Hemoperitoneum In Coagulopathy: Conservative Treatment

Author Information
Ansari MF*,  Parulekar  SV**
(* Assistant Professor, ** Professor and Head of Department
Department of Obstetrics and Gynaecology, Seth G.S. Medical College and K.E.M Hospital, Mumbai, India.)


Corpus  luteum  haematoma is known to develop after ovulation, especially in patients with bleeding disorders (like thrombocytopenia , pancytopenia ) and those on long term anticoagulant therapy. We report two cases of hemoperitoneum  secondary to ruptured  corpus luteum haematoma, one due to thrombocytopenia in a  case of aplastic anaemia, and the other due to warfarin toxicity. Both were managed successfully by conservative management.


Hemoperitoneum  secondary to ruptured corpus luteum haematoma can happen in patients with underlying blood  dyscrasias  like  thrombocytopenia , von Willebrand  disease , Glanzmann’s  thromboasthenia , other platelet disorders (qualitative/quantitative), pancytopenia  as in aplastic anaemia and also in those patients who are on long term anticoagulant therapy. In these patients coagulation mechanism is inefficient to control slight bleeding  that happens  normally  at the time of ovulation, which progresses to the formation of corpus luteum hematoma and its rupture leading to a hemoperitoneum.

Case 1

A 25 years old nulligravida ,  married for  4 years, a known case of aplastic anemia came to our hospital casualty with severe pain in abdomen for  2 days. She also had intermittent fever episodes  not associated with rigor. On inquiry the patient had neither any gastrointestinal complaints like nausea, vomiting,  diarrhea  nor  bleeding from any site. She was not sure of her last menstrual period. She had recent complaint of menorrhagia for which she was prescribed tablet Danazol 200 mg  q8h and with that her complaint was relieved. On clinical  examination, the patient had severe pallor , bilateral pedal edema grade 2,  pulse rate of 110 beats per minute , and BP  of 100/60 mm Hg. There was no icterus , cyanosis nor bleeding from any sites, ecchymoses or petechiae.  On  abdominal examination, tenderness and  guarding were present in the right iliac fossa. There was no rigidity. Systemic examination revealed normal findings. On vaginal examination, the uterus was anteverted, smooth, firm, and mobile. Its size could not be assessed due to hemoperitoneum. There was tenderness and fullness in the right lateral and posterior fornices. The left fornix felt free and non –tender. Urine pregnancy test was negative. Ultrasonography of the abdomen and pelvis done showed a hemoperitonium and a  ruptured corpus luteum haematoma on the right side. Her Hb was 5.8gm%, white cell count 3800/cmm, platelet count below 10000/cmm, liver and renal function tests within normal limits. The patient was transfused two units of packed red cells, 4 units of platelets, and intravenous antibiotics. She was monitored by recording her vital parameters, abdominal girth, input (iv fluid+ oral intake) and urine output  at frequent intervals. She remained hemodynamically stable and there was no further intraperitoneal hemorrhage. She was discharged  after 3 days of treatment, with advice to continue treatment of aplastic anemia and oral contraceptive pills to prevent ovulation and recurrence of formation of corpus luteum hematoma.

Case 2

A 38 years old woman, second para, presented with acute pain in the abdomen for one day. There were no symptoms suggestive of bowel dysfunction in any way. She had had menstrual flow four weeks ago. She was on oral warfarin therapy for deep vein thrombosis, as prescribed by a surgeon at another center. However she had continued the treatment without any monitoring of the prothrombin time and INR. She had been treated by a laparotomy, intestinal resection and anastomosis, and antituberculous therapy for abdominal tuberculosis 4 years ago. On examination, her general condition was fair and vital parameters were within normal limits.  Systemic examination was normal. There was a 15 cm long midline abdominal scar, equal length above and below the umbilicus, going around its left. There was tenderness and guarding over the entire abdomen, but no rigidity. Free fluid was present in the abdomen. Peristaltic sounds were normal. Her Hb was 8.5 g/dl, white cell count 6400/cmm, platelet count 234000/cmm, random plasma sugar 108 mg/dl, serum creatinine 1 mg/dl, SGPT and SGOT 12 and 18 U/l, prothrombin time 30 sec and INR 4.3. Her D-dimer level was 0.25 µg/mL. Abdominopelvic ultrasonography showed a moderate-sized hemoperitoneum and right sided corpus luteum hematoma. A diagnosis of overdose of warfarin induced coagulopathy, and hemoperitoneum secondary to a rupture of a corpus luteum hematoma was made. The patient was transfused six units of fresh frozen plasma and two units of packed red cells. Warfarin administration was stopped. Her vital parameters, abdominal girth, and urine output were closely monitored. She remained hemodynamically stable. Her abdominal girth did not increase and urine output was adequate. She made an uneventful recovery after 7 days, when her INR became 2.0. She was discharged after starting warfarin therapy again, with instructions to get prothrombin time and  INR monitored as advised.


