Acute hemoperitoneum due to a ruptured hemorrhagic ovarian cyst in a 19-year-old female

Abstract

Ruptured hemorrhagic ovarian cyst is a potentially life-threatening condition that can lead to significant hemoperitoneum and hypovolemic shock. Imaging plays a crucial role in rapid diagnosis and guiding management. We report the case of a 19-year-old female who presented to the emergency department with acute pain in the lower left quadrant. Ultrasonography and computed tomography revealed a left hemorrhagic cyst with associated moderate hemoperitoneum. The patient underwent laparoscopic cyst wall removal and evacuation of hemoperitoneum, with subsequent uneventful recovery. This case highlights the importance of early imaging and the sentinel clot sign in guiding timely surgical intervention.

Introduction

Hemorrhagic ovarian cyst rupture with hemoperitoneum is a potentially life-threatening condition that necessitates prompt recognition and intervention. Ovarian cysts are common in premenopausal women, with an estimated 20% developing at least 1 pelvic mass during their lifetime [1]. While most ovarian cysts remain asymptomatic and resolve spontaneously, hemorrhagic cyst rupture can lead to significant intra-abdominal bleeding, posing a risk of hemodynamic instability and requiring urgent management.

The clinical presentation varies widely, from mild abdominal discomfort to severe acute abdominal pain with signs of hypovolemia. In cases of significant bleeding, intraperitoneal blood accumulation may compromise organ perfusion, necessitating resuscitation and surgical intervention. Early imaging is crucial in establishing the diagnosis and guiding management. Ultrasound is the first-line modality, often revealing a complex adnexal mass with internal echoes and free fluid in the pelvis. When the diagnosis is uncertain or when assessing the extent of hemoperitoneum, computed tomography (CT) provides additional diagnostic accuracy.

We report the case of a 19-year-old female with no prior medical or surgical history who presented with moderate hemoperitoneum secondary to the rupture of a hemorrhagic ovarian cyst. This case underscores the importance of timely imaging in ensuring accurate diagnosis and appropriate management.

Case presentation

A 19-year-old female with no prior medical or surgical history presented to the emergency department with acute, severe lower abdominal pain, predominantly localized to the left lower quadrant, accompanied by nausea and vomiting. She denied any history of trauma, recent surgeries, or known gynecological conditions.

On initial assessment, the patient appeared pale and in hypovolemic shock. Her vital signs were as follows: Blood pressure of 90/50 mmHg, Heart rate of 115 beats per minute, Respiratory rate of 25 breaths per minute, Temperature of 36.7°C, and Oxygen saturation of 94% on room air. Abdominal examination revealed diffuse tenderness with guarding, raising suspicion for an intra-abdominal hemorrhagic process.

A serum beta-HCG test was urgently performed and returned negative, ruling out an ectopic pregnancy. A trans-abdominal ultrasound revealed a left hemorrhagic ovarian cyst, characterized by lace-like internal echoes and a fluid level, with a significant amount of free intraperitoneal fluid in the pelvis (Fig. 1).

Fig. 1.

Trans-abdominal ultrasound images. (A)-Left hemorrhagic ovarian cyst (Red arrow) characterized by lace-like internal echoes (Asterisk) with fluid level, notice the right ovarian cyst (Green arrow).

(B) Free pelvic intraperitoneal fluid. U: Uterus, F: Fluid, B: Bladder.

Given the clinical suspicion of intra-abdominal bleeding, and following initial hemodynamic stabilization with fluid resuscitation, a contrast-enhanced abdominopelvic CT scan was performed to better characterize the source and extent of bleeding.

The CT scan revealed bilateral ovarian cysts and a moderate volume of hemoperitoneum, demonstrated by high-attenuation free fluid (35-45 HU) accumulating in the pelvic cavity, as well as in the perihepatic, perisplenic, and paracolic regions. No active contrast extravasation was noted on arterial or venous phases, suggesting that bleeding had either decreased or ceased spontaneously. There were no signs of bowel injury, peritoneal enhancement, or pneumoperitoneum. The uterus appeared unremarkable, and no evidence of adnexal torsion was identified. These findings were consistent with rupture of a hemorrhagic ovarian cyst complicated by hemoperitoneum, warranting urgent surgical management (Fig. 2).

Fig. 2.

CT images. (A) and (B) axial nonenhanced and enhanced CT images demonstrating a pelvic hemoperitoneum (42UH) (Red arrow) with bilateral ovarian cyst (Asterisk). (C) and (D) Coronal and Axial CT images.

The patient was immediately taken to the operating room for diagnostic and therapeutic laparoscopy. Approximately 1 liter of hemoperitoneum was evacuated. The source of bleeding was identified as a ruptured hemorrhagic cyst on the left ovary. Additional cystic lesions were noted on the same ovary, while the right ovary appeared macroscopically normal, with the presence of simple cysts.

Hemostasis was achieved by careful suturing of the ruptured cyst, with preservation of both ovaries. The patient received 2 units of packed red blood cells intraoperatively to address the acute blood loss.

