{"paper_id":"bfb8fd13-8a9d-45c2-88ac-553fbe1fc4d8","body_text":"J Obst Gynecol Surg, \nVolume 3 • Issue 1 • 23\n \nJournal of\nObstetrics and Gynecological Surgery \nJain N, et al., J Obst Gynecol Surg 2022, 3:1\nSpontaneous Rupture of Huge Ovarian Endometrioma and Its Successful Laparoscopic Management: A \nCase-Study and Review of Literature\nNamita Jain1*         , Isha Kriplani2         , Seema Sharma3         , Alka Kriplani4\n1Consultant, Department of Obstetrics and Gynaecology, Paras Hospital, Gurugram, Haryana, India\n2Associate Consultant, Department of Obstetrics and Gynaecology, Paras Hospital, Gurugram, Haryana, India\n3Senior Consultant, Department of Obstetrics and Gynaecology, Paras Hospital, Gurugram, Haryana, India\n4Head of Department of Obstetrics and Gynaecology, Paras Hospital, Gurugram, Haryana, India\n       ABSTRACT\n Endometriosis is a common entity with varying clinical presentation. Spontaneous rupture of a huge ovarian \nendometrioma presenting as an acute emergency is a rare occurrence. One such case presenting as an emergency \nand its successful laparoscopic management is discussed here. \nKeywords: \n Endometriosis, Rupture, Ovarian, Laparoscopic.\nIntroduction \n Endometriosis is an enigmatic condition. Endometriosis has \nmany complications like infertility, chronic pelvic pain, infection, \ntorsion etc. Rupture of an endometrioma is a rare complication. \nIt can become quite painful, ending in a surgical emergency. One \nshould be conscious of such possibility to improve the patient \noutcome. The diagnostic gold standard remains laparoscopy.\n Hereby, we discuss the rare presentation of spontaneous \nrupture of huge endometrioma leading to severe anaemia \nand massive intraperitoneal haemorrhagic collection managed \nlaparoscopically. Very few such cases have been reported in \nliterature and managed laparoscopically.\nCase Report \n 37 year old P1L1 presented to the emergency with severe \nabdominal pain and breathing difficulty. Her previous cycles \nwere regular with gradually increasing dysmenorrhea over a \nperiod of 3 years. She gave history of intake of oral analgesics for \ndysmenorrhea with no prior history of hormonal medications. \nOn admission, she had pulse rate 110bpm, respiratory rate \n24/min, blood pressure 90/60mmHg and SpO2 of 97%. On an \nabdominal examination, gross distention with shifting dullness \nwas observed. On per vaginal examination, fullness in right \nadnexa with tenderness was noticed. Her urinary pregnancy test \nwas negative and USG showed huge right ovarian endometrioma \nand gross hemoperitoneum reaching upto hepatic pouch. A \ncontrast MRI was done which suggested 14 × 12cm ruptured \novarian endometrioma with gross hemoperitoneum (Figure 1). \nHer haemoglobin and CA-125 came out to be 7.2gm/dl and 400 \nIU/l, respectively. Laparoscopic surgery was planned.\n lntr a-operatively, omental adhesions were seen. Peritoneal \ncavity was filled with 5 litres of chocolate colored fluid (Figure \n2A). Uterus was bulky, 14 × 12cm ruptured huge right ovarian \nendometrioma stuck to posterior wall of uterus (Figure 2B). \nand in left ovary 5 × 5 cm endometriotic cyst were seen. \nRight salpingo-oopherectomy was done as no healthy ovarian \ntissue identified. Good amount of left ovarian tissue could be \npreserved after endometriotic cystectomy. 2 units of PRBC\nwere transfused during surgery. Her post-operative period \nwent uneventful. She was discharged on day 3 of her surgery. \nHer histopathology report confirmed endometriosis. She was\nCase Report\nCorrespondence to: Namita Jain, Consultant, Department of Obstetrics and Gynaecology, Paras Hospital, Gurugram, Haryana, India\nReceived date: April 15, 2022; Accepted date: April 28, 2022; Published date: May 5, 2022\nCitation: Jain N, Kriplani I, Sharma S, et al. (2022) Spontaneous Rupture of Huge Ovarian Endometrioma and Its Successful Laparoscopic Management: A Case-Study \nand Review of Literature. J Obst Gynecol Surg 3(1): pp. 7-9. doi: 10.52916/jogs224023\nCopyright: ©2022 Jain N, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted \nuse, distribution and reproduction in any medium, provided the original author and source are credited.