Clinical and laboratory presentation
When an "acute abdomen" is suspected, physical examination begins with percussion: free fluid may be detected in dependent areas (lateral gutters). Examination of the vaginal mucosa helps assess the severity of the condition—it becomes pale in cases of severe blood loss.
Bimanual examination is often difficult due to acute pain and tension of the anterior abdominal wall. Nevertheless, the physician may reveal:
- Bulging of the vaginal fornices.
- Sharp pain upon cervical motion (traction on the cervix).
- A slightly enlarged and painful ovary on the affected side (in apoplexy).
- The uterus itself remains of normal size and is painless.
A complete blood count typically shows a decrease in hemoglobin (Hb) levels. Some patients exhibit mild leukocytosis, but it occurs without a left shift in the leukocyte formula.
Instrumental search
The baseline method is ultrasound of the internal genitalia. It demonstrates the presence of free fine- and medium-disperse fluid in the abdominal cavity, as well as irregular echogenic structures corresponding to blood clots. In stable hemodynamics, posterior colpocentesis (culdocentesis) may be used.
The method of choice is laparoscopy. It allows visualization of:
- The ovulation stigma — a small raised spot (0.2–0.5 cm in diameter) with signs of bleeding or covered by a clot.
- Corpus luteum cyst in a "collapsed" state.
- Corpus luteum with a linear rupture or a rounded tissue defect.
Differential diagnosis spectrum
The clinical presentation of an "acute abdomen" requires the exclusion of a number of urgent conditions. The pathology must be differentiated from the following states:
- Ectopic pregnancy;
- Acute salpingo-oophoritis;
- Torsion of the uterine adnexa or a myomatous node;
- Acute appendicitis;
- Intestinal obstruction;
- Perforated gastric ulcer;
- Renal colic.
Special attention should be paid to torsion of the adnexal tumor pedicle, which occurs in 15–25% of cases. An unchanged ovary, adnexa, or subserosal node may undergo torsion. It is important to distinguish between the anatomical pedicle (consisting of stretched ligaments, vessels, and nerves) and the surgical pedicle, which is formed directly as a result of torsion from all structures involved in the conglomerate.
Management tactics: from conservative to surgical
The choice of treatment depends on the form of the pathology and the volume of intraperitoneal blood loss.
Conservative therapy is performed strictly in a hospital setting. It is indicated for the painful form of apoplexy, blood loss of less than 150 ml, and no signs of increasing hemorrhage. Rest, ice on the lower abdomen (to induce vascular spasm), hemostatics (ethamsylate, vicasol, ascorutin), antispasmodics (papaverine, no-shpa), and vitamins are prescribed.
Criteria for switching to surgical treatment:
- Recurrent pain attacks and worsening condition.
- Hemodynamic instability.
- Increase in the amount of blood in the abdominal cavity (based on clinical picture and ultrasound).
Laparoscopy is indicated in the presence of more than 150 ml of blood (if the patient is stable) or ineffectiveness of therapy within 1–3 days. The surgery should be as organ-sparing as possible: coagulation of the rupture or ovarian resection is performed. Radical removal (oophorectomy) is an extreme measure.
Laparotomy (lower midline access or Pfannenstiel incision) is used in hemorrhagic shock or the impossibility of laparoscopy due to adhesive disease. In this case, reinfusion of blood spilled into the abdominal cavity is possible.
Prevention and prognosis
For a first-time painful form of apoplexy, specific measures are not required since the disorders are reversible.
For recurrences or after the hemorrhagic form, long-term therapy is required to correct CNS dysfunction and hormonal status:
- 3-month course: nootropics, agents to improve cerebral perfusion (Tanakan, Cavinton), diuretics (for intracranial hypertension), and tranquilizers.
- 3–6 month course: ovulation suppression using COCs (Yarina, Jess, Jeanine, Femoden, Silest, Novinette, Mercilon, Logest, Marvelon, Regulon).
The prognosis for the painful form is favorable. For the hemorrhagic form, it directly depends on the timeliness of diagnosis.
Briefly: answers to topical questions
What clinical symptoms are characteristic of uterine adnexal torsion?
The clinical presentation of torsion depends on the degree of nutritional impairment of the tumor and differs between complete and partial torsion.
- Complete torsion — sudden onset, sharp pain in the lower abdomen on the affected side, nausea, vomiting, constipation, and gas retention (intestinal paresis).
- Partial torsion — symptoms are less pronounced, may periodically intensify or disappear without treatment.
- Objectively — pallor of the skin, cold sweat, elevated body temperature.
- Pathogenesis — circulatory disturbance leads to necrosis, aseptic inflammation, and spread of the process to the pelvic peritoneum with the development of peritonitis.
How to differentiate ovarian apoplexy and ruptured ectopic pregnancy?
Ovarian apoplexy and ruptured ectopic pregnancy are differentiated based on bimanual examination data and laparoscopic findings.
| Sign | Ovarian apoplexy | Ectopic pregnancy |
|---|---|---|
| Uterus upon examination | normal size, painless | "floating uterus" sign: excessive mobility of the enlarged and softened uterus |
| Cervix | cervical motion tenderness is sharp | sharp pain upon displacement of the cervix |
| Vaginal fornices | bulge | bulging and pronounced tenderness of the posterior fornix ("Douglas cry") |
| Laparoscopy | ovulation stigma; a corpus luteum with rupture and signs of bleeding may be visualized | the fallopian tube is purple-cyanotic, thickened at the site of the gestational sac localization; dark blood is flowing from the fimbriated end |
In tubal rupture, the definitive diagnosis is established intraoperatively.
What laboratory signs help distinguish ovarian apoplexy from acute appendicitis?
The sources provide laboratory signs of ovarian apoplexy, but there is no direct comparison with laboratory data for acute appendicitis.
- Hemoglobin (Hb): a decrease in levels is characteristic; in the first hours of acute blood loss, a falsely elevated Hb is possible due to hemoconcentration against the background of reduced circulating blood volume (CBV).
- Leukocytes: some female patients show mild leukocytosis without a left shift in the differential white blood cell count.
Thus, based on the cited sources, the laboratory signs of apoplexy can be indicated, but the laboratory differences from acute appendicitis cannot be reliably described.
Class and exam questions
Why might hemoglobin be normal in acute blood loss in gynecology?
In the first hours after the onset of bleeding, hemoconcentration occurs against the background of a decrease in circulating blood volume (CBV), which yields a falsely normal or even elevated hemoglobin level.
What is the difference between the anatomical and surgical pedicles of an ovarian tumor?
The anatomical pedicle consists of natural ligaments (infundibulopelvic, utero-ovarian), the mesovarium, blood vessels, and nerves. The surgical pedicle is formed directly at the moment of torsion and includes all tissues involved in this conglomerate.
When can ovarian apoplexy be treated conservatively?
Conservative management is acceptable for the painful form, an intra-abdominal blood loss volume of less than 150 ml, stable hemodynamics, and no signs of ongoing bleeding.
What else to study on this topic
- Technique of laparotomy and blood reinfusion
- Regimens for drug-based prevention of apoplexy recurrence
- Criteria for switching from conservative to surgical treatment
- Structural features of the anatomical ovarian pedicle
Master the entire topic in the "Obstetrics and Gynecology" course
This is a summary. The course covers everything tested in classes and exams.
- Complete study guide on "Differential Diagnosis of the 'Acute Abdomen' in Gynecology" and 973 more pages of the subject
- Assignments and quizzes after every topic — just like in a colloquium
- AI tutor answers questions on the topic anytime
- 21 video lessons on the subject
Other topics in the "Gynecology" section
Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.