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Thrombocytopenia & ruptured corpus luteal cyst: a deadly combination: a case report.

CASE REPORT: A 32 years, married female, [P.sub.2] [L.sub.2], presented to the emergency unit of our hospital, with complaints of abdominal pain for four days following six weeks of amenorrhea. Pain was more over lower abdomen. Her previous menstrual cycles were regular.

At admission she was pale, cold clammy extremities, conscious, but not well oriented, tachycardia of 128 beats/min; hypotension of BP110/50mmHg. There was mild abdominal distension with tenderness & guarding mainly over lower abdomen. On per vaginal examination there was no bleeding, the cervical os was closed, and uterus was normal size with tenderness in right fornix, cervical excitation test negative.

The investigations on emergency basis reveal -Hb-4.8gm%, Blood group-[O.sup.+ve], Liver & renal function tests were normal, urine for pregnancy-weakly positive. Paracentesis reveals unclotted dark blood confirms haemoperitoneum.

A provisional diagnosis of ruptured ectopic & hemorrhagic shock was made. She had undergone emergency laparotomy in view of haemoperitoneum with haemodynamic unstability.

At laparotomy--haemoperitonium of approximately 2 litre detected consisting of blood & clot. Right sided ovary was cystic & of normal size, showing ruptures at a point with active oozing. Bilateral tubes and left ovary were normal with flimsy adhesion between the posterior surface of the body of uterus & left tube. Right sided salpingo-ophrectomy done. While closing abdomen capillary oozing from wound was present, hence a subcutaneous drain kept, otherwise operation was uneventful. She was transfused 3 units of whole blood in Operation Theatre.

In immediate post-operative period her condition remains poor with pallor, tachycardia, soakage from wound, oozing from venepunctured sites & petechial rashes was noticed over chest & limbs. Report of Coagulation profile was available which reveals-Platelet count-20,000/cumm, bleeding time was prolonged, while Prothrombin Time & the Activated Partial Thromboplastin time were normal and blood smear shows large sized platelets. On enquiring patients' relative give history that she was having few rashes over arm & chest for last one month & one year back she had prolonged bleeding following tooth extraction. Platelet transfusion, FFP transfusion was arranged, injection Vitamin K was given. But the condition of the patient further deteriorated due to continued bleeding from different sites & gradually became unconscious probably due to spontaneous intracranial hemorrhage. She expired on post-operative day 2. Histopathology report of specimen confirm that it was a case of ruptured corpus luteal cyst. In this case, investigation & history of the patient suggested that thrombocytopenia combined with ruptured corpus luteal cyst turned to be fatal

DISCUSSION: Acute lower abdominal pain, dizziness, fainting attack in a reproductive age group with short history of amenorrhea, the disturbed ectopic pregnancy may be the first provisional diagnosis. A ruptured ovarian cyst can also produce massive hemoperitoneum, with clinical symptomatology and sonographic features that closely mimic those of other disorders, in particular ectopic pregnancy. Hence one should always keep in mind as differential diagnosis. Corpus luteum hemorrhage may occur spontaneously or often triggered by coitus, trauma, exercise, or vaginal examination (4). It is described more from the right ovary as it is believed that the recto-sigmoid colon helps to protect the left ovary from trauma or it is due to a higher intraluminal pressure on the right side because of the differences in ovarian vein architecture. (4-5)

Ovarian hemorrhage from corpus luteum of pregnancy or non-pregnancy state can be life threatening surgical condition for women with bleeding disorder. There have been case reports of luteal cyst rupture with massive hemoperitoneum during dialysis, thrombolytic therapy, patient with Hb SC disease, liver disease and patient on anticoagulation therapy. (1,6-8) Though there are many case series in the literature on corpus luteal bleeding, corpus luteal bleed related to idiopathic thrombocytopenia was discussed only in a few reports. In this case investigation & history of the patient suggested that thrombocytopenia combined with ruptured corpus luteal cyst turned to be fatal. Case reports have been made of ruptured corpus luteum being the first presentation of underlying bleeding diathesis. (9)

Our patient was suspected to be a case of idiopathic thrombocytopenic purpura (ITP), from the history & blood picture. Idiopathic thrombocytopenic purpura (ITP)-chronic variety affects mainly women in reproductive age group & are of insidious onset & have a chronic course. The diagnosis of ITP remains one of exclusion, where other causes of thrombocytopenia ruled out. The symptoms of ITP varies from the fairly common asymptomatic to frank bleeding from any site. Bleeding tendency increases if platelet count<30,000/cu mm & spontaneous bleeding particularly intra-cranial can occur if count<10,000/cu mm. In the reported case, blood platelet count was significantly decreased to 20,000/cmm with elevated bleeding time. This deranged coagulation profile was the precipitating factor for massive haemoperitoneum following rupture of luteal cyst.

