Corpus Luteum Rupture

Author: Charles J Ascher-Walsh, MD, Director of Gynecology, Female Pelvic Medicine and Reconstructive Surgery, Mt. Sinai School of Medicine; Past Clinical Assistant Professor, Department of Obstetrics and Gynecology, New York-Presbyterian Medical Center, Columbia University

Introduction

Background

Ruptured corpus luteum is a common phenomenon with presentation ranging from no symptoms to symptoms mimicking an acute abdomen. Sequelae vary. Resolution may be spontaneous (most often); intraperitoneal hemorrhage and death may occur. Although most patients require only observation, some need laparoscopy or laparotomy to achieve hemostasis.

Pathophysiology

Each month, a mature ovarian follicle ruptures, releasing an ovum so the process of fertilization can begin. Occasionally, this rupture site may bleed, causing abdominal pain and signs of hemorrhage. The etiology of this increased bleeding is unknown, although abdominal trauma and anticoagulation treatments may increase the risk.

Frequency

United States

Occurrence is unknown but is likely quite frequent and without symptoms.

International

Occurrence is unknown but is likely quite frequent and without symptoms.

Mortality/Morbidity

Although circulatory collapse, hemorrhagic shock, disseminated intravascular coagulation (DIC), and death have been reported, these are rare. Most cases are self-limiting, with abdominal pain relieved with analgesics.

Race

No differences in frequency are reported by race or socioeconomic standing.

Sex

Ruptured corpus luteum occurs only in females.

Age

The condition most commonly occurs in women aged 18-35 years (peak reproductive years).

Clinical

History

The patient often presents with an acute onset of abdominal pain, usually in the second half of the menstrual cycle. The pain often begins during strenuous physical activity, such as exercise or sexual intercourse. Other presenting symptoms may include the following:

  • Vaginal bleeding
  • Nausea and/or vomiting
  • Weakness
  • Syncope
  • Shoulder tenderness
  • Circulatory collapse

Physical

Vital signs are usually within normal range. Physical findings can range from mild unilateral low abdominal tenderness to those of an acute abdomen with severe tenderness, guarding, rebound, and peritoneal signs.

  • Low-grade fever is sometimes observed.
  • An adnexal mass may be palpable.
  • Orthostatic changes are consistent with a sizable hemorrhage.

Causes

Etiology remains unknown, but risk factors include abdominal trauma and anticoagulation therapy.

Differential Diagnoses

Abdominal Trauma, Blunt
Diverticulitis
Appendicitis
Ectopic Pregnancy
Bladder Stones
Nephrolithiasis
Cystitis, Nonbacterial
Ovarian Cysts

Other Problems to Be Considered

Ovarian torsion

Workup

Laboratory Studies

  • Monitor hematocrit (serially, if necessary) to ensure there is no continued bleeding.
  • Serum or urine pregnancy testing should be obtained. In the case of a positive result, the patient should be evaluated for ectopic pregnancy.
  • Blood type and crossmatch is indicated in patients with peritoneal signs or hemodynamic instability as they may require surgical intervention or blood transfusion.
  • Urinalysis should be obtained to evaluate for possible urinary tract infection and renal or bladder stones.
  • Blood, urine, and cervical cultures may be indicated in patients with concomitant fever to rule out pelvic or urinary tract infections.

Imaging Studies

  • Pelvic ultrasonography is the best imaging study to determine the amount of abdominal bleeding.
  • Obtain other imaging studies to exclude other diagnoses.

Other Tests

Although commonly performed in the past, culdocentesis usually is no longer involved when ultrasonography is available.

Procedures

Perform a diagnostic laparoscopy and/or laparotomy if the patient is hemodynamically unstable.

Treatment

Medical Care

Medical care consists of pain relief with an analgesic of choice. Medications may range from oral acetaminophen to intramuscular Demerol.

Surgical Care

If continued bleeding is a concern or if the patient is unstable hemodynamically, proceed with surgery.

  • This may entail laparoscopy or laparotomy depending on clinical presentation, amount of blood in the abdomen, patient stability, and operator comfort.
  • Most bleeding may be stopped with wedge resection, suture and/or fulguration, or cystectomy. Occasionally, salpingo-oophorectomy is needed to control hemorrhage.

Consultations

  • Obstetrician and gynecologist
  • Other consultations as needed to exclude other suspected diagnoses (eg, general surgeon for appendicitis)

Activity

Patients may return to normal activity as tolerated.

Medication

Medical therapy consists of appropriate pain relief. Pain relief medications can range from acetaminophen to meperidine (or an analgesic of choice).

Analgesics

Pain control is essential to quality patient care. These medications ensure patient comfort and have sedating properties, which are beneficial in the treatment of pain.

 

Acetaminophen (Tylenol)

DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, those with upper GI disease, or those who are taking oral anticoagulants.

Adult

325-1000 mg PO q6h; not to exceed 4 g/d

Pediatric

Not established

Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins (eg, phenytoin), ethanol, and isoniazid may increase hepatotoxicity

Documented hypersensitivity

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatotoxicity is possible in people with chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products, and combined use with these products may result in cumulative doses exceeding the recommended maximum dose; caution in renal impairment; cardiac and pulmonary disease increases risk of toxicity

 

Meperidine (Demerol)

Analgesic with multiple actions similar to those of morphine. May produce less constipation, smooth muscle spasm, and depression of cough reflex than similar analgesic doses of morphine.

Adult

50-150 mg PO/IV/IM/SC q3-4h prn

Pediatric

Not established

Follow-up

Further Outpatient Care

Patients should return within a week to make sure pain has decreased and bleeding has abated.

Inpatient & Outpatient Medications

An analgesic of choice is indicated.

Prognosis

The prognosis is good.

Miscellaneous

Medicolegal Pitfalls

  • Perform a urine pregnancy test. If the pregnancy test is positive, make sure to rule out an ectopic pregnancy.
  • Rule out ovarian torsion before discharge.
  • If a diagnosis of ruptured corpus luteum is considered, make sure hemoglobin is stable before discharging home.

References

  1. Muller CH, Zimmermann K, Bettex HJ. Near-fatal intra-abdominal bleeding from a ruptured follicle during thrombolytic therapy. Lancet . Jun 15 1996;347(9016):1697. [Medline] .

  2. Raziel A, Ron-El R, Pansky M. Current management of ruptured corpus luteum. Eur J Obstet Gynecol Reprod Biol . Jun 1993;50(1):77-81. [Medline] .

  3. Sivanesaratnam V, Singh A, Rachagan SP. Intraperitoneal haemorrhage from a ruptured corpus luteum. A cause of "acute abdomen" in women. Med J Aust . Apr 14 1986;144(8):411, 413-4. [Medline] .

  4. Tang LC, Cho HK, Chan SY. Dextropreponderance of corpus luteum rupture. A clinical study. J Reprod Med . Oct 1985;30(10):764-8. [Medline] .

Mon, 19 Jul 2010 @23:10

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