We had in mind to do something on one of the complications of bleeding in relation to child bearing or rather obstetrics known as Sheehan’s syndrome when we were again distracted. It had come in the form of a phone call about a 36 years old lady who had severe abdominal pains with progressive distension. The resident doctor had noticed that she was very pale, meaning that she was losing blood somewhere. Her PCV was 15 per cent. He did the needful by quickly transfusing her with three pints of blood. When he examined her, he had felt some mass in the abdomen. The lady was not pregnant going by the estimation of Human Chorionic Gonadodtropins (HCG) in her blood. Then he sent her for Magnetic Resonance Imaging (MRI).
On her way, she collapsed. She was brought back and resuscitated and arrangement was underway for Computerised Axial Tomography (CAT) scan when the call came through. As I listened, I wasn’t sure whether I heard what I wanted to hear. Well, I just kept it to myself. I was simply needed to come and explore the abdomen and arrest the bleeding. They had done a needle aspiration of the abdomen and obtained unclotted blood. It took some time to get there but we eventually did. When we opened up the abdomen, the bleed was massive and a total of about three litres of blood with huge clots was evacuated from the abdomen. After that, was this smooth surface ball shaped structure in the pelvis. We gently mobilised it into the wound. The size of this sack-like structure was about 10cm in diameter and had already burst with a lot of clots in it. It was a ruptured HAEMORRHAGIC OVARIAN CYST. We simply removed the cyst with some part of the right fallopian tube, left a drain in the Pouch of Douglas and prayed that no clotting challenge had set in.
Haemorrhagic ovarian cyst usually results from bleeding into a CORPUS LUTEUM. The Corpus Luteum is a product of the basic reproductive unit of the female known as the GRAAFIAN or ovarian follicle, which contains the egg known as Oocyte. When stimulated by sex hormones, they mature and acquire more blood vessels. During ovulation, the granular layer is softened and the egg is released. The graafian follicle, at this stage, continues increasing its vascularity and size and may rupture. But in most cases they involute, become atretic and are known as Corpus Albican. Most times, Corpus Luteum cysts are asymptomatic; and may just be incidental findings during routine pelvic scan.
Avery common tumour in our environment is the DERMOID CYST. This tumour is often referred to as a TERRATOMA, which means that in it you can find developmentally matured solid tissues like bone, hair, muscle, teeth, pockets of sweat glands, nails and so on. It is believed that the origin of this cyst is from GERM CELLS, which are responsible for the formation of sperm cells and eggs. They are derived from the outer layer of the skin of an embryo. In most adult females, they are benign, meaning that they are not cancerous. But immature ones can be malignant. They can grow to very large sizes.
The common lesions associated with dermoid cyst are that they can get infected, twisted or ruptured. Infection of a dermoid cyst can be severe because the fluid content of the cyst is very rich in protein and carbohydrate. When it twists or undergoes torsion, it could be an acute surgical emergency, especially if it is associated with haemorrhage. Not uncommonly do we have ENDOMETRIAL
cells situated in an ovarian cyst. In this situation, the cells respond to stimulations of hormones as it occurs in the normal menstrual cycle, which invariably will result in bleeding. This condition is commonly referred to as ENDOMETRIOMA.
In the diagnosis of pelvic mass, after a good history and physical examination, is ultrasound scan. We have always advocated that any health facility that has a reasonable pool of patients should have an in house scan. It saves time and besides the usage of scan machines can easily be learnt on the job. Besides saving time a reasonable clinical judgment can be made even by a rookie. So while my brother was going for Magnetic Resonance and Computerised Axial Tomography, I was waiting for him to tell me his ultrasound findings. He didn’t. By this time he had drawn my mind to some abdominal malignancy with poor prognosis, which I was just going to do some palliative surgery until I saw the patient! And she wasn’t looking that bad.
It is always good to make sure that one is not dealing with extra uterine pregnancy or ectopic gestation. That is one condition that commonly results in such massive bleeding as we had in our index case in this environment. Again a good history and simple pregnancy test easily gives it away. Estimation of blood level indices gives the care giver an idea of the amount of blood that would be needed for transfusion. As a rule, any lady that comes into the hospital with a history of abdominal pains without fever should make the caregiver think about ruptured cyst. Because of the additional feature of irritation of the covering of the inner wall of the abdomen by the exuding fluid and blood known as chemical peritonitis, it makes the index of suspicion on the diagnostic spectrum high.
With regards to bleeding in the abdomen, needle aspiration may yield a dry tap. And this does not rule out the existence of a haemorrhagic event going on. The truth is that if the lesion is slow leaking, blood clotting mechanism may make it difficult for blood in the peritoneal cavity to be readily available for a successful tap. A successful abdominal paracentecis or tap is an indication of an advanced lesion, just like we had in our index case.
In our environment, the management of haemorrhagic ovarian cyst is surgery, especially if the clinical features are florid. The various options carried out include complete removal of the affected ovary known as oophorectomy or the wedge excision of the affected area, known as ovariectomy. The truth is that whatever the surgeon does will depend on his findings. But in a great majority of cases with mild symptoms, as is often the situation, conservative management is the norm. The patient is kept in bed for watchful waiting. Some caregivers may administer antibiotics and analgesics to the patient, depending on the environment while on admission. This is usually an opportunity for further investigation. In a lot of instances the pain subsides and the patient feels well and goes home.