CONCLUSION: Although significant ovulation related ovarian bleeding is rare in healthy women, but it should be kept as a differential diagnosis if a women in reproductive as group presented with acute abdomen mimicking acute ruptured ectopic. The rupture of a corpus luteal cyst carries a considerable risk to women with bleeding diathesis & it should be prevented by inhibition of ovulation in those women on who is suffering from bleeding disorder. Intramuscular injection of DMPA consistently suppresses ovulation.10 DMPA seems to be safe and effective to suppress ovulation in those women.

To conclude, ruptured corpus luteum causing severe abdominal pain is indeed a diagnostic challenge. This can also be the first presentation of bleeding diatheses, requiring a full work-up. Ovulation suppression can prevent recurrences.

DOI: 10.14260/jemds/2015/1396

REFERENCES:

(1.) Nayak Samir R., Kasimbi G., Soren K. Dilip, Aswini V., Rao Bhaskara Ganni. Massive hemoperitoneum secondary to corpus luteal cyst rupture with nodular hepatic cirrhosisintraoperative diagnosis- Case Report. Int J Cur Res Rev. 2013 June; 05 (11): 111-15.

(2.) Hallatt JG, Steele CH Jr, Snyder M. Ruptured corpusluteal cyst with hemoperitoneum: A study of 173 surgical cases. Am J Obstet Gynecol. 1984 May 1; 149(1): 5-9.

(3.) Fitzgerald JA & Berrigan MV. Accurate Diagnosis of Ovarian Vascular Accidents: Review of 32 Instances with Clinical Conclusion, Obstet & Gynec.1959; 13: 175.

(4.) Stenchever M et al.: Comprehensive gynecology. 5-th edition. USA, Mosby, 2007; 460-461.

(5.) Payne JH, Maclean RM, Hampton KK, Baxter AJ and Makris M. Haemoperitoneum associated with ovulation in women with bleeding disorders: the case for conservative management and the role of the contraceptive pill. Haemophilia 2007; 13: 93-7.

(6.) Muller CH, Zimmermann K, Bettex HJ. Near-fatal intra-abdominal bleeding from a ruptured follicle during thrombolytic therapy. Lancet. 1996 June 15; 347(9016): 1697.

(7.) Gupta N, Dadhwal V, Deka D, Jain SK, Mittal S. Corpus luteum hemorrhage: rare complication of congenital and acquired coagulation abnormalities. J Obstet Gynaecol Res. 2007 June; 33(3): 376- 80.

(8.) Fraley DS, Johnston JR, Bruns FJ, Adler S, Segel DP. Rupture of ovarian cyst: massive hemoperitoneum in continuous ambulatory peritoneal dialysis patients: diagnosis and treatment. Am J Kidney Dis. 1988 Jul; 12(1): 69-71.

(9.) Tresch DD, Halverson G, Blick M and Keelan MH, Jr.: Ovarian (corpus luteum) hemorrhage during anticoagulation therapy. Ann Intern Med 1978; 88: 642-6.

(10.) Sonmezer M, Atabekoglu C, Cengiz B, Dokmeci F and Cengiz SD: Depot- medroxyprogesterone acetate in anticoagulated patients with previous hemorrhagic corpus luteum. Eur J Contracept Reprod Health Care 2005; 10: 9-14.

Baidya J. L [1], Chakraborty J [2], Ray J [3], Pradhan M [4]

AUTHORS:

[1.] Baidya J. L.

[2.] Chakraborty J.

[3.] Ray J.

[4.] Pradhan M.

PARTICULARS OF CONTRIBUTORS:

[1.] Associate Professor, Department of Obstetrics & Gynaecology, Agartala Government Medical College.

[2.] Post Graduate Student, Department of Obstetrics & Gynaecology, Agartala Government Medical College.

[3.] Senior Resident, Department of Obstetrics & Gynaecology, Agartala Government Medical College.

FINANCIAL OR OTHER

COMPETING INTERESTS: None

[4.] Associate Professor, Department of Obstetrics & Gynaecology, Agartala Government Medical College.

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Baidya J. L, Associate Professor, Department of Obstetrics & Gynaecology, Agartala Government Medical College & GBP Hospital, Kunjavan, Agarthala, Tripura-799006.

E-mail: iamjilbaidya@hotmail.com

Date of Submission: 17/06/2015.

Date of Peer Review: 18/06/2015.

Date of Acceptance: 01/07/2015.

Date of Publishing: 08/07/2015.
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Title Annotation:CASE REPORT
Author:L., Baidya J.; J., Chakraborty; J., Ray; M., Pradhan
Publication:Journal of Evolution of Medical and Dental Sciences
Date:Jul 9, 2015
Words:1329
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