1. Initial assessment and resuscitation
2. Pregnancy-related emergencies, especially ectopic pregnancy
3. Adnexal causes, such as ovarian torsion and ruptured/hemorrhagic cyst
4. Pelvic infection, including PID and tubo-ovarian abscess
5. Uterine causes, including fibroid degeneration/torsion
6. Non-gynecologic mimics and differential diagnosis
7. Investigations, ultrasound findings, and emergency management

1. Initial assessment and resuscitation
2. Pregnancy-related emergencies, especially ectopic pregnancy
3. Adnexal causes, such as ovarian torsion and ruptured/hemorrhagic cyst
4. Pelvic infection, including PID and tubo-ovarian abscess
5. Uterine causes, including fibroid degeneration/torsion
6. Non-gynecologic mimics and differential diagnosis
7. Investigations, ultrasound findings, and emergency management

Acute Abdomen in Gynecology and Obstetrics: Scope

Main topics

1. General emergency approach
   • Triage, resuscitation, focused history and examination
   • Recognition of shock, internal hemorrhage, peritonitis, and sepsis
   • Role of pregnancy testing, blood tests, pelvic ultrasound, and laparoscopy
2. Obstetric causes
   • Ectopic pregnancy, including ruptured ectopic pregnancy
   • Miscarriage and septic miscarriage
   • Acute complications of early pregnancy
   • Placental abruption and uterine rupture in later pregnancy
   • Acute fatty liver, HELLP syndrome, and other non-pelvic obstetric causes when relevant
3. Adnexal and ovarian causes
   • Adnexal torsion
   • Ruptured ovarian cyst
   • Hemorrhagic corpus luteum
   • Endometrioma rupture
   • Ovarian hyperstimulation syndrome
4. Pelvic infection
   • Acute pelvic inflammatory disease
   • Pyosalpinx and tubo-ovarian abscess
   • Pelvic peritonitis
   • Septic abortion
5. Uterine and cervical causes
   • Degeneration of leiomyoma, especially red degeneration in pregnancy
   • Torsion of a pedunculated subserosal fibroid
   • Fibroid-related bleeding or pressure complications
6. Non-gynecologic conditions that mimic gynecologic emergencies
   • Acute appendicitis
   • Urinary calculi and pyelonephritis
   • Intestinal obstruction, perforation, gastroenteritis
   • Cholecystitis and pancreatitis
   • Surgical emergencies should never be excluded merely because pelvic pathology is suspected.

Core rule

1. General approach, differential diagnosis, investigations, and management algorithm
2. Ectopic pregnancy and other early-pregnancy emergencies
3. Ovarian torsion, cyst accidents, and fibroid emergencies
4. PID, tubo-ovarian abscess, and septic abortion
5. A sequential full set of notes, beginning with the general approach

Ovarian Cyst Rupture and Adnexal (Ovarian) Torsion

1. Rupture of an ovarian cyst

Definition and pathology

• Follicular cyst
• Corpus luteum cyst
• Hemorrhagic cyst

Other cysts that may rupture

• Endometrioma: rupture may release old blood into the peritoneum, causing marked pain and chemical peritonitis.
• Dermoid cyst: rupture can produce chemical peritonitis due to leakage of sebaceous material.
• Tubo-ovarian abscess: rupture causes pelvic/generalized peritonitis and sepsis.
• Ovarian neoplasm: may occasionally rupture and bleed.

Clinical features

Uncomplicated rupture

• Sudden unilateral lower abdominal or pelvic pain
• Often around midcycle or in the luteal phase
• Pain after exercise, lifting, or sexual intercourse may be reported
• Mild abdominal tenderness
• Stable pulse and blood pressure
• Little or no intraperitoneal blood

Hemorrhagic rupture with hemoperitoneum

• Sudden severe pain, sometimes diffuse abdominal pain
• Dizziness, weakness, presyncope, or syncope
• Shoulder-tip pain from diaphragmatic irritation
• Tachycardia, orthostatic hypotension, pallor
• Abdominal distension, guarding, rebound tenderness
• Falling hemoglobin or hematocrit
• Peritoneal free fluid on ultrasound

Investigations

1. Immediate pregnancy test
   • Urine or serum beta-hCG.
   • A positive result requires urgent assessment for ectopic pregnancy.
2. Transvaginal pelvic ultrasound
   • Identifies ovarian cyst morphology.
   • May show a hemorrhagic cyst.
   • Detects and estimates pelvic free fluid or hemoperitoneum.
   • Assesses the uterus and adnexa for ectopic pregnancy.
3. Blood tests
   • Complete blood count, especially hemoglobin.
   • Blood group, Rh status, and cross-match if bleeding is suspected.
   • Coagulation studies if anticoagulant use, bleeding disorder, or major hemorrhage is suspected.
4. Serial observations
   • Pulse, blood pressure, postural vital signs, abdominal examination, and serial hemoglobin where indicated.

