Pandey Nihita*, Gupta AS**
(* Second Year Resident, ** Professor.Department of Obstetrics and Gynecology, Seth G.S. Medical College and K.E.M Hospital, Mumbai, India.)
Surgical and conservative approaches to manage the same patient of ruptured corpus luteal hematoma in non consecutive menstrual cycles indicate that conservative management is a practical alternative to surgery in patients on chronic anticoagulation.
A 35 year old multiparous woman, on oral warfarin therapy for prosthetic mitral valve, presented to the emergency room with acute abdominal pain and an INR of greater than 10.0. She had inadvertently doubled her warfarin dose (from 5 to 10mg daily) due to change in the brand for the past 2 weeks.
She had undergone an exploratory laparotomy for expanding hemoperitoneum due to ruptured corpus luteum hematoma 7 months back. The INR at that time was 5.8. Presently, the patient was pale. Her pulse was 110 /min, regular and blood pressure was 100/60 mm of Hg. On CVS auscultation a click was heard. Respiratory system was normal. Scars of midline sternotomy and a midline vertical infraumblical laparotomy were noted. Abdominal distension, tenderness and guarding were present. On vaginal examination the uterus was anteverted and normal sized, There was a left sided minimally tender cyst of 5x8 cm. Culdocentesis yielded 5 cc of altered blood that failed to clot. Her Hb was 6.9gm%, INR >10.0, aPTT 90 sec test and 30 sec control; electrocardiogram showed a RBBB pattern, Ultrasonography (USG) of the abdomen and pelvis showed signs of hemoperitoneum with loculated pocket of 20 ml in the left iliac fossa and free fluid in the remaining abdomen. A loculated, 5 cm x 7 cm cyst in the left ovary was reported.
Figure 1: Ultrasonographic scan showing hemoperitoneum. Arrow marks the free fluid.
Figure 2: Ultrasonographic scan showing corpus Luteum Hematoma (mass in pouch of Douglas)
β HCG levels were 1.2mg/dl. Liver, renal function tests, serum electrolytes were normal. The coagulopathy was corrected with fresh frozen plasma transfusion (15ml/kg body weight). Warfarin was stopped; INR was closely monitored until target INR of 2.5 to 3.5 was achieved. Subcutaneous Heparin 5000 U 6 hourly with warfarin 5 mg/day orally overlap was started to maintain the INR between 2.5 and 3.5. She was under close observation for 10 days. As her condition stabilized she was discharged on 5 mg oral warfarin and instructions for regular follow up. On follow up over the next 4 months resolution of the hemoperitoneum and the corpus luteum hematoma was confirmed clinically and by pelvic USG.
Normally the corpus luteum basement membrane degenerates and blood vessels grow into it due to various angiogenic factors. With normal hemostatic mechanisms, fibrin formation stops any bleeding. In coagulopathies the bleeding continues and a hematoma forms. Hematoma ruptures due to mounting intra-cystic pressures causing hemoperitoneum. Patients on chronic anti-coagulant therapy (warfarin) are at risk of recurrent vascular accidents like corpus luteal hematoma in every ovulatory cycle. However, as a hematoma does not form in every cycle, there is probably a threshold INR level above which these vascular accidents occur. This patient presented with a hematoma once with an INR of 5.87 and the next time with an INR of > 10. Conservative management should be the preferred mode of the treatment in hemodynamically stable patients where the collection is small. Careful monitoring, achieving target anticoagulation, serial USG for resolution of the hematoma are recommended. Conservative approach is recommended as repeated surgery and anesthesia increases the morbidity in an already moribund and high risk patient. Repeated wedge resection of the ovary for hematomas will eventually leave no ovarian tissue causing early menopause.
Surgery is reserved for large hemoperitoneums, vascular instability or collapsed patients.[4, 5, 6] Surgery consists of wedge resection of the ovary (hematoma), drainage of the hemoperitoneum. Prompt transfusion of plasma fractions, reversal of anti-coagulation with vitamin K or protamine sulfate and optimizing the INR levels to the target level (2.5-3.5) is mandatory. Ovulation suppression with oral contraceptive pills cannot be recommended in patients with valvular heart disease. Patient education and regular quarterly monitoring of INR levels can reduce risk of recurrent vascular accidents.
A determined effort resulting in optimal correction of the coagulation mechanisms can stop the ongoing bleeding and tilt the management option in favor of a conservative approach to a ruptured corpus luteum hematoma. However, this judgment is based on meticulous examination, monitoring, prompt corrections and round the clock facilities for an emergency exploration.
1. Olive DL, Palter SF. Reproductive Physiology. In Berek and Novak’s Gynecology, Wolters Kluwer Health – Lippincott Williams & Wilkins, 14th edition, pg 181.
2. Wong KP, Gillett PG. Recurrent hemorrhage from corpus luteum during anticoagulant therapy. Can Med Assoc J. 1977;116(4): 388–390.
3. Tresch DD, Halverson G, Blick M, Keelan MH Jr. Ovarian (Corpus Luteum) Hemorrhage During Anticoagulation Therapy. Ann Intern Med 1978; 88(5):642-646.
4. A Raziel A, Ron-El R, Pansky M, Arieli S, et al. Current management of ruptured corpus luteum. Eur J Obstet & Gynecol and Reprod Biol 1993; 50(1):77-81.
5. Takeda A, Sakai K, Mitsui T, Nakamura H. Management of ruptured corpus luteum cyst of pregnancy occurring in a 15-year-old girl by laparoscopic surgery with intraoperative autologous blood transfusion. J Ped Adol Gynecol. 2007; 20(2):97-100.
6. Webb N, Lucidi RS. Ovarian Cyst Rupture Treatment & Management. Available at http://emedicine.medscape.com/article/253620-overview#showall.
Pandey N, Gupta AS. Conservative Management of Corpus Luteum Hematoma and Hemoperitoneum Due to Warfarin Toxicity: An Alternative Treatment Modality. JPGO Volume 1 Issue 2, February 2014, available at:http://www.jpgo.org/2014/02/conservative-management-of-corpus.html