DISCUSSION
Ovarian cysts are fluid-filled structures that are commonly discovered
incidentally on physical examination or imaging. Ovarian cysts can cause
complications like rupture, hemorrhage, and torsion, which are
considered gynecological emergencies.8 Ovarian torsion
may potentially resemble an ovarian rupture cyst. On ultrasonography,
both may also have free fluid in the pelvis. Lower pelvic pain, fever,
nausea, vomiting and right sided pelvic discomfort can be a symptom of a
tubo-ovarian abscess and
appendicitis.4This case had a diagnostic dilemma misleading as ovarian torsion.
Corpus luteal cysts are a functional ovarian cyst that results when
a corpus luteum fails to regress after an ovum’s release and it is the
most frequent pelvic mass seen in the first trimester when linked to
pregnancy.5 The corpus luteum is a thick-walled cystic
structure that is prone to internal hemorrhage, and sometimes peritoneal
rupture.2Follicular collapse and luteinization of the blood vessel-free granulosa
layer occur after ovulation which is the Hyperaemic stage. The next step
is vascularization, in which blood vessels pierce the granulosa layer
and fill the cavity with blood. Intra-peritoneal hemorrhage could happen
if the corpus luteal hematoma bursts, particularly if a woman has
congenital bleeding issues or anticoagulant medication that inhibits her
clotting
processes.6
A dermoid cyst is a benign cutaneous developmental anomaly that arises
from the entrapment of ectodermal elements along the lines of embryonic
closure and are considered to be congenital, but not all of them are
diagnosed at birth. Only about 40% of dermoid cysts are diagnosed at
birth, while about 60% of dermoid cysts are diagnosed by five years of
age. Dermoid cyst on histology shows a well-defined wall lined by
stratified squamous epithelium and a lumen that may be filled with
mature adnexal structures of mesodermal origin, such as hair follicles
and shafts, sebaceous and eccrine glands. A small,
asymptomatic dermoid cyst may not necessitate immediate excision as it
can be stable for years or even regress. However, because
most dermoid cysts grow over time, complete surgical excision without
disruption of the cyst wall by an experienced surgeon is recommended
before the development of such complications.7
The emergency department practitioner has to ascertain the patient’s
menopausal status when a female patient arrives with symptoms resembling
those of a ruptured ovarian cyst, such as abrupt and severe abdominal
pain, nausea, and vomiting, as well as weakness. A urine pregnancy test
or a serum beta-HCG (Human Chorionic Gonadotropins) test is performed if
the patient is
premenopausal.8Then, as diagnostic tools, abdominal and pelvic exams together with
medical imaging enable the medical professional to diagnose the patient
for an ovarian cyst rupture or any abdominal ailment.9
In ultrasonography of the abdomen and pelvis, an adnexal thick-walled
cystic lesion with lace-like strands, an adnexal thick-walled cystic
lesion with low-level echoes within, and peripheral vascularity “a ring
of fire sign” are among the frequently reported findings. In about two
menstrual cycles or six weeks, a follow-up ultrasound is advised,
particularly to rule out endometriosis. Computed Tomography reveals a
hematocrit effect with fluid-fluid level, a thick-walled peripherally
enhancing cystic lesion, and a significant attenuation component (45-100
HU).10
In previous case reports many were reported among pregnant women or in
early
pregnancy.3In a recent case, A 22-year-old female patient arrived at the emergency
room complaining of lower left abdominal quadrant suprapubic pain. A
burst hemorrhagic corpus luteum cyst of the left ovary and subsequent
hemoperitoneum were seen on computed tomography and ultrasonography of
the abdomen and pelvis. Laparoscopic surgery was needed to remove the
patient’s left ovarian cyst wall and remove the
hemoperitoneum.8 In a different case, an adolescent
female who had hemoperitoneum from hemorrhagic corpus luteum underwent
urgent laparoscopy after her condition was appropriately diagnosed by
transabdominal ultrasound and contrast-enhanced computed
tomography.11Similarly, transabdominal sonography and magnetic resonance imaging of
the pelvis revealed a 10 cm * 5 cm sized cystic with a diagnosis of
retroperitoneal undescended ovary with corpus luteum hemorrhage managed
with diagnostic laparoscopy in a Chinese adolescent lady who presented
with right lower quadrant pain, nausea, and
vomiting.12In this case diagnosis was made post-operative and only ultrasonography
was used as an imaging modality. In our case, an emergency laparotomy
was done.
There is no established standard of care for ruptured corpus luteum.
When a patient is hemodynamically stable, does not have acute abdominal
pain, and has just a small amount of pelvic fluid detected on
ultrasound, observation is all that is needed.13 On
admission, laparoscopy should be carried out if there is a lot of pelvic
fluid or severe pain in the abdomen. Laparoscopy is seen to be better
than laparotomy in hemodynamically stable patients for both diagnosis
and treatment. It offers several advantages over laparotomy, including
as faster operating times, better wound care, reduced postoperative
discomfort, and shorter hospital stays without increasing the risk of
adverse events. 14 When there is a circulatory
collapse, a direct laparotomy is required.13