Management

Stable patient, minimal bleeding

• Stable vital signs
• No significant anemia
• No evidence of increasing hemoperitoneum
• Mild or improving pain
• Reliable observation and follow-up

Indications for surgery

• Hemodynamic instability or orthostasis
• Significant anemia or continued fall in hemoglobin
• Large or increasing hemoperitoneum
• Persistent severe pain or peritonitis
• Diagnostic uncertainty, especially inability to exclude ectopic pregnancy
• Ruptured endometrioma or dermoid with chemical peritonitis
• Ruptured tubo-ovarian abscess causing acute abdomen/sepsis

2. Adnexal torsion

Definition

Pathophysiology

1. The adnexa twists around its pedicle.
2. Lymphatic and venous drainage are obstructed first.
3. Ovarian congestion and edema develop, enlarging the ovary.
4. Continued twisting impairs arterial inflow.
5. Ischemia and hemorrhagic infarction occur.
6. Delayed treatment can result in necrosis and loss of the adnexa.

Predisposing factors

• Ovarian cyst or mass, especially a mass about 5 cm or larger
• Benign mature cystic teratoma, also called dermoid cyst
• Functional ovarian cyst or enlarged corpus luteum
• Pregnancy, especially early pregnancy
• Ovulation induction, ovarian hyperstimulation, or assisted reproduction
• Polycystic ovaries
• Paraovarian/paratubal cyst
• Previous tubal ligation
• Pediatric or adolescent age, where torsion can occur despite a normal ovary

Clinical features

Symptoms

• Sudden-onset severe unilateral lower abdominal or pelvic pain
• Pain may be sharp, colicky, constant, or intermittent
• Pain may wax and wane because intermittent torsion and spontaneous detorsion can occur
• Nausea and vomiting
• Pain following exercise, lifting, or intercourse in some cases

Signs

• Unilateral lower abdominal tenderness
• Guarding or rebound tenderness
• Unilateral adnexal tenderness on bimanual examination
• Palpable adnexal mass in some patients
• Tachycardia
• Mild fever and leukocytosis may occur later due to ischemic necrosis

Diagnosis

Initial work-up

• Urgent assessment of vital signs and abdominal findings
• Urine or serum beta-hCG
• Complete blood count, electrolytes, urinalysis
• Blood group and cross-match if surgery/bleeding is possible
• Transvaginal ultrasound with Doppler
• Urgent gynecologic review

Ultrasound findings

• Enlarged ovary, often more than 4 cm
• Ovarian stromal edema
• Peripherally displaced follicles, sometimes described as the “string of pearls” appearance
• Ovarian or adnexal mass/cyst
• Free pelvic fluid
• Thickened fallopian tube
• Twisted pedicle or whirlpool sign, if visualized
• Reduced or absent venous flow, followed later by impaired arterial flow

Important Doppler point

• The ovary has a dual blood supply.
• Venous obstruction occurs before arterial obstruction.
• Torsion may be intermittent or partial.
• The ultrasound study is operator-dependent.

Role of CT and MRI

• Ultrasound is the first-line imaging test.
• CT is not preferred when torsion is specifically suspected, but may reveal an enlarged or displaced ovary when performed for non-specific abdominal pain.
• MRI can be useful in selected equivocal cases, especially in pregnancy, but should not delay needed surgery.

Management of ovarian torsion

Immediate management

• Nil by mouth
• IV access and fluids
• Analgesia and antiemetics
• Pregnancy test and preoperative blood tests
• Urgent gynecology consultation
• Prompt operative assessment if suspicion is significant

Definitive treatment: urgent laparoscopy

1. Inspect the ovary and tube.
2. Detorse the adnexa.
3. Preserve the ovary, even if it appears blue-black, enlarged, or necrotic-looking.
4. Treat an associated cyst or mass appropriately.
5. Perform cystectomy selectively when indicated.
6. Consider oophoropexy only in selected recurrent torsion or special high-risk circumstances.

Oophorectomy or salpingo-oophorectomy

• The ovary is truly non-viable and disintegrates during surgery
• There is strong concern for malignancy
• Bleeding cannot be controlled with ovarian preservation
• The patient is postmenopausal with a suspicious adnexal mass, depending on operative findings and oncologic assessment

Distinguishing rupture from torsion

Exam-oriented emergency algorithm

1. Assess stability
   • Pulse, BP, pallor, syncope, abdominal rigidity, shock.
   • Resuscitate and arrange urgent surgery if unstable.
2. Do beta-hCG immediately
   • If positive, exclude ectopic pregnancy urgently.
3. Perform transvaginal ultrasound with Doppler
   • Free fluid plus hemorrhagic cyst suggests rupture.
   • Enlarged ovary, edema, peripheral follicles, mass, or whirlpool sign suggests torsion.
4. Do not dismiss torsion because Doppler arterial flow is present.
5. If torsion remains clinically likely, proceed to urgent laparoscopy.
   • Imaging should not delay surgery in a convincing clinical presentation.
6. If cyst rupture is suspected
   • Observe if stable with small fluid volume and no anemia.
   • Operate if instability, significant hemoperitoneum, worsening anemia, peritonitis, or diagnostic uncertainty.

