Massive ovarian hemorrhage

MASSIVE

OVARIAN

BY FRANK B. (From

the

Surgical

BLOCK,

Department

HEMORRHAGE*

M.D., the

of

PHILADELPHIA,

Jewish

Hospital,

PA.

Philadelphia)

M

ASSIVE intraperitoneal hemorrhage from a rupture of an ovarian follicle is not unusual. It might be of interest, however, to consider the subject from several angles, with particular reference to the material that has been presented since Phaneuf’s’ collective review in 1924. He found that the literature previous to 1900 did not clearly establish whether or not the hemorrhage was due to ectopic gestation, therefore he confined his observations to the literature after that date. He was able to find reports of 20 eases of ruptured follicular cyst, 22 cases of ruptured corpus luteum cyst and 17 cases of hematic cyst, type not stated. To these he added three cases of his own. Since then there have been several cases reported, the reports having little in common except that no case was diagnosed before operation. Report of Case.-A married woman, twenty-five years old, was admitted to the Jewish Hospital on October 22, 1928 complaining of severe abdominal pain. She stated that six hours before admission she experienced a sharp pain in the lower abdomen, chiefly in the right lower quadrant, which was followed by nausea but no vomiting. The pain persisted and later was accompanied by a sensation of chilliness but she had had no distinct chill. Her pulse was 90, temperature 99 and respirations 24. Her past history revealed that seven years ago she had an attack of “acute appendicitis ’ ’ and recovered without surgical intervention. Since then her general health has been good. Her menses have always been irregular, coming at three to six week intervals and lasting from seven to ten days. The last menstrual period was three weeks ago and was perfectly normal. She had had no intermenstrual bleeding nor discharge. She had one child and no miscarriages. On examination it was noted that her color was good but her expression was apprehensive. Her skin was warm and moist. Abdominal examination revealed some tenderness in the lower abdomen, especially in the midline and above Poupart’s ligament on the right side. There was slight rigidity of the lower part of the right reetus muscle. Bimanual vaginal examination revealed a sensation of tenseness in the right adnexa but no distinct masses were palpable. Her hemoglobin was 78 per cent, red blood cells 4,600,000, leucocytes 20,000 with 86 per cent of polynuclear cells. The blood pressure was 120/70. The urine was negative. She was kept under observation with tentative diagnoses of acute appendicitis or ectopic gestation. Seven hours later her temperature was 99.4”, her pulse had increased to 120 and her respirations to 32, and operation was decided upon as an immediate procedure. Feeling more inclined toward the diagnosis of acute appendicitis than tubal pregnancy, I made a McBurney incision which is my usual custom in all acute appendicitis cases. On opening the peritoneal cavity considerable blood gushed from the wound. Without great difilculty the right tube was brought up into the wound and found to be normal. On examining the right ovary however, a punched-out rupture about 3 mm. in diameter This rupture had perforated a small vein was found over the remains of a follicle. *Read

at

a meeting

of

the

Philadelphia

Obstetrical 102

Society.

May

2. 1929.

BLOCK and active hemorrhage mattress sutures of appendix was found was closed without disrharged as cured

:

MASSIVE

OVAkIAN

103

HEMORRRAGE

was still going on. The bleeding w’as controlled by two fine catgut which were placed under the site of rupture. The to be posterior but not inflamed aud was removed. The wound drainage. The convalescence was entirely normal and she was on November 1, ten days after admission.

ETIOLOCrY

For an intelligent interpretation of the literature on this subject it is necessary to properly classify the cases according to their etiology. The classification of Stein, quoted by Feiner,z seems adequate for this purpose. He states that the hemorrhage may be due to the following causes : Local 1. Menstrual (excessive menstrual hyperemia) 2. Nonmenstrual a. Active hyperemia, as acute or chronic oophoritis b. Passive hyperemia, as thrombus, torsion, varix c. Primary or secondary neoplasm d. Trauma, excessive coitus, etc. General 1. Diseases altering the composition of the blood a. General disorders of nutrition as anemia or chlorosis b. Hemophilia c. Infectious disorders, as typhoid, acute exanthemas, etc. 2. Phosphorus poisoning 3. Venous congestion of the abdominal viscera, as in heart or lung

