​Kembara Xtra - Medicine - Ruptured Ovarian Cyst

​Kembara Xtra - Medicine - Ruptured Ovarian Cyst
Most ovarian cysts are benign physiologic follicles produced by the ovary at the time of ovulation. Ovarian cysts are common in reproductive-aged women.
When ovarian cysts develop and put pressure on neighboring structures, or when they burst and the cyst contents irritate the peritoneum or nearby pelvic organs, symptoms may result.
Patients who have a symptomatic burst cyst typically experience unilateral, acute lower abdomen pain.
Sexual activity, the luteal phase, physical activity, trauma, pregnancy, or an idiopathic condition can all result in rupture.
Once a ruptured cyst is determined to be the cause of the patient's pain, most can be treated conservatively as outpatients with adequate pain management, including excluding other urgent causes like ovarian torsion, ectopic pregnancy, and nongynecologic sources of acute unilateral lower abdominal pain. Rarely is surgical intervention necessary.



Until proven otherwise, a suspected burst ovarian cyst should be handled as an unknown adnexal mass (ovary, fallopian tube, and surrounding tissue mass).

Epidemiology 

It is challenging to estimate the exact prevalence of ovarian cysts because many burst cysts are asymptomatic or discovered by chance.
Nearly all premenopausal women and up to 18% of postmenopausal women have ovarian cysts visible on transvaginal ultrasounds. Most burst ovarian cysts are physiologic occurrences and self-limited; the vast majority of these cysts are benign or functioning. Usually, expectant management combined with pain treatment is sufficient.
● In women of reproductive age, 13% of ovarian masses are malignant, compared to 45% of postmenopausal women. Ruptured ovarian cysts most frequently affect the right ovary, 63%, and about 70% of ovarian cancers are detected at a late stage.
Incidence
In their lives, about 7% of women worldwide will develop a symptomatic cyst.
Prevalence
Prevalence during pregnancy ranges from 1 to 5.3%; only 0.63% of those are symptomatic and 1% are malignant.


Pathophysiology and Etiology 

A mature follicle ruptures during normal ovulation, releasing an oocyte and leaving behind a corpus luteum, which then involutes. A follicular cyst develops if the follicle does not break and instead keeps expanding. A corpus luteum cyst develops when the corpus luteum does not involute and keeps expanding. The majority of cysts are like this. Both categories have no malignant potential and are physiological (sometimes referred to as "functional"). Endometriomas, which are filled with menstrual blood, dermoid cysts, which contain mature tissue of ectodermal, mesodermal, and/or endodermal origin, and ovarian cancer coming from any of the ovary's structural components are other forms of cysts.

Risk Elements 
medications or health issues that enhance the likelihood of cyst rupture or increased ovulation
Tamoxifen raises the likelihood of ovarian cysts in women of reproductive age. Ovulation inducing drugs (such as Clomid, aromatase inhibitors, and GnRH agonists). Polycystic ovarian syndrome (common), fibrous dysplasia/McCune-Albright syndrome (rare).
Endometriosis in the ovaries

Basic Prevention 
The major treatment for preventing recurrent ovarian cysts is ovulation suppression with combination hormonal contraceptives.

Accompanying Conditions 
20-55% of endometriosis-afflicted women have endometriomas on or around their ovaries.
● PCOS


Diagnosis 
The typical signs of a burst cyst can resemble an ectopic pregnancy. When a ruptured cyst is thought to have occurred, ectopic pregnancy should be checked out.
Diagnostic aids for gynecologic emergencies include sonographic imaging, computed tomography (CT), and magnetic resonance imaging (MRI).
After CT and ultrasound, MRI can help when the diagnosis is still unclear. CT is important to confirm a hemoperitoneum.
Additionally, ultrasonography is helpful in establishing normal Doppler flow to the afflicted ovary and adnexa, which has reduced the necessity for diagnostic surgical intervention.


History If a burst ovarian cyst is suspected, the following questions should be addressed: - Onset and features of pain - Pain related to the timing of sexual activity, strenuous activity, or trauma
- The most recent day of menstruation
- Vaginal bleeding, whether present or not - Nausea or vomiting - Shoulder or upper abdomen pain from subphrenic extravasation - Hypotension/hypovolemia symptoms, such as palpitations, shortness of breath, a feeling of being hot or clammy, and dizziness
Age, prior or known ovarian cysts, and reproductive history of the patient are other factors that should help with diagnosis.

Alert 

Hemorrhagic cysts can cause substantial bleeding in patients with bleeding disorders or who are receiving anticoagulant medication.

clinical assessment 
Unless there has been a considerable blood loss, vital signs are often normal.
Pallor, pale mucosal membranes, and tachycardia are all signs of rupture with considerable blood loss.
In some cases, a palpable adnexal mass can be felt on a bimanual exam. If the peritoneum is irritated or inflamed, patients will have substantial discomfort to palpation or an acute abdomen. A violent examination should be avoided in order to prevent further damage.

