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Evaluation and management of ruptured ovarian cyst

Evaluation and management of ruptured ovarian cyst
Author:
Howard T Sharp, MD
Section Editor:
Deborah Levine, MD
Deputy Editor:
Alana Chakrabarti, MD
Literature review current through: Jan 2024.
This topic last updated: Oct 24, 2023.

INTRODUCTION — Rupture of an ovarian cyst is a common occurrence in females of reproductive age. Physiologic cysts (eg, follicular cyst, corpus luteal cyst) or, less commonly, pathologic cysts (eg, endometriomas, benign adult teratomas, cystadenomas, malignant neoplasms) may rupture, resulting in release of cyst contents (eg, serous fluid, blood, sebaceous material) that may irritate the peritoneal cavity.

Most symptomatic patients with a ruptured ovarian cyst are successfully managed with observation and analgesics; however, some patients require surgery. Decisions regarding management are based on examination findings, severity of symptoms, presence of ongoing bleeding and/or hemodynamic instability, and the presumptive histologic diagnosis.

Diagnosis and management of patients with a ruptured ovarian cyst are reviewed here. The diagnosis and management of adnexal masses that are not ruptured are discussed separately. (See "Approach to the patient with an adnexal mass" and "Adnexal mass: Differential diagnosis" and "Adnexal mass: Ultrasound categorization".)

PATHOPHYSIOLOGY — In the normal menstrual cycle, physiologic rupture of follicular cysts, which typically are <3 cm in size, occur with every ovulatory cycle. This cyclic event is generally asymptomatic or associated with mild mid-cycle pain (also referred to as mittelschmerz), likely due to the release of a small amount of blood with follicular capsule rupture.

Serous fluids are not typically irritating, and patients with rupture of a simple cyst may remain asymptomatic despite accumulation of a large volume of intraperitoneal fluid. By contrast, rupture of a hemorrhagic cyst is often associated with pain; this may be due to blood accumulating in the ovary and stretching the ovarian cortex, or blood flowing into the abdomen and irritating the visceral peritoneum. Just as ovulation pain is not always perceived in all patients, some patients may not perceive small amounts of hemoperitoneum. Rupture of a dermoid cyst with spillage of sebaceous material may cause a marked granulomatous reaction and chemical peritonitis, which is usually quite painful. (See "Ovarian germ cell tumors: Pathology, epidemiology, clinical manifestations, and diagnosis", section on 'Mature teratoma (dermoid)'.)

The right ovary is more commonly affected, possibly because the rectosigmoid colon protects the left ovary (during vaginal intercourse or from abdominal trauma). In a series of 244 cases of ovarian cysts, 63 percent were right-sided [1].

EPIDEMIOLOGY — The true incidence of ruptured ovarian cysts is not known. Hospital admission rates with a diagnosis of a benign ovarian cyst provide some information for calculating an incidence. However, these rates are an overestimate, because they also include admission for other complications of ovarian cysts (eg, hemorrhage, torsion).

Ruptured ovarian cyst is most likely to occur in patients of reproductive age. In a series of 70 patients with a ruptured corpus luteum, the average age was 27 years [2]. Postmenopausal patients with ovarian cyst rupture have also been reported [3].

RISK FACTORS AND PREVENTION

Risk factors

Conditions that predispose a patient to ovarian cyst formation – Conditions that predispose a patient to ovarian cyst formation (eg, ovulation induction, prior history of ovarian cysts) increase the risk of cyst rupture [4].

Current, known cyst – Patients with current, known cysts (eg, endometrioma, teratoma, tubo-ovarian abscess) are at an increased risk of rupture. This is discussed in more detail below. (See 'Special considerations' below.)

Vaginal intercourse Vaginal intercourse appears to be a risk factor for ovarian cyst rupture, although in some reports, postcoital hematoperitoneum has been attributed to a ruptured cyst even without a cyst ever being visualized [5,6].

Other – Ruptured ovarian cysts in patients with thrombocytopenia [7] or receiving anticoagulation therapy [8] have also been described.