disease

While the foregoing classification seems thoroughly comprehensive, there is quite a etiologic difference of opinion among other reporters as to the most important factor. Traugotts admits the possibility of grave hemorrhage from the ovary only in leucemia, phosphorus poisoning, extensive burns, hemorrhagic diathesis, hypertension, neoplasms and acute torsion. All the other reported instances he regards as overlooked extrauterine (usually tubal) pregnancy. Such was his case with apparent bleeding from a large ruptured cyst in the ovary in a young married woman. The ovum was found in the abdomen but the tube was macroscopically normal. However, sections of the specimen revealed syneytial cells resembling chorion. Toldy4 calls attention to the statement of earlier writers that ovarian hemorrhage frequently occurs at the time of menstruation or a little before, as in the case here reported. He is of the opinion that this is not due to hyperemia but to increased permeability of the capillaries during menstruation. Wilsons reporting 7 cases, states that the process underlying this form of hemorrhage seems to be an exaggeration of the normal physiologic mechanism of rupt,ure of the graafian follicle. Roth6 thinks that changes in the intraperitoneal pressure play a part in the production of these hemorrhages, particularly the negative pressure which is frequent in the peritoneal cavity. Positive pressure keeps the tube applied to the ovary, but if there is negative pressure in the pelvis this application will be incomplete and the Simon’ in a aspiration exercised by the peritoneal cavity may cause hemorrhage. study of 30 cases found the onset of the hemorrhage to occur invariably in the interval between ovulation and menstruation, i.e., during the empt,ying of the follicle but if such be the case it is difficult to explain the case reported by They report a patient who had 200 C.C. of blood in the Dolynskyj and Benzions.

104

THE

AMERICAN

JOURNAL

OF

OBSTETRICS

AND

GYNECOLOGP

peritoneal cavity as the result of a ruptured foIIicle which occurred u;hen she was between three and four months pregnant. The patient aborted and recovered. Iuasmuch as ovulation and menstrual congestion probably do not occur during pregnancy, it is reasonable to suppose that in their case the hemorrhage was from a corpus luteurn. Klein9 reports a massive hemorrhage frpm a ruptured corpus luteum cyst probably occurring during coitus. He x~s able to demonstrate a rupture in a vein in the wall of the cyst. Hemorrhage from twisted cysts of the type reported by Chamberslo and from endometriomas as reported by Beall are quite common and seldom of massive proportions and nerd not be eonsidcred here. SY&IPTOI\IATOLOGY

In the large majority of the cases reported, the history is almost uniform. The patient is in the menstruating age, and while in apparent health, she suddenly develops lower abdominal pain of varying degrees. The onset is apt to be in the premenstrual period and as a rule is not severe enough to give the appearance of shock but if the bleeding continues, the signs of internal hemorrhage will appear later. The pain is probably due to the irritation of the free blood in the pelvis. We should expect that the pain would be referred to the left side as is quite common in pelvic irritations but curiously enough it is usually referred to the right side and many cases have been diagnosed as acute appendicitis on this account. This reference of pain to the right side has been noted by Hadden,l= GrossI and Lurje14 in cases in which the ruptured follicle was in the left ovary, so that the pain is probably not due to the traumatism of the ovary as the result of follicular rupture. The pain usually continues and is associated with tenderness in the lower abdomen and some rigidity due to the peritoneal irritation and if the hemorrhage continues, the condition of the patient points to the necessity of surgical intervention. DIAGNOSIS

No cases have been found in the literature in which the diagnosis was made before operation. Korach15 states that it is frequently impossible to differentiate between appendicitis and a follicular rupture and advises operation in cases of doubt. Toldy* says that the differential diagnosis from ectopic pregnancy is impossible and only when the patient is a virgin can ovarian hemorrhage be thought of as a diagnosis. Simon’ emphasizes the important differential point that, in ovarian follicular hemorrhage, vaginal bleeding is always absent as contrasted with its frequent presence in cases of ectopic pregnancy. While the differential diagnosis from ectopic pregnancy may be only of academic and medicolegal interest, the differentiation from appendicitis is often of more importance on account of the type of incision to be employed. However, from personal experience as well as from a perusal of the reported cases it would seem that a positive diagnosis will seldom be made, a tentative diagnosis being the most that can be expected.

BLOCK

:

MASSIVE

OVARIAN

HEMORRHAGE

105

TREATMENT

It is probable that in many cases small hemorrhages occur, giving transitory symptoms, are relieved by palliative measures, and are never diagnosed. However, when the condition has progressed to a point where it has affected the pulse rate, operation is indicated. If the case has been diagnosed as an ectopic pregnancy or other internal hemorrhage, a midline incision will always be the incision of choice. When however, the case has been diagnosed as acute appendicitis, the lateral muscle splitting incision of McEurney will often be made. If blood is noted on opening the peritoneal cavity a search must be made beyond the appendix. In the case reported by Lurje,14 a twenty-three year old gir1 had her appendix removed through a NcBurney incision and even though blood appeared in the wound the pelvic organs were not examined. Her symptoms continued and four days later she was reoperated upon, and old blood clots were removed which mere coming from a small rupture of the left ovary. If the patient is not too stout and the incision is not too high, a rupture in the right ovary can often be taken care of through the McBurney incision as in my own case. However, there need be no hesitation in making a second incision in the midline as reported by Lassen.16 After exposure of the pelvic organs, conservatism should be the rule. Of the cases reviewed in the preparation of this paper, the ovary was removed in about two-thirds of the cases, resected in about one-sixth and in only the remaining one-sixth was simple suture of the rupture performed. It is my belief that these figures should and could be reversed. A carefully placed mattress suture, using a fine needle and thin pliable suture material, will probably control the bleeding in the large majority of the cases. When such a conservative measure fails, resection or removal of the ovary will have to be done. If the hemorrhage has been severe, transfusion from donors or autotransfusion of the blood from the abdominal cavity should be considered. SUMMARY

