{"paper_id":"31258dd2-4561-434a-86ad-574af242eea2","body_text":"~ 111 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2022; 6(1): 111-112 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com \n2022; 6(1): 111-112 \nReceived: 26-11-2021 \nAccepted: 28-12-2021 \n \nDr. Bhaktii Kohli \nSenior Resident, Department of \nObstetrics & Gynaecology, \nMaharishi Markandeshwar Medical \nCollege & Hospital, Solan, \nHimachal Pradesh, India \n \nDr. Anushree Sharma  \nPost Graduate Resident, \nDepartment of Obstetrics and \nGynaecology, Maharishi \nMarkandeshwar Medical College & \nHospital, Solan, Himachal \nPradesh, India \n \nDr. Santosh Minhas \nProfessor and Head of \nDepartment, Department of \nObstetrics & Gynaecology, \nMaharishi Markandeshwar Medical \nCollege & Hospital, Solan, \nHimachal Pradesh, India \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nCorresponding Author: \nDr. Santosh Minhas \nProfessor and Head of \nDepartment, Department of \nObstetrics & Gynaecology, \nMaharishi Markandeshwar Medical \nCollege & Hospital, Solan, \nHimachal Pradesh, India \n \nRuptured endometrioma: A rare event \n \nDr. Bhaktii Kohli, Dr. Anushree Sharma and Dr. Santosh Minhas \n \nDOI: https://doi.org/10.33545/gynae.2022.v6.i1b.1125 \n \nAbstract \nEndometriosis is a benign condition which invades locally and hence disseminates widely. Though, it is a \nhormone dependent and a non -neoplastic condition, yet malignant transformation is possible. When \nencysted, the cyst enlarges with the cyclic bleeding and the serum gets absorbed in between the menses to \nmake the contents chocolate coloured. The cyst can rupture spontaneously causing acute abdomen and is \noften confused with ovarian torsion, ectopic pregnancy. Thus, we are reporting a similar case of \nspontaneous ruptured endometrioma, which is a rare entity. \n \nKeywords: Chemical peritonitis, endometriosis, laparotomy, ruptured ovarian cyst \n \nIntroduction \nEndometriosis represents the presence of endometrial glands and s troma in locations other than \nthe uterine cavity [1]. It affects about 10% of reproductive aged women [2]. Most commonly the \nendometrial tissue gets implanted on the pelvic peritoneum, ovaries and uterosacral ligaments. \nRetrograde menstruation is a propose d theory for development of adhesions and subsequent \ngrowth in the peritoneum  [3]. It is a benign condition associated with chronic pelvic pain, \ncongestive dysmenorrhea, dyspareunia and infertility. Spontaneous rupture of an ovarian \nendometrioma is a rare complication manifested by acute abdomen and is one of the rarest \ncauses of gynecological emergency.  The aim of this case report is to differentiate the rare \npresentation and associated complications of endometriosis and hence its management. \n \nCase  \nA 32-year-old P1L1 reported to the emergency with the complaint of pain lower abdomen for \npast 5-6 days with increasing severity for past 1 day and with associated nausea and vomiting \nfor past 1 day. She had a history of open cystectomy 6 years back at a private hospital with no \nrecords available. On examination, the patient was cooperative with a pulse rate of 120/min low \nvolume pulse and a blood pressure of 80/60 mmHg.  On per abdomen examination tenderness, \nguarding and rigidity was present in the right iliac re gion. On per speculum examination, no \nabnormality was detected while on per vaginal examination, uterus was retroverted, normal size \nwith fullness and tenderness present in bilateral fornixes.  \n \nUrine pregnancy test was negative \nUltrasound features were suggestive of a right ovarian cyst of approx. 5*5 cm (figure 1) with no \ndefinitive vascularity in the periphery and moderate amount of fluid in the pelvis (figure 2).  \n \n \n \nFig 1: arrow shows cyst of 5*5 cm \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 112 ~ \n \n \nFig 2: Shows fluid in pelvis (hemoperitoneum) \n \nAll the routine blood investigations were normal. \nPlan of emergency laparotomy was made in view of \nhemodynamic instability of the patient, keeping in mind a \ndifferential diagnosis of ruptured ovarian cyst, ovarian torsion \nand chronic ectopic pregnancy. Per operatively, right ovarian \nruptured hemorrhagic cyst of approximate size of 10*16 cm was \npresent with rest of the adnexa and uterus normal. (F igure.3). \n250 -300 ml of chocolate colored fluid was drained from the \nabdominal cavity. Endometriotic lesions were  identified on the \ngut and uterosacral ligament. A thorough saline wash of the \nperitoneal cavity was done intraoperatively.  \n \n \n \nFig 3: Ovary with ruptured chocolate cyst with fallopian tube of that \nside \n \nIn the postoperative period, patient developed abdo minal \ndistention with features suggestive of chronic peritonitis and \nbilateral pleural effusion on postoperative day 2. Patient was \ninvestigated to rule out tuberculosis and all the investigations \nwere negative. Patient was managed conservatively with Ryle ’s \ntube insertion, antibiotics and diuretics and was later discharged \nunder satisfactory conditions on 13th postoperative day. \n \nDiscussion \nEndometriosis was first described in 1860 and the cause of this \nenigmatic female disease is still unclear  [4]. It is a common \ndiagnosis in gynecology OPD but its presentation as acute \nabdomen in emergency is a rare event. Until date only a few \ncases of spontaneous endometrioma rupture have been reported  \n[5-6]. The etiology of spontaneous rupture is the increasing size of \nthe ovarian cyst due to the rapid growth of the endometriotic \ntissue causing increased pressure in the cyst. The event of \nrupture is proposed to be more common in patients with \nprevious history of endometriosis due to the increased stretching \nforces between the previous adhesions and the enlarging ovarian \ncyst. The diagnosis is often missed due to low suspicion and \nnon-specific presentation.  \nOften the diagnosis is made intraoperatively although \nsonography is a useful aid which reveals an ovarian cyst with  \nlow level internal echoes and free fluid in the pelvis. \nRuptured ovarian cyst can be managed conservatively unless \nhemodynamic instability ensues. As in our case, the patient was \ntaken up for emergency laparotomy in view of hemodynamic \ninstability. An imp ortant postoperative complication which \noccurred in our case was chemical peritonitis due to the \ninflammatory response of the peritoneum to the endometriotic \ntissue released after the cyst rupture. This complication often \nprolongs the hospital stay and add s to the morbidity of the \npatient. Thus, a timely diagnosis and a thorough saline wash \nintraoperatively becomes an important prerequisite to reduce the \ncomplication rate. \n \nConclusion \nRuptured endometriomas should be kept in mind while attending \nthe patient of acute abdomen, especially those with an ovarian \ncyst or previous history of endometriosis.  Timely surgical \nintervention can help to reduce the morbidity and improve the \nprognosis of the patients. Those presenting with recurrent cysts \ngenerally have a poorer outcome. \n \nReferences \n1. Lonescu AM, Dimithu NI, Socea B, Ionescu CA, Gheorghiu \nDC, Pans 1, et al. Ovariar. entomethotic cyst in a 28, years \nold women. case report. Res. & Sci. Today. 2019 ;1730. \n2. Mounsey Al. ; Wilgus A, Slawne DC. Dia gnosis and \nmanagement of endome triosis. Am. Fam. Ph ysician. \n2006;74:594-600. \n3. Pandey D , N'tIsingen P , Hung  KG. Laparoscopic \nManagement of Pertonitis Due to a Ruptured overian \nEndometnoma wilh Extemely High Level s of Cancer \nAntigen-125 and Cancer Antigen -19-9. Journal of \nGynecologic surger y. jun  2019.198-200. \nhttp://doio.org/10.1089 n11.2018.0089 \n4. Kralickova M, V etvicka V. End ometiosis and  overian. \ncancer. world J Clin Onco1. 2014;5:803. \n5. Reif P  , Scholl CV , Klritsch P , Lang U. Rupture of \nendometroitic cyst  causes acute hemoperitoneum in twin  \npregnancy. Fertility and Strility. 2011May 1;95(6):2125-e1. \n6. Pratt JR , Shamblin AVM . Spontaneous rupture of \nendomterial cysts of ovary presenting as an acute abdominal \nemergency American journal of obstetrics and gynecology. \n1970 Sep 1;108(1):456-62.","source_license":"CC0","license_restricted":false}