Etiology and key pathogenetic mechanisms
Apoplexy is not exclusively a local problem—it is a systemic disease involving various levels of neural regulation. There are so-called "critical periods" (ovulation and the corpus luteum phase) when the permeability of the vascular wall physiologically increases and the blood supply to the appendages intensifies.
The leading pathogenetic factors include:
- Pelvic inflammatory processes. Chronic inflammation causes stromal sclerosis, fibrous changes in the epithelium, vascular hyalinosis, and varicose dilation of ovarian veins.
- Hormonal imbalance. Disrupted production of gonadotropins (FSH and LH) and elevated prolactin levels lead to tissue hyperemia and the formation of retention cysts.
- Hemostatic system disorders. Blood diseases or long-term anticoagulant therapy reduce blood clotting, predisposing to massive hemorrhage.
Triggering factors
Against the background of pre-existing morphological changes in the tissues, the immediate trigger for a rupture can be situations that increase intra-abdominal pressure or enhance blood flow to the pelvic organs:
- traumatic impact on the abdominal area;
- intense physical exertion;
- active sexual intercourse;
- medical manipulations (vaginal examination) or douching.
It is important to note that in some female patients, an acute abdominal catastrophe develops without apparent causes—in a state of absolute rest or during night sleep.
Classification of forms and severity
Depending on the prevailing clinical picture and further management tactics, three main forms of the disease are distinguished: pain form, hemorrhagic (anemic) form, and mixed form.
For the hemorrhagic form, the volume of blood poured into the abdominal cavity is of critical importance. The degree of severity is determined by this criterion:
- Mild degree — blood loss ranges from 100 to 150 ml.
- Moderate degree — intra-abdominal blood loss from 150 to 500 ml.
- Severe degree — massive blood loss exceeding 500 ml.
Clinical presentation: general symptoms and pain form
The main symptom of any form of apoplexy is sudden, sharp pain in the lower abdomen. The pain syndrome arises due to irritation of ovarian receptors, spasm of the ovarian artery, and the chemical impact of the spilled blood on the peritoneum.
In the pain form (as well as in mild hemorrhagic form), the hemorrhage is usually limited to the tissue of the follicle or corpus luteum. There are no signs of massive internal bleeding.
- Complaints: an acute attack of pain without radiation, nausea is possible.
- Objectively: skin of normal color, pulse and blood pressure are stable, the tongue remains moist.
- Status localis: the abdomen is soft; there are no peritoneal signs or free fluid upon percussion. Only local tenderness in the iliac region is noted.
- Gynecological status: the uterus is unchanged, the affected appendage is enlarged and tender upon palpation, the vaginal fornices remain deep.
- Diagnosis: ultrasound reveals a rupture and a small amount of hypoechoic fluid (blood with follicular fluid) in the pouch of Douglas. A blood test may show moderate leukocytosis without a left shift.
Hemorrhagic (anemic) form
In moderate and severe cases, symptoms of acute blood loss come to the fore. The onset is always acute, often associated with a triggering factor.
- Character of pain: intense, radiating to the sacrum, rectum, leg, or external genitalia.
- Symptoms of anemia: pronounced weakness, dizziness, fainting, nausea, and vomiting.
- Objectively: pallor of the skin and mucous membranes, cold clammy sweat. Hemodynamics is unstable — pronounced tachycardia against the background of a drop in blood pressure. The tongue becomes dry.
- Status localis: the anterior abdominal wall is tense and may be bloated. Palpation is sharply painful in the hypogastrium, with clear symptoms of peritoneal irritation in the lower sections.
Briefly: answers to topical questions
What are the indications and scope of conservative therapy for ovarian apoplexy?
Indications for conservative treatment of ovarian apoplexy are the pain form, minor intra-abdominal blood loss (less than 150 ml), and the absence of signs of ongoing hemorrhage. Therapy is performed strictly in a hospital setting under round-the-clock observation.
The scope of conservative therapy includes:
- Regimen — strict bed rest and quiet.
- Local treatment — cold (ice) to the lower abdomen for vasospasm.
- Hemostatic therapy — etamsylate, tranexamic acid, menadione, ascorutin.
- Spasmolytics and analgesics — papaverine, drotaverine.
- Vitamins — thiamine, pyridoxine, cyanocobalamin.
What types of surgical interventions are performed for ovarian apoplexy?
For ovarian apoplexy, maximally gentle (organ-preserving) and radical surgical interventions are performed via laparoscopic or laparotomic access.
Types of surgical interventions:
- Coagulation of the rupture site — an organ-preserving method of surgical treatment.
- Ovarian resection.
- Oophorectomy — radical treatment (removal of the ovary), which is performed only for major damage and the absolute impossibility of preserving the organ.
During laparotomy, reinfusion of blood spilled into the abdominal cavity is also possible.
With which acute surgical and gynecological diseases is differential diagnosis of ovarian apoplexy carried out?
Differential diagnosis of ovarian apoplexy is performed with a wide range of acute gynecological and surgical pathologies.
Diseases for differential diagnosis:
- Gynecological diseases — ectopic pregnancy, acute salpingooophoritis, adnexal torsion, torsion or necrosis of a uterine fibroid.
- Surgical diseases — acute appendicitis, intestinal obstruction, perforated gastric ulcer, renal colic.
The “R” rule for localization: the Right ovary is affected more often, because its vessel branches directly off the aorta (the left ovarian artery arises from the renal artery).
Class and exam questions
Why does ovarian rupture most frequently occur in the middle of the menstrual cycle?
During the ovulation period and the second phase of the cycle, the permeability of the vascular wall physiologically increases and the blood supply to ovarian tissues reaches its maximum.
How to differentiate between the painful and hemorrhagic forms during the initial examination?
In the painful form, hemodynamics (pulse, blood pressure) are normal, skin color is regular, and peritoneal signs are absent. In the hemorrhagic form, pallor, tachycardia, hypotension, and marked abdominal muscle rigidity are observed.
Is the presence of trauma or physical exertion mandatory for the development of apoplexy?
No, although physical exertion or vigorous sexual intercourse often act as triggers, in many patients rupture occurs spontaneously — at complete rest or during sleep.
What else to study on this topic
- Differential diagnosis of right ovarian apoplexy and acute appendicitis.
- Features of the ultrasound picture in various forms of pelvic hemorrhage.
- Tactics of conservative and surgical treatment depending on the volume of intra-abdominal blood loss.
- Impact of chronic inflammatory diseases (perioophoritis) on ovarian stroma sclerosis.
- Role of hyperprolactinemia and FSH/LH imbalance in the formation of retention cysts.
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