\nPage 7 of 9\nFigure 1: MRI images showing huge ovarian endometrioma.\nFigure 2A: Intra operative images showing chocolate colored \nendometriotic fluid.\n\n\nJ Obst Gynecol Surg, \nVolume 3 • Issue 1 • 23\nCitation: Jain N, Kriplani I, Sharma S, et al. (2022) Spontaneous Rupture of Huge Ovarian Endometrioma and Its Successful Laparoscopic Management: A Case-Study \nand Review of Literature. J Obst Gynecol Surg 3(1): pp. 7-9. doi: 10.52916/jogs224023\nPage 8 of 9\nminimise long term effects like chronic pelvic pain, adhesions \nand infertility.\n Pandey et al. published a case of 23 year nulliparous women \nwho presented with acute pain abdomen [3]. Her CT showed \n12 cm left ovarian mass with fluid collection in the intra-\nabdominal cavity and thickened omentum mimicking ovarian \ncancer. The patient’s CA-125 and CA–19-9 levels were 25,149 U/\nmL and 5379 U/mL, respectively. On laparoscopy, ruptured left  \novarian endometrioma with diffused chocolate content all over \nintra-abdominal cavity was seen. They concluded that high-\ncombination CA-125 and CA–19-9 concentrations could indicate \nthe presence of a ruptured endometrioma. Our case also had \nhigh CA-125 levels.\n Huge ovarian endometrioma with gross intraperitoneal \ncollection with raised CA 125, can masquerade as ovarian \nmalignancy. Rao et al4 reported a case of bilateral ovarian \nendometrioma (6.5cm) with unilateral leak with moderate \nhaemorrhagic fluid and raised CA 125 of 8482 managed \nlaparoscopically [4]. Rare instances of malignancy have been \ndocumented, therefore, histology specimen must be sent \nin cases of ovarian endometrioma and/or deep infiltrating \nendometriosis. \n Wang L, et al. published a case of a 35-year-old unmarried \nfemale had multiple episodes of pain in the left lower abdomen \nthat recurred during menstruation. Ultrasound examination \nsuggested a 4.9 cm × 4.6 cm left endometriotic cyst [5]. CT of \nthe abdomen and pelvis revealed a low-density focus measuring \napproximately 38 mm in diameter, a blurred mesentery fat plane \nin the pelvic cavity, and pelvic effusion. Left ovarian cystectomy, \nelectrocautery for endometriotic lesions, myomectomy, and \npelvic adhesion lysis were performed under laparoscopy. The \npostoperative diagnosis was left ovarian chocolate cyst rupture. \n Rupture of endometrioma is also reported during pregnancy. \nZhen lieu et al6 reported a case of ruptured endometrioma \nof approx. 5cm in pregnancy at 18 weeks and CA 125 1010 \nmanaged laparoscopically. Author suggested rapid growth \nunder hormonal stimulation or increased blood supply or \ndue to increased pressure effect of rising uterine size on \nthe endometriotic cyst might be a predisposing factor. They \nconcluded that such event can be life-threatening and managing \nit timely improves maternal and fetal outcome. \n Size of endometrioma or massive hemoperitoneum is not a \ncontra-indication for laparoscopy. Certain deviations we used to \nmanage it laparoscopically were supraumbilical primary port in \nplace of umbilical port, irrigation with high pressure fluid and \n10mm suction irrigation tips. Irrigating more mature clots will \nhelp lyse the solid portions, also facilitating removal of blood \ncollection. \nConclusion \n Early and accurate diagnosis is paramount. Emphasis should be \ntowards early surgical intervention with aim of effective disease \neradication and in long term, preventing adhesion formation \nand preserving fertility. \nConflict of Interest \n The author declares no conflict of interest.