential diagnosis for ovarian apoplexy

Differential diagnosis for apoplexy is carried out with the following diseases:
1. Gynecological: rupture of the tube during ectopic pregnancy, purulent formation of the fallopian tube, torsion of the leg of the ovarian cyst.
2. Surgical: appendicitis, acute intestinal obstruction, pancreatitis, intestinal colic, gastric ulcer.

Pregnancy after ovarian apoplexy

Ovarian rupture by itself does not affect the further possibility of conception, because during the operation, partial removal of the ovary is performed. But even when the ovarian tissue is completely removed, the egg can mature in a second, healthy ovary.

Difficulty conceiving can arise when adhesions form in the abdominal cavity. To minimize the consequences of ovarian apoplexy, it is necessary to follow all the doctor's recommendations during the rehabilitation (recovery) period:
After undergoing surgery for ovarian apoplexy, the need for prophylaxis is determined by the form of the disease. If there was a painful form of apoplexy, special preventive measures to prevent re-apoplexy are not required, since all changes in the level of hormones and blood supply in the ovary soon return to normal on their own.

Prophylaxis is necessary for those patients who have suffered a hemorrhagic form of apoplexy, since they have persistent hormonal disorders and the functioning of the central nervous system.
In such a situation, a set of measures is assigned, which includes the use of:

• Medicines that improve the activity of the nervous system (the so-called nootropic drugs - piracetam, nootropil).
• Drugs that improve cerebral circulation (tanakan, cavinton, vinpocetine).
• Diuretics for increased intracranial pressure.
• Drugs that normalize the hormonal status of the body (

Ovarian apoplexy- sudden damage to tissue and blood vessels ovary, as a result of which there is bleeding into the abdominal cavity. This pathology is accompanied by pain and blood loss of varying degrees. The tenth revision of the International Classification of Diseases ( ICD-10) ovarian apoplexy is highlighted in two points. Item N83.0 corresponds to hemorrhagic follicular ovarian cyst, and item N83.1 corresponds to hemorrhagic cyst of the corpus luteum.

This pathology is usually typical for women of reproductive age. As a rule, women 25-40 years old suffer from this disease. Ovarian apoplexy is more often observed in the second phase of the menstrual cycle or during ovulation ( the process by which a mature egg leaves the ovary). It is not uncommon for ovarian tissue to rupture during pregnancy. Relapse ( re-exacerbation) ovarian apoplexy occurs in 40 - 70% of cases.

Interesting Facts

• Long-term anticoagulant treatment ( anticoagulants) increases the likelihood of ovarian apoplexy.
• A sudden rupture of ovarian tissue sometimes occurs even during sleep.
• Horseback riding can cause ovarian apoplexy.
• According to statistics, apoplexy of the left ovary occurs 3 times less often. The thing is that the left ovary is fed by a smaller artery, and the blood circulation in it is less intense than in the right ovary.
• Not only women of reproductive age can suffer from this pathology. Cases of ovarian apoplexy at the age of fourteen have been described.
• Ovarian apoplexy can cause severe bleeding. The volume of blood loss in some cases is more than 1 liter. This massive bleeding can be life-threatening.

Ovary anatomy

The ovaries are a paired female organ. The average size of an ovary is 3 to 4 cm in length, 2 to 2.5 cm in width and 1 to 1.5 cm in thickness. In shape, the ovary resembles a peach bone. The weight of the ovary of an adult woman is 5 - 7 g, in an elderly woman - 3 g, and in a newly born girl - less than a gram. The ovaries are located in the small pelvis, on both sides of the uterus. The ovaries are connected to the uterus with the help of ligaments. The blood supply to the ovaries is provided by the egg arteries. The right testicular artery has a larger caliber, since it departs directly from the abdominal aorta. The left testicular artery is a branch of the renal artery. Due to the fact that the right ovary is supplied with blood by a larger artery in size, it is slightly larger than the left.

The following components can be distinguished in the structure of the ovary:

• coelomic epithelium;
• tunica albuginea;
• cortical substance;
• medulla.