Prevention

Combined estrogen-progestin oral contraceptives – Hormonal therapies that suppress ovulation (eg, combined oral contraceptive pills [COCs]) may prevent the development of new cysts, thus reducing the risk of ruptured ovarian cyst. However, COCs do not always prevent ovulation. In a review of the literature, the overall incidence of ovulation in COCs users was found to be 2 percent [9]. COCs with lower estrogen amounts were less likely to suppress ovulation compared with higher-dose COCs. By contrast, progestin-only pills (POPs) are less likely to suppress ovulation; in this study, the incidence of ovulation in POP users was 42 percent.

Surgical drainage or removal – While surgical drainage or removal of an existing cyst may prevent future cyst rupture, prevention of cyst rupture is not a surgical indication. Rather, surgical drainage or removal of a cyst is performed only for other indications (eg, relieve symptoms, provide a histologic diagnosis for patients in whom malignancy is suspected).

CLINICAL PRESENTATION — Rupture of an ovarian cyst may be asymptomatic or associated with pelvic and/or abdominal pain (see 'Pathophysiology' above). The classic presentation is the sudden onset of unilateral, lower abdominal pain, often following strenuous physical activity (eg, sexual intercourse, exercise) [5]. A history of ovarian cysts, or a known current ovarian cyst, should raise suspicion for this diagnosis.

The character of the pain is typically sharp and focal, and the intensity may be moderate or severe. In cases of massive hemorrhage, shoulder pain or upper abdominal pain is present due to subphrenic blood extravasation. In addition, patients may have increased pain with sitting, possibly due to psoas irritation.

Due to the severity of the pain, patients usually present to the emergency department or other urgent care setting.

CLINICAL FINDINGS

Physical examination — Findings on physical examination are variable.

Vital signs – In most patients, vital signs are usually in the normal range. While a low-grade fever may be present, fever ≥100.4 may be a sign of another infectious process. (See 'Differential diagnosis' below.)

Any signs of hemodynamic instability require that the evaluation for bleeding and potential surgery be expedited (see 'Hemodynamic instability' below). However, in young healthy patients, vital signs, including postural changes, may be normal early in the course of significant bleeding due to compensatory mechanisms. In addition, some patients with acute hemoperitoneum and hypotension may not show tachycardia or may display bradycardia [10-12]. Significant hemorrhage leading to shock is uncommon. Because patients may initially present as hemodynamically stable, their hemoglobin/hematocrit should be rechecked if there is concern for ongoing blood loss. (See 'Heavy or ongoing blood loss' below.)

Abdominal examination – One side of the lower abdomen is often tender to palpation. As noted above, the right lower quadrant is more commonly affected (see 'Pathophysiology' above). Rupture of a simple cyst usually results in only mild to moderate tenderness on deep palpation. By contrast, patients with a large volume of intraperitoneal blood will have tenderness and possibly peritoneal signs. Similarly, release of sebaceous material or blood into the abdomen may cause overt peritonitis with rigidity of the abdominal wall and rebound tenderness.

Intra-abdominal hemorrhage may also be associated with Cullen's sign (ie, periumbilical ecchymoses) (picture 1).

Pelvic examination – If the cyst has not completely collapsed, an adnexal mass may be palpable on bimanual examination. Cervical motion tenderness may also be present.

Laboratory findings — Laboratory abnormalities may be absent or include the following:

Low hemoglobin/hematocrit – Low hemoglobin/hematocrit may be caused by hemorrhage, although the initial hemoglobin/hematocrit may be normal or mildly decreased with acute blood loss.

Thrombocytopenia – Severe thrombocytopenia can worsen bleeding associated with cyst rupture.

The white blood cell count is typically normal or only mildly elevated with cyst rupture; therefore, leukocytosis or left shift should raise suspicion of an infectious or necrotic process as the etiology of the symptoms rather than cyst rupture.

We do not routinely test serum CA 125 in patients with suspected ruptured ovarian cyst. Rather, we perform this test only if there is a suspicion of ovarian cancer. It is important to note that CA 125 may be elevated with hemoperitoneum or irritation of the peritoneum by cyst contents, as well as a number of other benign conditions (table 1) [13]. (See "Approach to the patient with an adnexal mass", section on 'Role of tumor markers and multimodal tests'.)