After ovulation mature graafian follicle is transformed to corpus luteum. The basement membrane of corpus luteum degenerates so that blood vessels can grow into it in response to various angiogenic factors.[1]  The slight bleeding that occurs as a result of this  at the time of ovulation is efficiently controlled by fibrin formation in women with normal  clotting  system. Therefore  rupture of corpus luteum hematoma is rare in healthy women in reproductive age group. But it is not so uncommon in women with congenital or acquired bleeding disorders or those on anticoagulant therapy. Corpus luteum hematoma rupture is one of the differential diagnoses of “acute abdomen” in women of reproductive age. Although it can occur at any time of life, it is likely to develop in the early period after menarche.[2] It is described  more from the right ovary as it is believed that the recto-sigmoid colon helps protect the left ovary from trauma,[3] or it is due to a higher intraluminal pressure on the right side because of the differences in ovarian vein architecture.[4] In both of our cases, the patients had right corpus luteum hematoma rupture. Women with coagulation disorders can have varied hemorrhagic manifestations ranging from mild mucocutaneous bleeds to potentially life-threatening internal bleeding. Purpura, epistaxis, gingival bleeding, and menorrhagia are the most common clinical features. Female patients in particular are prone to  continuous gynecological and obstetric bleeding challenges, menorrhagia  being the most common. Menorrhagia  has been reported in 10–70%  of  women with bleeding  disorder.[5] Hemorrhagic ovarian cysts are less commonly described in coagulation disorders. Various studies have described it in conditions such  as  von-Willierand  disease, afibrinogenemia , and deficiencies in factors X and XIII.[3,6-9] The principle of  management  is   correction  of  underlying  coagulation defect to secure  hemostasis. In the past, a surgical intervention has been the mainstay of therapy - either laproscopy or laparotomy - resulting in lutectomy (corpus luteum cystectomy), wedge excision or oophorectomy. But the coagulopathy has to be corrected prior to any surgical intervention. Conservative management of hemoperitoneum  includes   transfusion of  blood  and blood products to correct the coagulopathy. It not only avoids unnecessary surgery, but also conserves ovarian function. To prevent recurrences, combined oral contraceptive  pill should be prescribed safely in women with bleeding disorders but with caution in those who are on anticoagulant.  World Health Organization  states that combined contraceptives are deemed unsuitable for use in women who are currently anticoagulated.[10] Progestin-only   methods  are all effective contraceptives, though they are not effective ovulation inhibitors. Progestin-only pill like oral desogestrel  consistently inhibits ovulation, whereas norethindrone acetate of  0.35 mg  inhibits  ovulation  only  in  about 30% of the times.[11]


1.      David L. Olive SF. Palter; Ch 7 ‘Reproductive Physiology’; Berek and Novak’s Gynaecology 14th edition, pg 181
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4.      Stenchever M et al.: Comprehensive gynecology. 5-th edition. USA,Mosby, pp 460-461, 2007.
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9.      Dafopoulos K, Galazios G, Georgadakis G, Boulbou M, et al. Two episodes of hemoperitoneum from luteal cysts rupture in a patient with congenital factor X deficiency. Gynecol Obstet Invest 2003;55(2):114-5.
10.  World Health Organization: Medical Eligibility Criteria for Contraceptive Use (4th ed.); 2009.
11.  Rice CF, Killick SR, Dieben T and Coelingh Bennink H: A comparison of the inhibition of ovulation achieved by desogestrel 75 micrograms and levonorgestrel 30 micrograms daily. Hum Reprod 1999;14:982-5.

Ansari MF, Parulekar SV. Hemoperitoneum  In Coagulopathy: Conservative Treatment JPGO 2014 Volume 1 Number 2 Available from:http://www.jpgo.org/2014/02/hemoperitoneum-in-coagulopathy.html