Coelomic epithelium

From above, the ovary is covered with coelomic epithelium. In its shape, it is a single-layer cubic epithelium. Its height is about 20 microns. This type of epithelium serves as a barrier and limits the ovary from other organs and tissues. Also, the coelomic epithelium takes part in the synthesis of certain substances.

Albuminous membrane

The tunica albuginea is located immediately under the coelomic epithelium. The thickness of this shell is 100 µm. The tunica albuginea contains significant amounts of collagen and elastin. Collagen is the main protein in connective tissue and is responsible for strength. The function of elastin is to give elasticity and flexibility to tissues. Also elastin contributes to the regenerative function ( allows tissues to rebuild their structure after injury). Along with collagen and elastin, the tunica albuginea contains a small amount of smooth myocytes ( muscle cells). It should be noted that the tunica albuginea is formed in the fourth year of life.

Cortical substance

Two structures can be distinguished in the cortex - the stroma and the parenchyma. The stroma is the base of the organ, it is rich in connective tissue, which gives strength to this organ. The stroma of the cortex contains a large amount of collagen. Also, the stroma contains interstitial cells that perform the function of synthesizing estrogen precursors ( female sex hormones). In the parenchyma, where the main functioning cells are located, follicles are distinguished ( special formations that contain an egg) at different stages of development, corpus luteum, white bodies and atretic bodies.

The following stages of follicle development are distinguished:

• Primordial follicle. This follicle is the most immature form. On average, the primordial follicle is 50 µm in size. It is surrounded by only one layer of follicular cells. Primordial follicle is the most numerous form of all types of follicles. Each follicle contains one oocyte ( immature egg cell). At the time of birth, there are 1 to 2 million primordial follicles in each ovary. Follicular maturation occurs after puberty ( puberty).
• Primary or preantral follicle. A follicle in which the process of egg maturation has already begun due to the influence of follicle-stimulating hormone. The primary follicle is several times larger than the primordial follicle. The size of the primary follicle is approximately 150-200 microns. This follicle is covered with two or three layers of follicular cubic cells.
• Secondary or antral follicle. The secondary follicle differs from the previous ones in that a follicular cavity with fluid is formed in it. The cells of the secondary follicle are capable of producing estrogen. This hormone has a feminizing effect and leads to the development of the uterus, fallopian tubes, vagina, mammary glands, and also participates in the formation of female secondary sexual characteristics. The secondary follicle contains granulosa cells that synthesize progestin. This hormone prepares the body for pregnancy and, when it occurs, supports it ( gestation). The size of the secondary follicle is 500 µm.
• Tertiary or preovular follicle. The tertiary follicle is characterized by rapid cell growth and differentiation. The tertiary follicle contains 100 times more follicular fluid than the secondary follicle. The size of the tertiary follicle is about 1 mm.
• Mature follicle or Graaf vesicle. The size of a mature follicle is 18 - 20 mm. The egg cell, which is part of the Graafian bubble, is completely ready for ovulation. Before ovulation, the follicle wall protrudes slightly. Subsequently, a rupture occurs at the site of the protrusion. The ovum leaves the follicle and enters the oviduct ( ovulation). In place of Graaf's vesicle, a corpus luteum is formed, which subsequently produces progesterone. This hormone stops premature menstruation and promotes normal fertilization.
• Atretic follicle. Only one mature follicle is needed for the ovulation process. If there are two or more mature follicles, then some of them undergo atresia ( doom). Under the influence of a special hormone gonadokrinin, tertiary or mature follicles can be programmed to be destroyed. In their place, an atretic body is formed, which is able to synthesize estrogens.

The corpus luteum is a special endocrine gland that is formed from the cells of a mature follicle after ovulation. The formation of the corpus luteum is directly affected by the luteinizing hormone of the adenohypophysis ( anterior pituitary gland). The main function of the corpus luteum is the production of the hormone progesterone. It is this hormone that prepares the lining of the uterus for potential pregnancy. If the pregnancy was not successful, then the corpus luteum involutions ( reverse development process), turning into connective tissue. This process leads to menstruation. With successful fertilization, the corpus luteum continues to produce progesterone and thereby maintains pregnancy. On average, the corpus luteum of pregnancy is active for 9 to 12 weeks.