Imaging studies — Pelvic ultrasound is the mainstay of evaluation as it is readily available, inexpensive, is a sensitive method for detecting ovarian cysts, and does not expose a patient to radiation. Sonographic findings suggestive of ruptured ovarian cyst include (image 1):

An adnexal mass and fluid in the pelvis; however, fluid may be present in the pelvis without a ruptured cyst. A small amount of anechoic fluid in the pelvis is a normal finding in patients of reproductive age. If the fluid has debris within it, then it is suspicious for blood (eg, from a ruptured cyst or an ectopic pregnancy) or infection. Scanning with the vaginal probe in the region of the mass will often elicit pain.

Rupture of cyst contents typically yields only a small pool of peritoneal fluid, but large amounts of fluid may be present if rupture is accompanied by hemorrhage. If bloody-appearing fluid is seen extending beyond the upper margin of the uterus on ultrasound, then the upper abdomen should be evaluated by abdominal ultrasound.

Ultrasound evaluation performed as part of the initial examination in hemodynamically unstable patients is known as the Focused Assessment with Sonography for Trauma (FAST); this is readily employed in most emergency departments. With FAST, four areas are evaluated in a timely fashion including the pericardium, right flank (hepatorenal recess or Morison's pouch), left flank (perisplenic view), and pelvis (retrovesical view). (See "Emergency ultrasound in adults with abdominal and thoracic trauma", section on 'Focused Assessment with Sonography for Trauma'.)

Infrequently, the cyst that has ruptured will be seen with a break in the cyst wall and surrounding clot. This allows for the imaging diagnosis of a ruptured cyst. (See 'Diagnosis' below.)

Features suggestive of malignancy or a specific pathology (eg, dermoid cyst), if present. (See "Adnexal mass: Ultrasound categorization".)

We do not find computed tomography or magnetic resonance imaging to be useful in the evaluation of a ruptured ovarian cyst; these imaging modalities are associated with increased expense and additional radiation exposure (computed tomography).

DIAGNOSTIC EVALUATION — Imaging of the pelvis, preferably with pelvic ultrasound, is the mainstay of evaluation in patients in whom ovarian cyst rupture is suspected. Human chorionic gonadotropin, complete blood count, blood type and crossmatch (in patients with peritoneal signs or hemodynamic instability), and testing for sexually transmitted disease are also obtained to aid in the differential diagnosis. (See 'Laboratory findings' above and 'Imaging studies' above and 'Differential diagnosis' below.)

DIAGNOSIS — A definitive diagnosis of ruptured ovarian cyst is made by the visualization of an ovarian cyst that is leaking fluid or blood or has evidence of capsular disruption at the time of surgical evaluation or, less frequently, on pelvic ultrasound. (See 'Surgical procedure' below and 'Imaging studies' above.)

A presumptive diagnosis of ruptured ovarian cyst can be made with a fair degree of confidence in a patient with a symptom pattern that is consistent with this condition (see 'Clinical presentation' above), and with sonographic findings of an ovarian cyst plus blood or a large amount of serous fluid in the pelvis. While an ovarian cyst is not always visualized, as the cyst may collapse after cyst rupture, the absence of a cyst makes the diagnosis less likely.

DIFFERENTIAL DIAGNOSIS — The differential diagnosis of a ruptured ovarian cyst includes other conditions associated with pelvic or abdominal pain, hemoperitoneum, or a peritoneal fluid collection. The most common or urgent differential diagnoses are discussed here; the differential diagnosis of abdominal pain and evaluation of acute pelvic pain is discussed in detail separately. (See "Causes of abdominal pain in adults" and "Acute pelvic pain in nonpregnant adult females: Evaluation".)

Ectopic pregnancy – Ectopic pregnancy is the most important diagnosis to exclude, since it may be life-threatening. In patients with acute pelvic pain or abnormal vaginal bleeding, a positive pregnancy test strongly suggests the presence of an ectopic pregnancy if an intrauterine pregnancy cannot be visualized sonographically. If an intrauterine pregnancy is visualized, then pelvic pain and intraperitoneal fluid could be due to a ruptured ovarian cyst (eg, corpus luteum cyst, theca lutein cyst) or heterotopic pregnancy. (See "Ectopic pregnancy: Clinical manifestations and diagnosis".)

Adnexal torsion – Adnexal torsion is another condition that closely mimics the presentation of a ruptured cyst and requires urgent surgery to avoid loss of function of the ovary or fallopian tube. Nausea and vomiting frequently accompany torsion, but are less common with cyst rupture. Imaging studies of patients with adnexal torsion typically show an enlarged edematous ovary on the side of the patient's pain; Doppler examination may or may not show flow to the ovary due to incomplete occlusion, intermittent torsion, and collateral blood supply. When a cyst is the cause of torsion, the distinction between a ruptured cyst and torsion may be difficult. (See "Ovarian and fallopian tube torsion".)