Rupture of an ovarian follicle as a cause of profuse intraperitoneal hemorrhage is becoming increasingly important. It is usually diagnosed either as acute appendicitis or ectopic pregnancy since there is no pathognomonic sign of this condition. It occurs most frequently in the premenstrual period and should always be suspected in a virgin presenting signs of internal hemorrhage from no evident cause. The most common cause of the condition is probably an exaggeration of the normal ovulation especially if the follicular rupture involves a small vein as in the case here reported. The treatment is surgical as soon as the pulse rate is affected and the ovary should be retained if possible. Only in cases of hemorrhage uncontrollable by suture should the ovary be removed.

106

THE

AMERICAN

JOURNAL

OF OBSTETRICS

AND

GYNECOLOGY

REFERENCES (1) Phavreuf, L.: J. A. M. A. 83: 658, 1924. (2) Feiner, David: Surg. Gynec. Obst. 42: 671, 1926. (3) Traiugott, Marcel: Monatschr. f. Geburtsh. u. Gynlk. 72: 307, 1926. (4) Toldy, Lo-rant: Zentralbl. f. Gynak. 48: 138, 1924. (5) Wilson, &. E.: Lancet 214: 1221, 1928. (6) Roth, H.: Gynec. et Obst. 16: 464, 1927. (7) Simon, L. : Acta Obst. et Gynec. Scnndinsvica. 7: Fast. l-3, 1928; Abst. J. Obst. & Gynec. Brit. Emp. 35: 845, 1928. (8) Dolynskyj, 111., and Be%&n, 1.: Zentralbl. f. Gynlk. 50: 117, 1926. (9) Elein, Paul: Zentralbl. f. Gynlk. 50: 111, 1926. (10) Chambers, G. : British Med. J., 493, Sept. 17, 1927. (11) Beall, Frank C.: Texas State J. Med. 21: 724, 1926. (12) Hadden, David: AK J. OBST. & GYNEC. 7: 600, 1924. (13) Gross, IFiZheZm: Zentralbl. f. Chir. 54: 2075, 1927. (14) Lzlrje, 4.: Zentralbl. f. Chir. 55: 22, 1928. (15) Eorach: Miinchen. med. Wchnschr. 72: 1199, 1925. (16) Lassen, H. K.: Hospitalstidende 69: 825, 1926. MEDICAL

ARTS

BUILDING.

(For

A REPORT BY

OF FOUR CLIFFORD

B.

discwkm,

CASES OF UNUSUAL DEFECTS” LULL,

M.D.,

see page

188.)

CONGENITAL

PHILADELPHIA,

YA.

the past year there have come under my observation several D URING newborn children who presented anomalies which were incompatible either with life or with nornal extrauterine development. A report of four of the more unusual ones forms the basis for this paper. l.-Coag&tal absence of the left Mrs. F., aged twenty-nine, was seen when pregnant for the first time. Her general no signs of any organic disease. There were Wassermann was negative. Throughout her to handle, because of dietary’ indiaerctions, intestinal symptoms. She was uncooperative but did not develop any toxic symptoms. CASE

femur. she was about condition was no symptoms entire pregnancy giving rise as regards her

three and one-half months satisfactory and showed of toxemia and the blood she was rather difticult to rather severe gastrodiet and general hygiene,

She went into labor about three days beyond her expected time. She had a normal blood pressure and normal urine. The child was in the L.O.P. position, and the head well engaged. The first stage of labor lasted twelve and one-half hours, the second stage two hours, at which time the head was arrested at the transverse of the outlet, with the sagittal suture lying transversely. The labor was terminated by rotation of the head with forceps, median episiotomy, and forceps extraction. The third stage of labor was uneventful. The child was a female, weighing 8 pounds, 4 ounces; it cried vigorously immediately after birth and was normal in every respect, except for the left lower extremity. This presented a rather unusual deformity, as the knee joint was attached to the hip on the left side and there was a marked clubbing of the left foot. The other extremities were normal. X-ray confirmed the diagnosis of absence of the left femur, and also showed an absence of the left fibula. The result is that this child has what looks like a normal knee joint coming from the hip on the left side, with a marked decrease in circumference of the lower leg and a marked clubbing of the left foot. This child is now six months old and has shown no other peculiari*Read

at a meeting

OF the Philadelphia,

Obstetrical

Society,

May

2, 1929.