The white body is a reborn corpus luteum. If fertilization has not occurred, the corpus luteum is reorganized in the form of connective tissue. After some time, the white body of the ovary can completely disappear.

Brain matter

The medulla consists of connective tissue, which contains a large amount of elastin. The central part contains blood vessels and nerve fibers. More than 90% of women have a structure in their medulla called the ovarian reticulum. This network consists of cords and epithelial tubules. It is formed from the remains of the tubules of the primary kidney.

Causes of ovarian apoplexy

The causes of apoplexy can be pathological modifications at the level of tissue structures and vessels of the cortical or medullary substance of the ovary. The main causes of ovarian apoplexy are varicose veins of the ovaries, inflammation of the uterine appendages, polycystic, repeated pregnancy.

The most common causes of ovarian apoplexy include:

• ovarian inflammation ( oophoritis);
• varicose veins of the ovary;
• drug stimulation of ovulation;
• polycystic ovary disease.

Ovarian inflammation

Ovarian inflammation or oophoritis is an inflammatory disease of an infectious nature. This pathology ranks first among all diseases of the pelvic organs. Oophoritis can be unilateral and bilateral. In most cases, inflammation in the ovary is not isolated. The infection that causes oophoritis can also cause inflammation in the fallopian tubes ( salpingitis). If the infection affects the ovary and fallopian tube, then this disease is called salpingo-oophoritis, or adnexitis. The causative agents of this disease are Trichomonas, gonococcus, mycoplasma, chlamydia, which are transmitted during sexual intercourse. In case of a decrease in immunity, opportunistic microflora can cause oophoritis - E. coli, staphylococcus, streptococcus, candida, etc. Various surgical operations on the genitals, menstruation, childbirth and sometimes hypothermia can cause oophoritis.

Oophoritis occurs due to the ingress of microorganisms into the membrane of a mature follicle after ovulation. As in any inflammatory process, oophoritis is characterized by the onset of a painful sensation, the appearance of hyperemia ( organ overflow), the formation of a pathological secret ( exudate), the occurrence of ovarian edema. The same processes take place in the fallopian tubes. The painful sensation is projected at the location of the ovary and fallopian tube, in the lower abdomen. Often, salpingo-oophoritis can lead to acute appendicitis.

Ovarian varicose veins

Ovarian varicose veins is a pathological condition that occurs when the outflow of blood from the ovarian venous network is obstructed. Most often this is a consequence of partial or complete obstruction of one or more ovarian veins. This pathology should be considered in the context of pelvic varicose veins. The main reason for the occurrence of varicose veins in the small pelvis is a violation in the structure of the connective tissue that is part of the venous walls. In these vessels, the amount of collagen fibers decreases. As a consequence, this leads to hypertension in the veins ( pressure rise), the diameter of the veins increases, and local expansion of the venous walls also appears.

The causes of ovarian varicose veins:

• Difficult working conditions. Daily activities in a forced position ( sitting or standing) leads to a significant increase in pressure in the venous system of the pelvic organs and becomes a trigger for varicose veins of the ovaries. Venous hypertension is considered the main factor in the appearance of ovarian varicose veins.
• Repeated pregnancy and childbirth. During pregnancy, as well as during childbirth, the female body experiences an enormous load on various organs. As a rule, under these physiological conditions, an increase in pressure in the vessels occurs. Blood pressure rises not only in the arteries, but also in the veins. Statistics indicate that it is repeated pregnancy and childbirth that are the main cause of ovarian varicose veins.
• Diseases of the female reproductive system. A number of diseases of the female genital organs can lead to the appearance of ovarian varicose veins. Such diseases include ovarian tumor, twisting of the wide ligament of the uterus, endometriosis.
• Hyperestrogenism. Hyperestrogenism is characterized by an increase in the synthesis of female sex hormones - estrogens. This endocrine disorder may be a consequence of ovarian cancer. In turn, an ovarian tumor can lead to the occurrence of ovarian varicose veins. Also, hyperestrogenism is the reason for a number of serious diseases, of which endometriosis, the formation of uterine polyps, uterine fibroids, etc. can be distinguished.
• Hormonal contraception. This type of contraception is one of the most popular and effective. If hormonal contraception was not correctly selected, then various side effects may occur. One of the side effects is increased pressure in the venous network of the pelvis.