Appendicitis – Appendicitis also presents with lower abdominal pain; however, the typical time course and character of the pain are somewhat different. The classic presentation of appendicitis is a dull periumbilical pain followed by sharp pain that localizes to the right lower quadrant if rupture occurs. Appendicitis is also classically accompanied by nausea, anorexia, and a low-grade fever. Since the presence of an ovarian cyst is common in reproductive-age patients, this finding alone should not exclude a diagnosis of appendicitis. (See "Acute appendicitis in adults: Clinical manifestations and differential diagnosis".)

Pelvic inflammatory disease (PID) – Lower abdominal pain is the cardinal presenting symptom in patients with PID. The onset of pain is more gradual than that with ruptured ovarian cysts, it is likely to occur during or shortly after menses rather than midcycle, and it is typically bilateral rather than unilateral. Free intraperitoneal fluid (pus) may or may not be observed on imaging. Tests for sexually transmitted infections should be obtained from patients with concomitant fever and/or peritoneal symptoms to exclude PID. (See "Pelvic inflammatory disease: Clinical manifestations and diagnosis".)

Tubo-ovarian abscess (TOA) – TOA is a subset of PID presenting with fever and lower abdominal pain. The characteristic sonographic appearance of an abscess is a complex, multilocular, highly vascular mass in which the ovary margins are ill defined and unseparable from the potentially dilated fallopian tube. This complex adnexal appearance is not found in a ruptured ovarian cyst. While blood around the cyst may make the ovary margins difficult to assess, TOA will be hyperemic, whereas rupture of an ovarian cyst may show some flow in the cyst wall, but not throughout the entire mass, which includes surrounding blood clot. Rupture of a TOA requires urgent treatment to avoid sepsis. (See "Epidemiology, clinical manifestations, and diagnosis of tubo-ovarian abscess".)

Ovarian hyperstimulation syndrome (OHSS) – OHSS is an iatrogenic complication of ovulation induction therapy and may be accompanied by, or mistaken for, cyst rupture. While mild OHSS is characterized by bilateral ovarian enlargement with multiple follicular and corpus luteum cysts, severe OHSS is characterized by large ovarian cysts, ascites, and, in some patients, pleural and/or pericardial effusion, electrolyte imbalance (hyponatremia, hyperkalemia), hypovolemia, and hypovolemic shock. Marked hemoconcentration, increased blood viscosity, and thromboembolic phenomena including disseminated intravascular coagulation occur in the most severe cases. (See "Pathogenesis, clinical manifestations, and diagnosis of ovarian hyperstimulation syndrome".)

Other

Other gynecologic etiologies associated with pelvic pain include endometriosis, leiomyomas, and endometritis. Acute pain occurs infrequently with these conditions. (See "Endometriosis: Clinical features, evaluation, and diagnosis" and "Endometritis unrelated to pregnancy", section on 'Acute endometritis' and "Uterine fibroids (leiomyomas): Epidemiology, clinical features, diagnosis, and natural history", section on 'Pelvic pressure or pain'.)

Other nongynecologic etiologies of a pain pattern similar to a ruptured ovarian cyst include nephrolithiasis, interstitial cystitis, irritable bowel syndrome, inflammatory bowel disease, and diverticulitis. Acute episodes of abdominal pain are also a common manifestation of vaso-occlusive events in patients with sickle cell disease. (See "Causes of abdominal pain in adults" and "Overview of the clinical manifestations of sickle cell disease", section on 'Acute painful episodes'.)

MANAGEMENT — Most patients with ovarian cyst rupture have an uncomplicated course, remain hemodynamically stable, and are candidates for observation. Complicated cases (ie, hemodynamic instability, large or ongoing blood loss, signs of an infection process, findings suggestive of malignancy) may require inpatient management and/or surgery. An algorithm outlining our management approach is provided (algorithm 1).

Pregnant patients, patients with a bleeding diathesis, or those with a ruptured teratoma or endometrioma may be managed differently. (See 'Special considerations' below.)