Postoperatively, the patient showed progressive clinical improvement, with resolution of abdominal pain and stabilization of vital signs. She remained hemodynamically stable throughout her hospital stay and was discharged home in good condition, with recommendations for outpatient gynecological follow-up.

Discussion

A hemorrhagic ovarian cyst is a common cause of acute pelvic pain in women of reproductive age and often prompts referral for ultrasound assessment. While the most frequent origin is a corpus luteum cyst, other potential sources include follicular or corpus albicans cysts [2].

Hemorrhagic ovarian cyst can present with variable clinical symptoms and signs ranging from no symptoms up to acute abdomen [3].

The incidence of hemorrhagic ovarian cyst rupture is not precisely established. However, ruptured hemorrhagic cysts represent the predominant diagnosis in women presenting with acute abdominal pain and hemoperitoneum, underscoring their clinical relevance in reproductive-aged females [4].

The symptoms of a ruptured hemorrhagic ovarian cyst typically include sudden, severe abdominal pain, accompanied by nausea, vomiting, and weakness [5].

A ruptured hemorrhagic ovarian cyst can cause severe pain and hemoperitoneum, a potentially life-threatening condition. The rupture releases fluid and blood into the abdominal or pelvic cavity, which may lead to hypovolemic shock, organ damage, organ failure, and, in severe cases, death [1].

In the presence of such symptoms in a woman of childbearing age, it is essential to rule out pregnancy by performing a plasma or urinary beta-HCG test.

Medical imaging and abdominal and pelvic exams are then utilized as diagnostic tools. These allow the provider to determine whether the patient is experiencing a ruptured ovarian cyst or an alternate abdominal concern [1].

Hemorrhagic ovarian cysts can present with a variety of ultrasound appearances, which are influenced by both the size of the lesion and the time elapsed since the bleeding occurred. Due to this variability, they are sometimes referred to as “the great imitator.” Typical sonographic features may include a cystic mass with a thickened wall, internal septations or fibrin strands, echogenic content, fluid-debris levels, or a uniformly hyperechoic appearance. In rare cases, rupture and bleeding may occur in association with an ovarian cyst or tumor. This can be a serious complication, potentially resulting in hemoperitoneum and significant intra-abdominal hemorrhage. While the precise cause of rupture is not fully understood, it is hypothesized that the increased ovarian vascularity during the luteal phase might contribute to the spontaneous rupture of corpus luteum cysts [2].

In cases of ruptured hemorrhagic cysts, computed tomography (CT) commonly demonstrates the presence of hemoperitoneum associated with an adnexal cyst showing a peripheral rim of contrast enhancement. This particular enhancement pattern is thought to be linked to the increased vascular supply of the ovary during the luteal phase, which may make the cyst more susceptible to rupture [6].

When evaluating a patient with hemoperitoneum, the identification of active bleeding on CT—characterized by the arterial phase extravasation of contrast material with attenuation values exceeding those of surrounding unclotted or clotted blood—strongly suggests the need for urgent surgical management. This active bleeding may present as a serpiginous or irregularly shaped area of high attenuation, often embedded within or encircled by a sizable hematoma [6].

MRI is a valuable modality in the evaluation of hemorrhagic ovarian cysts, particularly in cases of suspected rupture where ultrasound or CT findings may be limited. Its superior soft tissue resolution allows for better characterization of hemorrhagic content, which typically appears hyperintense on T1-weighted sequences due to the presence of methemoglobin [7]. Signal intensity on T2-weighted images may vary depending on the age of the hemorrhage, and the “T2 shading” sign is considered a classic imaging feature [8] .In cases of rupture, MRI may also demonstrate hyperintense free fluid on T1-weighted sequences, consistent with hemoperitoneum [9]. Furthermore, MRI plays an important role in ruling out alternative diagnoses such as ectopic pregnancy, tubo-ovarian abscess, appendicitis, or malignancy as reviewed by Patel and colleagues in the context of emergency radiology [10].

Management of ruptured hemorrhagic ovarian cysts with hemoperitoneum generally requires a tailored approach that depends on the patient's clinical presentation and the severity of symptoms. In most cases, conservative management, including close monitoring and supportive care, is sufficient, especially in patients who are stable and do not exhibit signs of active bleeding or hemodynamic instability. The use of analgesics and fluid resuscitation may be necessary to manage pain and maintain hemodynamic stability [11].

In more severe cases, like our case, particularly when the patient presents with significant blood loss, hypotension, or an expanding hemoperitoneum, surgical intervention is indicated. Surgical management involves either laparoscopy or laparotomy to control active bleeding, evacuate blood, and repair any damage. Early identification of hemorrhage and prompt surgical exploration is crucial to prevent complications, such as shock or organ damage [12].

Once hemodynamic stability is restored, further imaging studies should be performed to assess for any residual cysts or ongoing complications [11].

Conclusion

Given the potential for both clinical and radiologic misdiagnosis, the radiologist must consider and actively pursue the diagnosis of a ruptured hemorrhagic ovarian cyst in any woman of reproductive age presenting with pelvic pain and a large volume of complicated intraperitoneal fluid.

Patient consent

The authors of this manuscript declare that an informed consent for publication of this case was obtained from the patient.