Medication stimulation of ovulation

Medication stimulation of ovulation is a method that helps to achieve pregnancy, due to the lack of ovulation in a woman. This method is suitable only when healthy follicles are formed in the cortical substance of the ovary, but the process of their development for some reason does not occur to the end. Medication stimulation is a way out of the situation in case of irregular ovulation or polycystic ovary disease.

The use of various drug regimens for stimulating ovulation has several disadvantages. Side effects of this method include ovarian cysts, hormonal imbalance, ovarian apoplexy.

Polycystic ovary

Polycystic ovary disease or polycystic ovary syndrome is a pathology in the structure and function of the ovaries, which leads to menstrual dysfunction and, as a result, to infertility. Polycystic ovary syndrome is characterized by hyperandrogenism ( increased production of male sex hormones).

With this pathology, the following modifications are distinguished: bilateral enlargement of the ovaries 2-6 times, stromal hyperplasia ( the formation of an abundance of new structural elements), the presence of a large number of cystic follicles ( a cyst is formed from a mature follicle), thickening of the ovarian capsule.

In the cortical substance with polycystic ovaries, there are many cystic-atretic follicles. These follicles are a pathological formation, and the body seeks to reduce their number. When reorganizing ( connective tissue replacement) of large cystic-atretic follicles, their destruction may occur, which will lead to rupture of ovarian tissue and the appearance of bleeding.

Symptoms of ovarian apoplexy

Symptoms of ovarian apoplexy are temporary or permanent. Symptoms usually depend on the amount of blood lost. The most common, and sometimes the only symptom, is pain in the pubic region.

Ovarian apoplexy is characterized by the following symptoms:

• lower abdominal pain;
• a sharp decrease in blood pressure, increased heart rate;
• general weakness;
• violation of the menstrual cycle;
• increased urination.

Lower abdominal pain

Pain in the pubic region is the main symptom of ovarian apoplexy. In the case of unilateral apoplexy, pain can be projected at the location of the affected ovary, and with bilateral apoplexy, the pain is diffuse. Painful sensations can begin abruptly, at times they can be strong and intolerable. Quite rarely, pain can occur at night, during sleep. Sometimes, a day before the attack, a woman may feel muffled pain in the lower abdomen. The pain occurs due to the fact that the resulting hematoma ( accumulation of blood) produces pressure on the surrounding tissues, which contain pain receptors. Also, if a hematoma forms in the ovary itself, then it is capable of squeezing the vessels and nerves in the cortical substance. In this case, the pain will be acute. If pain becomes the main symptom, and bleeding was insignificant, then we are talking about painful or pseudo-appendicular form of ovarian apoplexy. Severe acute pain with unilateral apoplexy of the right ovary may resemble pain characteristic of acute appendicitis.

A sharp drop in blood pressure, increased heart rate

A sudden rupture of ovarian tissue leads to bleeding into the abdominal cavity. Even if there is a slight damage to the ovarian tissue, this can cause profuse bleeding. If internal bleeding predominates over pain, then this form is called anemic. In the context of the anemic form, a number of symptoms are distinguished. As with any other bleeding, blood pressure reflexively decreases, the heart rate increases, the skin turns pale. These signs depend on the amount of blood lost. Due to bleeding, the amount of blood delivered to the heart decreases and, as a result, the pressure in the arteries drops. Depending on the volume of blood loss, three degrees of severity of the anemic form of ovarian apoplexy can be distinguished. For mild apoplexy, blood loss does not exceed 150 ml of blood. If we are talking about moderate severity, then the amount of blood loss does not exceed 500 ml, and for a severe degree - over 0.5 liters.