Patients with complicated cyst rupture

Hemodynamic instability — Patients with hemodynamic instability (eg, hypotension, tachycardia) require surgery. However, in a healthy young patient, a large blood loss that occurs quickly may not immediately cause a change in vital signs or anemia. (See 'Physical examination' above and 'Laboratory findings' above.)

Such patients should be transferred to a center where resuscitation and immediate surgical treatment can be provided. (See "Initial management of moderate to severe hemorrhage in the adult trauma patient", section on 'Resuscitation and transfusion' and 'Surgical procedure' below.)

Heavy or ongoing blood loss — Patients with ovarian cyst rupture complicated by a large and/or ongoing blood loss (eg, large volume of hemoperitoneum, 10-point drop in hematocrit [or less if the original hematocrit is already low]) are managed with inpatient observation or surgery; there are no high-quality data to support either approach. We rely on the patient's vital signs and hemoglobin/hematocrit trend as it may not be immediately apparent if bleeding is ongoing or has stopped. In our experience, bleeding stops in the majority of cases. This may be due to tamponade from increased intra-abdominal pressure caused by the volume of blood.

If the patient has stable vital signs and a stable hemoglobin/hematocrit, we suggest observation rather than immediate surgery. The patient is hospitalized, administered fluid replacement, and monitored with frequent vital signs and serial hemoglobin/hematocrit testing. Repeat pelvic ultrasound to evaluate for an increased volume of blood is performed when there is uncertainty if bleeding is ongoing [5]. If on serial evaluation, the hemoglobin/hematocrit continues to decrease or the patient becomes hemodynamically unstable, we recommend surgery. (See 'Surgical procedure' below.)

Blood transfusion may be required (up to 53 percent in one study [5]) (see 'Outcome' below). We transfuse if a patient has a hemoglobin/hematocrit that dropped but has stabilized (as defined by serial similar hematocrits) and is orthostatic by blood pressure or heart rate criteria (see "Mechanisms, causes, and evaluation of orthostatic hypotension", section on 'Diagnosis'). Transfusion alone (rather than transfusion plus surgery) should not be performed in a patient with brisk bleeding, as the vessel may not tamponade, and further blood loss may be ongoing. Thus, the patient would be exposed to blood products without stopping the source of bleeding.

Infection or malignancy — Other causes of complicated cyst rupture include infectious processes and malignancy.

Signs of an infectious process – Patients with signs of an infectious process (eg, fever, leukocytosis) and peritoneal signs require further evaluation. While a low-grade fever and peritoneal signs may be present in some patients with a ruptured cyst, a fever ≥100.4 plus peritoneal signs are concerning for intraperitoneal infection. (See 'Differential diagnosis' above.)

Findings suggestive of malignancy – While patients with an ovarian mass frequently have physiologic cysts or benign ovarian tumors, malignancy must be excluded, particularly in postmenopausal patients. For patients with an adnexal mass with features suspicious for malignancy, consultation with a gynecologic oncologist is recommended. Evaluation and treatment of patients with suspected ovarian cancer are discussed separately. (See "Adnexal mass: Ultrasound categorization", section on 'Malignancy' and "Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Clinical features and diagnosis".)

Patients with uncomplicated cyst rupture — Patients with uncomplicated cyst rupture have an ovarian cyst that bleeds a small or moderate amount, the bleeding is self-limited, and are without a significant drop in hemoglobin/hematocrit.

For such patients, we recommend observation rather than surgical intervention; however, there are no data comparing these two strategies.

In our practice, we tend to counsel these patients with precautions similar to those undergoing expectant or medical management of an ectopic pregnancy and that they should return for immediate evaluation if they experience increased pain or signs of anemia (eg, dizziness, lightheadedness). Ultrasound is repeated only as clinically necessary (eg, new or worsening symptoms) and is not needed to confirm resolution of peritoneal blood/fluid. Oral analgesics (eg, acetaminophen, nonsteroidal antiinflammatory drugs) are given as needed.

SURGICAL PROCEDURE — When surgery is performed, laparoscopy is the preferred surgical approach because it results in less morbidity than laparotomy [14]. If laparoscopic equipment is not readily available, or if the surgeon is not trained in operative laparoscopy, a laparotomy is appropriate. A large volume suction/irrigation system should be available. Large volumes of intraperitoneal blood and clot can be removed by using a 10 mm port and alternating suction and irrigation. (See "Abdominal access techniques used in laparoscopic surgery", section on 'Open (Hasson)'.)