Red flags requiring emergency care

• Fainting, dizziness, collapse, or shoulder-tip pain
• Severe sudden pelvic pain with vomiting
• Heavy vaginal bleeding or a positive pregnancy test
• Tachycardia, low blood pressure, pallor
• Rigid abdomen, rebound tenderness, fever, or rapidly worsening pain

Ovarian Apoplexy

Definition

Etiology and risk factors

Common setting

• Reproductive-age patient
• Luteal phase of the menstrual cycle, often around days 20-26
• Corpus luteum cyst, the commonest cyst responsible for significant rupture and hemoperitoneum
• Right ovary more often affected

Precipitating events

• Sexual intercourse
• Strenuous exercise
• Lifting heavy objects
• Pelvic examination
• Trauma

Risk factors for severe bleeding

• Anticoagulants
• Inherited or acquired bleeding disorder
• Thrombocytopenia
• Ovulation induction or assisted reproduction
• Enlarged functional ovarian cyst
• Pregnancy, because a corpus luteum may persist and be vascular

Pathogenesis

1. Ovulation occurs and the follicle becomes the corpus luteum.
2. Bleeding develops in the corpus luteum or another functional cyst.
3. The ovarian capsule becomes stretched, causing acute pain.
4. The cyst may remain intact, forming a hemorrhagic cyst.
5. If it ruptures, blood escapes into the pelvis and abdomen.
6. Large blood loss produces hemoperitoneum, tachycardia, hypotension, syncope, and shock.

Clinical presentation

Symptoms

• Sudden-onset unilateral lower abdominal or pelvic pain
• Pain may start in the midcycle or luteal phase
• Pain may begin after intercourse or exertion
• Increasing pelvic pain progressing to generalized abdominal pain
• Nausea or vomiting
• Dizziness, weakness, or fainting if blood loss is substantial
• Shoulder-tip pain in major hemoperitoneum due to diaphragmatic irritation

Signs

• Lower abdominal tenderness, often unilateral initially
• Guarding or rebound tenderness if peritoneal irritation is present
• Abdominal distension
• Decreased bowel sounds in significant hemoperitoneum
• Cervical-motion or adnexal tenderness on pelvic examination
• Palpable adnexal mass if the cyst has not fully ruptured
• Tachycardia and postural hypotension
• Pallor, cold extremities, and shock in severe internal bleeding

Clinical forms

Differential diagnosis

Investigations

1. Immediate pregnancy testing

• A positive test does not prove ectopic pregnancy, but it makes exclusion of ectopic pregnancy urgent.
• Ovarian apoplexy can occur during an intrauterine pregnancy because of a corpus luteum cyst.

2. Blood tests

• Complete blood count: hemoglobin/hematocrit
• Blood group and Rh typing
• Cross-match if substantial hemorrhage is suspected
• Coagulation profile, especially if anticoagulants or a bleeding disorder are possible
• Serial hemoglobin where ongoing bleeding is suspected

3. Pelvic ultrasound

• Hemorrhagic corpus luteum or complex ovarian cyst
• Internal echoes, clot, or reticular/lacy cyst contents
• Free pelvic fluid in the pouch of Douglas
• Larger-volume hemoperitoneum
• An intrauterine pregnancy or features concerning for ectopic pregnancy

4. Serial clinical assessment

• Pulse and blood pressure, including postural observations
• Abdominal signs
• Hemoglobin/hematocrit
• Ultrasound when the diagnosis or bleeding trend is uncertain

Management

A. Conservative management

• Hemodynamically stable
• Not orthostatic
• Not significantly anemic
• Has no evidence of ongoing major bleeding
• Has only a small amount of pelvic fluid
• Has manageable or improving pain
• Has reliable observation and follow-up

• Observation, often in hospital initially
• IV fluids if required
• Analgesia and antiemetics
• Serial vital signs and abdominal examination
• Repeat hemoglobin and ultrasound as clinically indicated

B. Indications for urgent surgery

• Hemodynamic instability or shock
• Persistent tachycardia or hypotension
• Orthostatic hypotension
• Significant or falling hemoglobin
• Large or increasing hemoperitoneum
• Ongoing active bleeding
• Severe persistent pain despite analgesia
• Peritonitis
• Failure to exclude ectopic pregnancy
• A ruptured endometrioma/dermoid causing chemical peritonitis
• Suspicion of torsion or another surgical emergency

C. Operative treatment

• Confirmation of diagnosis
• Suction and evacuation of hemoperitoneum
• Identification and control of ovarian bleeding
• Cystectomy or suturing/coagulation of the bleeding site when needed
• Preservation of ovarian tissue

Important distinction: ovarian apoplexy vs ovarian torsion

Exam summary

Ovarian apoplexy is hemorrhage into the ovary, most often a corpus luteum cyst, with or without rupture into the peritoneal cavity. It presents with acute unilateral pelvic pain and may cause hemoperitoneum, anemia, shock, and an acute abdomen. Ectopic pregnancy must be excluded with beta-hCG and transvaginal ultrasound. Stable patients with minimal bleeding may be observed; hemodynamic instability, falling hemoglobin, substantial hemoperitoneum, or diagnostic uncertainty require urgent operative management, usually laparoscopy with ovarian conservation.

Emergency warning