General weakness

General weakness is the result of blood loss. Since the volume of circulating blood decreases during blood loss, this also affects the general condition. Blood performs a transport function and delivers oxygen and all the necessary nutrients to the tissues of the body. If the volume of circulating blood is reduced, then the tissues cease to receive the necessary substances in sufficient quantities. Some cells and tissues are highly oxygen dependent. Thus, the central nervous system consumes 20-25% of all inhaled oxygen. With bleeding, the nerve cells of the brain are not able to function at the required level and, as a result, this manifests itself in the form of rapid fatigue, lethargy, and sometimes the appearance of apathy. Muscle tissue also needs a lot of oxygenated and glucose-rich blood. If myocytes ( muscle cells) do not get the necessary substances, this leads to muscle weakness.

Disruption of the menstrual cycle

Ovarian apoplexy can cause irregularities in the menstrual cycle. For normal menstruation, bleeding occurs every 21 to 35 days and continues for 3 to 7 days. Most often, ovarian apoplexy is characterized by the appearance of intermenstrual bleeding from the vagina, which is not normally observed. Less commonly, there is spotting that occurs after a delay in menstruation. These phenomena, as a rule, quickly stop after the disappearance of pain. It should be noted that irregularities during the menstrual cycle are optional and in some cases may be absent.

Frequent urination

Frequent urination is characterized by visiting the toilet more than 10 times a day. Also taking certain medications ( diuretics) or a large amount of liquid drunk contribute to this phenomenon.

In some cases, ovarian apoplexy can cause hormonal imbalance. As a result, the effect of certain hormones on the bladder can cause the bladder wall to stretch. As a result of excessive stretching of the bladder wall, an increase in the frequency of urination occurs. Also, the convergence of massive ovarian edema may be accompanied by increased urination.

Diagnosis of ovarian apoplexy

In order to correctly diagnose, it is necessary to carefully collect anamnesis ( patient interview), conduct an examination and use invasive or non-invasive diagnostic methods.

The following methods are used to confirm the diagnosis of ovarian apoplexy:

• gynecological examination;
• Ultrasound of the pelvic organs;
• puncture of the posterior fornix of the vagina.

Gynecological examination

This type of examination begins with an examination of the genitals. As a rule, a special gynecological chair is used for it. The gynecologist sequentially examines the labia majora and minora. The examination of the external genital organs ends with an examination of the vestibule of the vagina.

Next, the vaginal wall is examined. For this manipulation, special gynecological mirrors are used ( a tool that is used to expand and unfold the vagina). Most often, the vaginal mucosa remains of the usual color. If ovarian apoplexy leads to massive bleeding, characteristic of the anemic form, then the vaginal mucosa has a pale pink color.

The next step in the gynecological examination is bimanual ( two-handed) vaginal examination. This manipulation is necessary to determine the position, condition and size of the uterus, as well as the uterine appendages ( ovaries and fallopian tubes). Quite often, a bimanual examination of the vagina reveals soreness at the site of the projection of one of the ovaries with unilateral apoplexy. Palpation of the affected ovary is painful. The size of the ovary remains normal or slightly increased.

Ultrasound of the pelvic organs

Ultrasound examination is one of the main methods used in the diagnosis of ovarian apoplexy. This method is non-invasive ( does not damage the integrity of the skin) and is able in most cases to confirm the presumptive diagnosis.

An ultrasound scan usually helps to see some structural changes in the ovary. The size of the affected ovary may be slightly enlarged or within the normal range. With apoplexy, you can notice a heterogeneous structure in the cortical substance. This structure is a corpus luteum. In most cases, it is the corpus luteum that is the cause of bleeding. If there are no concomitant gynecological diseases ( polycystic ovary), then no pathologies are found in the follicles. The main confirmation of the diagnosis of anemic form of ovarian apoplexy is the detection of free fluid in the abdominal cavity behind the uterus.

It is worth noting that the assessment of the condition of the affected ovary should be made in comparison with a healthy ovary, and the period of the menstrual cycle should also be taken into account.