\nFigure 2B: Intra operative images showing ovarian endometrioma.\nsymptom free after one year of surgery. Follow-up USG showed \nnormal uterus and normal left ovary.\nDiscussion \n The most common presenting symptoms of endometriosis \nare dysmenorrhea and pelvic pain. Spontaneous rupture of a \nhuge ovarian endometrioma presenting as an acute emergency \nis a rare occurrence. Such presentation might be unknown \neven to the experienced clinicians. Massive hemoperitoneum \nwith endometriosis is extremely rare with less than 100 cases \nreported in literature. All patients were of childbearing age \nlikely due to hormonal levels and occurrence of menses.\n Differential diagnosis most commonly is the ruptured ectopic \npregnancy, ovarian or adnexal torsion, ruptured dermoid \ncyst, pelvic inflammatory disease, follicular rupture in \nwomen with coagulopathy, abdominal tuberculosis, ovarian \nhyperstimulation, ovarian malignancy or surgical emergencies.\n Medical management has been attempted but 89% cases of \npatients ultimately underwent a surgical procedure. The average \nvolume of abdominal collection was 4470 ± 2625 mL. Various \nsurgical interventions reported include drainage of collected \nblood, excision or endometriotic spot fulguration through \nlaparotomy or laparoscopy, lysis of adhesions, abdominal \nhysterectomy, uni or bilateral salpingo-oophorectomy, ovarian \nwedge resection or a combination of these [1].\n Several aspects of the case like acute presentation, size of \nendometrioma and its laparoscopic management are the main \nhighlights. \n Why endometrioma ruptures, the exact cause is not known \nbut a huge endometrioma due to rapid accumulation can cause \nweakening of the cyst wall. It can present as chemical peritonitis \ndue to the leakage of old blood. Various predisposing factors \nlike sexual intercourse, ovarian aspiration for IVF or PID could be \nidentified in the literature. \n Morgan et al. reported a case of a 27-year-old who presented with \npain and required multiple blood transfusions [2]. Ultimately, a \ndiagnostic paracentesis was performed and 4.5 litres of grossly \nbloody ascitic fluid was removed. Oral contraceptive pills were \nstarted with diagnosis of endometriosis. At 2 weeks follow-\nup visit, no recurrence of symptoms noted. However, some \nauthors suggest early tendency towards surgical exploration to \n\n\nJ Obst Gynecol Surg, \nVolume 3 • Issue 1 • 23\n Page 9 of 9\nReferences\n1. Gonzalez A, Artazcoz S, Elorriaga F, et al. (2020) Endometriosis \npresenting as recurrent haemorrhagic ascites: a case report and \nliterature review. Int J Fertil Steril 14(1): pp. 72-75.\n2. Morgan TL, Tomich EB, Heiner JD (2013) Endometriosis \npresenting with hemorrhagic ascites, severe anemia, and shock. \nAm J Emerg Med 31(1): pp. 272.\n3. Pandey D,  Wasinghon P , Huang KG (2019) Laparoscopic \nManagement of Peritonitis Due to a Ruptured Ovarian \nEndometrioma with Extremely High Levels of Cancer \nAntigen–125 and Cancer Antigen–19-9. J Gyne Surg35(3): pp. \n198-200 \n4. Rao S, Kapurubandara S, Anpalagan A (2018)  Elevated CA 125 \nin a CASE of Leaking Endometrioma. Case Rep Obstet Gynecol \n2018: pp. 5.\n5. Wang L, Jiang YJ (2021) Rupture of ovarian endometriotic cyst \ncomplicated with endometriosis: A case report. World J Clin \nCases 9(28): pp. 8524-8530 \n6. Liu Z, Kang  JZ , Yin L (2018) Laparoscopic management for \nruptured endometrial cyst in a mid-term pregnancy woman: A \ncase report and literature review Int J ClinExp Med 11(9): pp. \n10140-101.\nCitation: Jain N, Kriplani I, Sharma S, et al. (2022) Spontaneous Rupture of Huge Ovarian Endometrioma and Its Successful Laparoscopic Management: A Case-Study \nand Review of Literature. J Obst Gynecol Surg 3(1): pp. 7-9. doi: 10.52916/jogs224023","source_license":"CC0","license_restricted":false}