In a premenopausal patient with a benign ovarian cyst (physiologic or nonphysiologic), cystectomy with preservation of ovarian tissue is generally preferable to complete oophorectomy. In a postmenopausal patient, unilateral oophorectomy is generally performed; bilateral salpingo-oophorectomy is only indicated if malignancy is suspected.

The procedure for ovarian cystectomy or oophorectomy is discussed in detail separately. (See "Oophorectomy and ovarian cystectomy".)

OUTCOME — There are few data regarding outcomes of ruptured ovarian cysts [2,5]. In one retrospective study including 78 patients with a ruptured ovarian cyst and hematoperitoneum, patients who underwent surgery (19 percent) compared with those managed conservatively had a more rapid decrease in hemoglobin (1.7 versus 1.3 g/dL over four hours) and needed transfusions more frequently (53 versus 11 percent, respectively) [5]. Data regarding cyst rupture and other patient important outcomes (eg, ovarian reserve, future fertility) are limited; these outcomes are more likely to be associated with the management technique (eg, cystectomy, bipolar cauterization, oophorectomy) than cyst rupture itself.

Other surgical outcomes are likely to be similar to other laparoscopic procedures. (See "Complications of laparoscopic surgery".)

FOLLOW-UP — Patients managed surgically are typically seen for a postoperative visit in the office within two to six weeks after surgery. The need for repeat pelvic ultrasound is based on intraoperative findings and the procedure performed.

For patients managed with observation, after discharge we have them seen in the office within one week, or sooner if they are having any symptoms of worsening pain or lightheadedness. Nonhemorrhagic cyst fluid (from follicular or corpus luteum cysts) is usually resorbed within 24 hours and symptoms typically resolve within a few days. By contrast, a large volume hemoperitoneum may take several weeks to resolve. If repeat pelvic ultrasound is performed, many patients will continue to have a cyst visualized, since the cyst wall may reapproximate after rupture; continued surveillance with ultrasound may be performed until the cyst resolves. Follow-up intervals for repeat ultrasound are discussed in detail separately. Surgery is performed for patients with continued symptoms or if malignancy is suspected. (See "Adnexal mass: Ultrasound categorization", section on 'Step four: Is additional evaluation needed?' and "Approach to the patient with an adnexal mass", section on 'Management'.)

SPECIAL CONSIDERATIONS

Ruptured teratoma — Rupture of a mature teratoma (dermoid cyst) with spillage of sebaceous material into the abdominal cavity is uncommon but has severe consequences. Shock and hemorrhage are the immediate sequelae of rupture; a marked granulomatous reaction (chemical peritonitis) may subsequently develop and lead to formation of dense adhesions and chronic pain [15]. For these reasons, we suggest emergency surgery if a ruptured teratoma is suspected. Surgical intervention includes suction of spilled ovarian cyst contents, copious irrigation with warmed normal saline (to avoid hypothermia) and suction to eliminate any residual sebaceous material, and cystectomy. As fat will float on top of the irrigation fluid, sebaceous material is optimally removed by suctioning on the surface of the fluid level. We alternate between Trendelenburg and reverse Trendelenburg positioning to improve irrigation and suction. (See "Ovarian germ cell tumors: Pathology, epidemiology, clinical manifestations, and diagnosis", section on 'Mature cystic teratomas'.)

A low-grade fever may be associated with a chemical peritonitis caused by a ruptured dermoid cyst [16].

Ruptured endometrioma — Rupture of an endometrioma may be associated with significant hemorrhage [17-20]. Thus, if a ruptured endometrioma is suspected (eg, history of endometriosis, finding of endometrioma on ultrasound), the patient should be considered at an increased risk of bleeding. (See "Endometriosis: Management of ovarian endometriomas".)

Bleeding diathesis — Patients with ovarian cyst rupture and a bleeding diathesis (eg, von Willebrand disease) or on anticoagulation therapy are at risk for significant hemorrhage [21-27]. Management of such patients are discussed in detail separately. (See "Approach to the adult with a suspected bleeding disorder".)

Pregnant patients — In pregnant patients, rupture of an ovarian cyst is most likely to occur in the first or early second trimester as most functional ovarian cysts resolve by the mid-second trimester.