Laparoscopy

Laparoscopy is a surgical way to diagnose or treat certain abdominal conditions. The main advantage of laparoscopy is minimally invasiveness. Access to the abdominal organs is achieved through a small opening in the navel. The size of this hole on average does not exceed 1 - 2 cm. In the case of ovarian apoplexy, laparoscopic diagnostics has almost 100% accuracy.

With laparoscopic diagnostics, it is almost always possible to find some amount of blood in the small pelvis. If apoplexy has occurred recently, then the blood will be a homogeneous consistency without a lot of clots. The presence of clots indicates that ovarian tissue rupture and hemorrhage occurred the day or several days before laparoscopy. In the future, these clots can lead to adhesion of the abdominal organs. When examining the uterus, its size and color remain normal. Quite often, chronic inflammation of the fallopian tubes can be found, which is expressed in the presence of peritubal adhesions ( adhesions around the fallopian tubes).

When the corpus luteum ruptures, the ovary usually maintains its normal size. An enlargement of the ovary is observed only when hemorrhage leads to a hematoma in the cavity of the ovary itself. If ovarian apoplexy is a consequence of a ruptured cyst of the Graafian vesicle or corpus luteum, then the affected ovary has a purple-purple color. Also, the presence of a cyst causes an increase in the size of the ovary.

Puncture of the posterior fornix of the vagina

Puncture of the posterior vaginal fornix or culdocentesis - puncture of the posterior wall of the vaginal fornix in order to take fluid from the utero-rectal cavity ( Douglas space). This manipulation helps to determine the type of fluid that accumulates in the uterine-rectal space. Depending on the disease, punctate may be blood, exudate, or pus. Douglas space normally contains a small amount of light yellow liquid. The main criterion for confirming the diagnosis is the detection of blood that does not clot.

Conservative treatment of ovarian apoplexy

The choice of treatment depends on the result of hematological tests ( general blood analysis), the degree of bleeding, and the presence or absence of peritoneal symptoms ( painful sensations arising from irritation of the peritoneum). Conservative treatment is performed in a hospital and is indicated only when the pain syndrome is not pronounced, and the amount of lost blood is insignificant.

The main drugs in conservative treatment are coagulants ( hemostatic drugs), antispasmodics and vitamins. A ward ( half-bed) mode. To stop bleeding, as a rule, apply cold to the lower abdomen.

Drug treatment includes:

• antispasmodics;
• hemostatic drugs;
• vitamins.

Antispasmodics

Antispasmodics are a group of medicines that relieve muscle spasm that occurs in smooth muscles. Antispasmodics are widely used to relieve pain associated with the gastrointestinal tract, as well as when pain occurs in gynecology. The main action of antispasmodics is based on blocking the transmission of nerve impulses in smooth muscles, which helps to relieve pain.

Antispasmodics have a different form of release. In each individual case, it is the attending physician who must select the necessary medication, dosage, as well as the duration of use of this medication.

Antispasmodic drugs

Drug name	Release form	Active substance	Mechanism of action	Mode of application
Drotaverin	Injection	Drotaverin	It relieves spastic pain, leads to relaxation of smooth muscles, due to the expansion of the lumen of the vessels, it contributes to an improved supply of oxygen to the tissues.	Intramuscular injections of 2 ml 2 times a day.
Papaverine	Injection	Papaverine	Leads to a decrease in tone and relaxes the smooth muscles of the internal organs.	Intramuscular injections of 1 - 2 ml 2 - 4 times a day.
Buscopan	Film-coated tablets	Hyoscine butyl bromide	It leads to a decrease in the tone of the smooth muscles of the internal organs, and also reduces their contractile activity.	Orally with a small amount of water, 10 - 20 mg 3 times a day.

Hemostatic drugs

Hemostatic or hemostatic drugs are a group of drugs that help stop bleeding. Allocate hemostatic substances of local and resorptive action. A group of local hemostatic drugs is used to stop bleeding from the skin or mucous membranes. In case of bleeding from internal organs, it is necessary to use resorptive hemostatic drugs. They directly enter the bloodstream and are able to stop bleeding by increasing the process of thrombus formation in damaged vessels.

