Abdominal examination is notable for tenderness and guarding in one or both lower quadrants. With the development of hemoperitoneum, generalized abdominal distention and rebound tenderness are prominent and bowel sounds are decreased. Pelvic examination generally reveals mild tenderness on motion of the cervix. Adnexal tenderness is present, usually more pronounced on the side of the ectopic pregnancy, and a mass may be palpated. The diagnostic approach and the medical and surgical management of ectopic pregnancy are discussed in Chapter 20 (12,13).
Leaking or Rupture of an Ovarian Cyst
Functional cysts (e.g., follicle or corpus luteum) are the most common ovarian cysts and are more likely to rupture than benign or malignant neoplasms. The pain associated with rupture of the ovarian follicle at the time of ovulation is called mittelschmerz. The small amount of blood leaking into the peritoneal cavity and high concentration of follicular ﬂuid prostaglandins contribute to this midcycle pelvic pain. The pain is usually mild to moderate and self-limited, and with an intact coagulation system, hemoperitoneum is unlikely.
A hemorrhagic corpus luteum cyst develops during the luteal phase of the menstrual cycle. The rapidly expanding ovarian capsule or, with rupture, the blood in the peritoneal cavity is responsible for the acute pain. Rupture of this cyst can produce either a small amount of intraperitoneal bleeding or frank hemorrhage, resulting in significant blood loss and hemoperitoneum.
Cystic ovarian neoplasms or inﬂammatory ovarian masses, such as endometriomas or abscesses, can leak or rupture. A history of a dermoid cyst or endometrioma that has not yet undergone surgical extirpation is not uncommon. Surgical exploration is indicated if the rupture leads to significant hemoperitoneum (corpus luteum) or chemical peritonitis (endometrioma or dermoid), which could impair future fertility, or an acute abdomen (abscess), which is life threatening.
An ovarian cyst that is not undergoing torsion, rapidly enlarging, infected, or leaking does not usually cause acute pain. A corpus luteum cyst is the most common cyst to rupture and leads to hemoperitoneum. Symptoms of a ruptured corpus luteum cyst are similar to those of a ruptured ectopic pregnancy. The patient is in the luteal phase or can have delayed menses due to the persistently functioning corpus luteum. The onset of pain is usually sudden and is associated with increasing pelvic then generalized abdominal pain and dizziness or syncope with development of significant hemoperitoneum.
A ruptured endometrioma or benign cystic teratoma (dermoid cyst) produces similar symptoms; however, dizziness and signs of hypovolemia are not present because blood loss is minimal.
Orthostasis resulting from hypovolemia is present only when there is intravascular volume depletion, such as with a hemoperitoneum. Fever is rare. The most important sign is the presence of significant abdominal tenderness, often associated with localized or generalized lower quadrant rebound tenderness because of peritoneal irritation. The abdomen can be moderately distended with decreased bowel sounds. On pelvic examination, a mass is often palpable if the cyst is leaking and has not completely ruptured.