Conservative management is preferable in pregnancy. If surgery is necessary due to pain or hemorrhage, laparoscopy is a reasonable method [28]. If the corpus luteum is removed prior to 10 weeks, it will be necessary to provide progesterone supplementation. (See "Laparoscopic surgery in pregnancy" and "Adnexal mass: Evaluation and management in pregnancy", section on 'Management of corpus luteum'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Ovarian and fallopian tube disease".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topic (see "Patient education: Ovarian cysts (The Basics)")

Beyond the Basics topic (see "Patient education: Ovarian cysts (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Clinical significance – Rupture of an ovarian cyst is a common occurrence in reproductive age females. Physiologic cysts (eg, follicular cyst, corpus luteal cyst) or pathologic cysts (eg, endometriomas, malignant neoplasms) may rupture resulting in release of cyst contents (eg, serous fluid, blood, sebaceous material) that may irritate the peritoneal cavity. (See 'Introduction' above.)

Clinical presentation – Cyst rupture may be asymptomatic, associated with mild mid-cycle pain (also referred to as mittelschmerz), or may be characterized by the sudden onset of unilateral, lower abdominal pain, often following strenuous physical activity (eg, sexual intercourse, exercise). (See 'Clinical presentation' above and 'Pathophysiology' above.)

Evaluation – Pelvic imaging, preferably with ultrasound, is the mainstay of evaluation in symptomatic patients in whom ruptured ovarian cyst is suspected. (See 'Diagnostic evaluation' above.)

Diagnosis – A definitive diagnosis of ruptured ovarian cyst is made by the visualization of an ovarian cyst that is leaking fluid or blood or has evidence of capsular disruption at the time of surgical evaluation. A presumptive diagnosis of ruptured ovarian cyst can be made with a fair degree of confidence in a patient with a symptom pattern that is consistent with this condition, and with sonographic findings of an ovarian cyst plus blood or a large amount of serous fluid in the pelvis. The absence of a cyst makes the diagnosis less likely. (See 'Diagnosis' above.)

Differential diagnosis – The differential diagnosis includes other conditions associated with pelvic or abdominal pain, hemoperitoneum, or a peritoneal fluid collection, including ectopic pregnancy, adnexal torsion, appendicitis, and tubo-ovarian abscess. (See 'Differential diagnosis' above.)

Management – Most patients with ovarian cyst rupture have an uncomplicated case and are candidates for observation. Complicated cases (ie, hemodynamic instability, large or ongoing blood loss, signs of an infection process, findings suggestive of malignancy) may require inpatient management and/or surgery (algorithm 1). (See 'Management' above.)

Patients with hemodynamic instability require immediate surgical management. (See 'Hemodynamic instability' above.)

For most patients with a ruptured ovarian cyst who are hemodynamically stable but have significant hemoperitoneum or concern of ongoing blood loss, we suggest hospitalization with close observation rather than immediate surgery (Grade 2C). Close observation includes frequent vital signs, serial hemoglobin/hematocrit testing, fluid replacement, and repeat pelvic ultrasound, if needed. Surgery is required if ongoing hemorrhage needs to be controlled and/or if the patient's clinical condition is unstable. (See 'Heavy or ongoing blood loss' above.)

Patients with uncomplicated cyst rupture do not require immediate surgery. Later surgical intervention may be indicated for diagnosis and treatment of ovarian cysts that are large or persistent, patients with continued symptoms, or those with findings suspicious for malignancy. (See 'Patients with uncomplicated cyst rupture' above.)

Pregnant patients, patients with a bleeding diathesis, or those with a ruptured teratoma or endometrioma may be managed differently. (See 'Special considerations' above.)

Surgical procedure – When surgery is performed, laparoscopy is the preferred surgical approach because it results in less morbidity than laparotomy. In a premenopausal patient with a benign ovarian cyst (physiologic or nonphysiologic), preservation of ovarian tissue via cystectomy is generally preferable to complete oophorectomy. In a postmenopausal patient, unilateral oophorectomy is generally performed; bilateral salpingo-oophorectomy is only indicated if malignancy is suspected. (See 'Surgical procedure' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Andrew Blechman, MD, and William Mann, Jr, MD, who contributed to an earlier version of this topic review.

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Topic 3298 Version 39.0

References

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