Resorptive hemostatic drugs

Drug name	Release form	Active substance	Mechanism of action	Mode of application
Etamsilat	Ampoules for intramuscular injection	Etamsilat	Leads to accelerated platelet formation. Promotes the process of platelet adhesion and thrombus formation. It has an angioprotective effect.	Intramuscular injections of 2 ml 2 - 4 times a day.
Tranexam		Tranexamic acid	Has antifibrinolytic effect. Promotes a decrease in the activity of profibrinolysin and its conversion into plasmin.	Intravenous 1 - 1.5 g 3 - 4 times a day for 4 days.
Amben	Intravenous solution	Aminomethylbenzoic acid	Has antifibrinolytic effect. Has an inhibitory effect on plasmin. Inhibits the conversion of profibrinolysin to plasmin.	Intravenous jet in 5 - 10 ml of 1% solution.

In the case of concomitant hematological diseases ( von Willebrand disease, autoimmune thrombocytopenia), conservative treatment can be carried out only after consulting a hematologist.

Vitamins

Vitamins are a group of organic substances that are absolutely necessary for the normal functioning of the body. There are two large groups of vitamins - fat-soluble and water-soluble. Vitamins are part of various enzymes, and can also act on organs and tissues like hormones. With bleeding, B vitamins lead to an increase in the compensatory-restorative functions of the body and can reduce the degree of blood loss.

B vitamins

Drug name	Release form	Active substance	Mechanism of action	Mode of application
Vitamin B1		Thiamine	Participates in carbohydrate, protein and fat metabolism.
Vitamin B6	Solution for intramuscular injection	Pyridoxine	Participates in the exchange of various amino acids. Takes part in lipid metabolism.	Intramuscular injections of 1 ml once a day every other day.
Vitamin B12	Solution for intramuscular injection	Cyanocobalamin	Promotes blood clotting. Increases thromboplastic activity. Takes part in normal blood formation.	Intramuscular injections of 200 mcg 1 time per day every other day.

It is worth noting that drug treatment has several disadvantages. Blood clots that cannot be removed without surgery lead to the formation of adhesions in 80% of cases. As a result of conservative treatment, infertility is observed in 40% of cases. In 15% of cases, recurrence of ovarian apoplexy occurs. Such serious violations force to reconsider the treatment tactics, even with a mild degree of apoplexy, in favor of surgical treatment.

Surgical treatment of ovarian apoplexy

In the treatment of ovarian apoplexy, preference is given to surgical treatment.
In most cases, the laparoscopic method is used to treat ovarian apoplexy. This method has several advantages over conventional abdominal surgery. If there are contraindications for laparoscopy, then laparotomy surgery is an alternative.

Indications for surgery

In most cases, if a woman wants to maintain fertility, or with moderate or severe apoplexy, surgical treatment is indicated. Also, an indication for surgery is the ineffectiveness of conservative treatment, in which signs of internal hemorrhage appear, the general condition worsens, and the hemogram indicators ( blood test) fall sharply. The main indication for the operation is the presence of fluid in the abdominal cavity, which is confirmed by ultrasound examination. In the event of an increase in pain, an urgent need to resort to surgery.

Contraindications

Contraindications for laparoscopic surgery for apoplexy can be absolute or relative. Laparoscopic surgery is absolutely contraindicated for severe cardiovascular diseases, severe hypertension ( high blood pressure), hemorrhagic shock ( acute blood loss), cachexia ( severe depletion of the body), in case of serious disorders in the blood coagulation system, in the presence of a hernia of the white line of the abdomen ( runs along the midline of the abdomen) and aperture. Acute or chronic renal failure or liver failure is also a contraindication. From diseases of the respiratory system, this operation is contraindicated in the presence of bronchial asthma. Relative contraindications include polyvalent drug allergy ( allergy to two or more medications), malignant tumor of the ovaries and fallopian tube, peritonitis ( inflammatory process of the peritoneum), late pregnancy ( more than 16 weeks).

Apoplexy surgery methods

There are two surgical methods that can be used to treat ovarian apoplexy. We are talking about the laparoscopic and laparotomy method. Laparoscopic surgery is the gold standard in the treatment of ovarian apoplexy. Laparotomy is performed only if contraindications to laparoscopic surgery are identified.