Included in the differential diagnosis are all gynecologic and non-gynecologic causes of sudden abdominal pain.
When a pregnancy test comes back negative, ectopic pregnancy should always be ruled out.
Common gynecologic etiologies include: - Ovarian torsion - Functional ovarian cysts
Abscess in the tubo-ovary
Teratomas and thinning fibroids
- Endometrioma - Mucinous or serous cytodenoma - Hydrosalpinx
The numerous gynecologic malignancies of the reproductive tract are typically the causes of malignant gynecologic etiologies.
The following benign nongynecologic conditions might result in acute lower abdomen pain: - Appendicitis - Diverticulitis - Urinary tract infections - Renal colic
Neoplastic processes of the lower GI tract can be blamed for malignant nongynecologic causes of acute lower abdominal discomfort.

Laboratory Results 
Pregnancy must be ruled out in all premenopausal women by a urine test. Quantitative serial hCG testing are useful in assessing ectopic pregnancies.
If there is continuing hemorrhage, a complete blood count (CBC) may show a considerable decrease in hematocrit.
Urinalysis and STD testing should be done in order to check for infectious causes, PID, or symptomatic renal stones. Leukocytosis should increase the suspicion that an infectious process is at play.
If surgery is anticipated or blood products are being evaluated, a type and screen are indicated.
The primary imaging modality is ultrasound; CA-125 may aid in evaluation but may be raised in a variety of diseases.
Initial Tests (Lab, Imaging) CBC, Urinalysis, Serial Quantitative -hCG, and STD Testing
Tests in the Future & Special Considerations
When ultrasonography is inconclusive, CT and MRI may help to reduce the differential diagnosis.

Other/Diagnostic Procedures
In urgent situations, laparoscopy may be both diagnostic and therapeutic.

Management 
The discomfort brought on by a ruptured cyst will frequently be brief and self-limiting for patients.
In 80% of cases, a cyst rupture in a stable, healthy patient can be treated conservatively.
With the help of a multidisciplinary team, patients on anticoagulation can also be managed conservatively when a cyst ruptures. Scheduled NSAIDs or oral opioids can be provided depending on how bad the pain is.
OCPs can be taken into consideration for ovulation suppression and prevention in patients who have experienced numerous occurrences or a single severe incidence. The treatment of already existing ovarian cysts is ineffective with them.
Patients who are hemodynamically compromised or who have considerable hemoperitoneum should be kept alive while laparoscopy or a laparotomy are being evaluated. If there is a worry of malignancy, surgical exploration should also be taken into consideration.

Problems to Refer 
Obstetrician (OB)/GYN - If an adnexal lump is discovered during pregnancy, take referral to an OB into consideration. Low risk of acute pregnancy complications or cancer exists for these tumors. The majority of cysts disappear without treatment in 2 to 3 weeks; those that do not disappear after 12 weeks need to be quickly referred for surgical evaluation.
Gynecologic oncology - Referral to a gynecologic oncologist should be taken into consideration in cases of complex adnexal masses with an elevated CA-125 and associated symptoms that may indicate malignancy, such as ascites, thick septation seen on ultrasound, early satiety, pleural effusion, enlarging abdominal mass, or bowel obstruction.
General surgery or a gastroenterologist should be seen for acute lower abdomen discomfort that is not gynecologic and suspects bowel involvement.

Further Therapies 
Although neither the diagnosis nor the therapy of guided cyst aspiration is advised, it may be used in individuals with high risk who are not suitable surgical candidates.

Surgical Interventions Although it is uncommon, surgical intervention is typically urgent.
Patients who have a lot of hemoperitoneum and a low diastolic blood pressure frequently require surgery.
Laparoscopy is typically used for both diagnosis and treatment.
After a thorough assessment of the intra-abdominal environment has been accomplished, the choice to move forward with cystectomy or oophorectomy should be made intraoperatively. A laparoscopic procedure has the benefits of a shorter hospital stay, a quicker recovery, a smaller scar, and less adhesions. A minimally invasive procedure greatly reduces postoperative recovery time and increases patient satisfaction. If there is severe hemodynamic instability or a shortage of surgeons with laparoscopic training, a laparotomy should be done. Laparotomy may be the chosen surgical procedure if cancer or metastases are a concern.

Admission 

Serial abdominal exams, analgesics, and intravenous resuscitation should be used to manage patients who need inpatient care as indicated by their first presentation.

Follow-Up Patients who were treated conservatively should be seen again 72 hours after their symptoms started.
Patients should come in sooner if their symptoms are new or getting worse.
Patients can follow up as necessary if their symptoms completely go within a few days. However, these patients should get advice on the possibility of recurrence and available preventative measures.
Postop follow-up appointments for patients who underwent surgery should be made two weeks after the procedure, and for those in whom an ovarian cyst was unintentionally discovered, follow-up should be depending on the size of the cyst.

pregnant women's issues
It is debatable how to treat adnexal masses while pregnant. Due to the low risk of malignancy, the majority of adnexal masses during pregnancy can be handled patiently.
Early surgical intervention can lower the likelihood of cyst fluid leaking, reducing adhesions and maintaining fertility if there is a danger for ruptured endometriotic cyst. MRI can be used safely during pregnancy to further describe a mass. The potential for torsion or rupture, however, shouldn't be used as justification for surgery.

Customer Care 

The foundation of patient education is reassuring them that most ovarian cysts are benign.


Ovarian reserve loss may happen after any ovarian surgery. Surgical procedure problems associated to any laparoscopic surgery. Surgical choices should take future fertility goals into account. Cysts that are 5 cm in diameter or larger have the potential to jeopardize the ovarian reserve on their own. It's unknown whether the result is transitory or long-lasting.

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