Laparoscopic method
Laparoscopic surgery is a modern surgical method of operating the abdominal organs using special equipment. The main instrument is a laparoscope with a video camera, which transmits the image to a special screen. This method has a number of advantages over abdominal operations. It is minimally invasive and does not cause large scars or scars. For several months after laparoscopic surgery, the sutures at the site of the incision become almost invisible. The postoperative period is much faster, and the time spent in the hospital after surgery is significantly reduced. During the operation, 3-4 small holes less than 1.5 cm are made in the abdominal wall, through which the laparoscope and auxiliary instruments are inserted.

Laparoscopy with ovarian apoplexy is extremely gentle. In most cases, only suturing of the ovarian rupture site is performed. If apoplexy occurs during pregnancy, then in order to preserve it, no resection is performed ( excision), and suturing the corpus luteum. Cauterization of the bleeding area of ​​the tunica albuginea is performed using an electrosurgical coagulator. It does this by supplying a high-frequency current that heats up the surrounding tissue. As a result of heating, the protein that is in the tissues coagulates, and the bleeding stops. If there is massive bleeding, prolonged coagulation is performed ( using an electrosurgical coagulator).

Removal of the ovary is necessary only when apoplexy is observed together with another disease of the uterine appendages, such as when the leg of the fallopian tube is twisted. In any other cases, the site of the ovarian rupture is sutured or part of the ovary is removed in order to preserve fertility and not disrupt hormonal levels. During laparoscopy, it is imperative to examine both ovaries for bilateral apoplexy. It is also necessary to examine the fallopian tubes and the appendix ( appendix), since apoplexy can occur in combination with an ectopic pregnancy or occur with acute appendicitis.

Endotracheal anesthesia is most often used for anesthesia. During the operation, the abdominal cavity is washed and blood clots and all blood are removed. Further, the abdominal cavity is sutured in layers. If it is impossible to carry out a laparoscopic operation, they resort to laparotomy.

Laparotomy method
Laparotomy surgery is an operation on the abdominal organs in which a wide incision is made in the abdominal wall for access. This operation is performed in case of contraindications to the laparoscopic operation. Laparotomy is indicated in the case of a hernia of the white line of the abdomen or if the laparoscopic method fails to stop bleeding with an electrocautery. Dissection of the abdominal wall is made 8 - 10 cm long. The site of the incision is the suprapubic region.

For anesthesia, endotracheal anesthesia is usually used. During ovarian surgery, it is necessary to remove all accumulated blood in the abdominal cavity. At the end of the operation, the abdominal cavity is sutured in layers. In the days following the operation, it is imperative to carry out antibiotic therapy.

The recovery period after apoplexy

With an uncomplicated form of apoplexy, the average recovery period after laparoscopic surgery lasts a week, and after laparotomy - two weeks. Already on the first day after laparoscopic surgery, it is allowed to get out of bed, as well as eat diet broths.

In dynamics, an ultrasound examination of the ovaries is performed for the presence of a relapse of apoplexy. If various changes are detected in the results of blood and urine tests, then they are corrected. In case of hormonal imbalance, the attending physician individually selects the necessary treatment regimen. Antibiotic therapy is prescribed in the case of laparotomy surgery, as well as when indicated. During laparotomy, it is necessary to wear compression garments, as well as various belly bandages for two months.

The sparing nature of the laparoscopic operation allows, in most cases, to preserve the woman's fertility. Even with the removal of one ovary, the chance of getting pregnant remains extremely high. However, with oophorectomy ( oophorectomy) the risk of ectopic pregnancy increases. Natural pregnancy is impossible only with inflammatory-dystrophic changes at the level of both uterine appendages or in the case of a tumor disease. It is worth noting that within 1 - 2 months after the operation, it is necessary to exclude any sexual intercourse.

Disability recovery occurs after 30 - 50 days. In the event of various gynecological complications, it is necessary to urgently call an ambulance or go to the hospital.