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Muacevic A, Adler JR, Acharya S, Joshi K, Mohammad S. Post-ovulatory Hemoperitoneum in a Patient on Anticoagulation Therapy for Mitral Valve Replacement. Cureus 2023; 15:e33674. [PMID: 36788926 PMCID: PMC9918852 DOI: 10.7759/cureus.33674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 01/11/2023] [Indexed: 01/14/2023] Open
Abstract
When a patient is receiving anticoagulant therapy, the rupture of a corpus luteum cyst may go unrecognized in healthy women but becomes clinically relevant as it might exacerbate a hemoperitoneum episode. This report describes the case of a 26-year-old primipara who underwent surgical treatment for a heart defect and later experienced extensive hemoperitoneum. The patient reported to the casualty with symptoms of unstable hemodynamic status such as hypotension 90/60 mmHg and tachycardia 120 beats/minute. A multidisciplinary team decided upon surgical management after stabilizing the coagulation profile and correcting the shock with blood and blood products. The reason was discovered to be a ruptured cyst wall, which was fixed electrosurgically. The patient had a full recovery with no postoperative complications. The most noteworthy aspect of this case was the catastrophic hemoperitoneum caused by improper anticoagulant treatment monitoring. Management of such cases depends on the age of the patient, fertility, and calculating the long-term prognosis of the anticoagulation therapy for the patient.
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Nagandla K, Jamli MFBM, Hanim F, Xu Mei JL, Din SFS. Recurrent haemorrhagic ovarian cyst and anticoagulant therapy: a case report with review of treatment modalities. Pan Afr Med J 2021; 40:52. [PMID: 34795832 PMCID: PMC8571930 DOI: 10.11604/pamj.2021.40.52.30961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 09/03/2021] [Indexed: 01/19/2023] Open
Abstract
The common gynaecological causes of acute pelvic pain include ruptured ectopic pregnancy, haemorrhagic corpus luteal cyst or torsion of an ovarian cyst. Ovarian vascular accidents are reported in women on oral anticoagulation presenting as an acute pelvic pain. Although such vascular accidents with anticoagulation therapy are an unusual entity, a meticulous history, clinical examination, and laboratory workup to confirm the diagnosis and timely intervention is needed to reduce attending morbidity and mortality. However, a standard algorithm for management is not described in the literature. We hereby report successful management of recurrent hemorrhagic ovarian cyst due to coagulopathy in a woman with mechanical heart valves with timely surgical intervention. This case report discusses operative versus non operative management approach and may provide value addition to readers encountering such cases in their clinical practice.
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Affiliation(s)
- Kavitha Nagandla
- Department of Obstetrics and Gynaecology, International Medical University, Clinical Campus, Jalan Rasah, 70300 Seremban, Negeri Sembilan, Malaysia
| | - Mohamed Faiz Bin Mohamed Jamli
- Department of Obstetrics and Gynaecology, Hospital Tuanku Jaffar, Jalan Rasah, 70300 Seremban, Negeri Sembilan, Malaysia
| | - Faridah Hanim
- Department of Obstetrics and Gynaecology, Hospital Tuanku Jaffar, Jalan Rasah, 70300 Seremban, Negeri Sembilan, Malaysia
| | - Joanne Lim Xu Mei
- Department of Obstetrics and Gynaecology, Hospital Tuanku Jaffar, Jalan Rasah, 70300 Seremban, Negeri Sembilan, Malaysia
| | - Siti Fathima Syazliana Din
- Department of Obstetrics and Gynaecology, Hospital Tuanku Jaffar, Jalan Rasah, 70300 Seremban, Negeri Sembilan, Malaysia
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A novel homozygous variant of the thrombomodulin gene causes a hereditary bleeding disorder. Blood Adv 2021; 5:3830-3838. [PMID: 34474479 DOI: 10.1182/bloodadvances.2020003814] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 05/17/2021] [Indexed: 11/20/2022] Open
Abstract
We report a 19-year-old Vietnamese woman who experienced several life-threatening bleeding events, including ovarian hemorrhage. Blood analysis revealed a decreased fibrinogen level with markedly elevated fibrinogen/fibrin degradation products and D-dimer levels. Despite hemostatic surgery and administration of several medications, such as nafamostat mesylate, tranexamic acid, and unfractionated heparin, the coagulation abnormalities were not corrected, and the patient experienced repeated hemorrhagic events. We found that administration of recombinant human thrombomodulin (rhTM) remarkably improved the patient's pathophysiology. Screening and sequencing of the TM gene (THBD) revealed a previously unreported homozygous variation: c.793T>A (p.Cys265Ser). Notably, the Cys265 residue forms 1 of 3 disulfide bonds in the epidermal growth factor (EGF)-like domain 1 of TM. Transient expression experiments using COS-1 cells demonstrated markedly reduced expression of TM-Cys265Ser on the plasma membrane relative to wild-type TM. The TM-Cys265Ser mutant was intracellularly degraded, probably because of EGF-like domain 1 misfolding. The reduced expression of TM on the endothelial cell membrane may be responsible for the disseminated intravascular-coagulation-like symptoms observed in the patient. In summary, we identified a novel TM variant, c.793T>A (p.Cys265Ser). Patients homozygous for this variant may present with severe bleeding events; rhTM should be considered a possible treatment option for these patients.
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Singh U, Agarwal R, Dhar M, Biswas S. Emergency surgery for a ruptured ovarian cyst in an anticoagulated patient with artificial mitral valve and massive haemorrhage: Maintaining a delicate balance. Indian J Anaesth 2019; 63:499-501. [PMID: 31263306 PMCID: PMC6573038 DOI: 10.4103/ija.ija_18_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Ummed Singh
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Rishabh Agarwal
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Mridul Dhar
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Sujoy Biswas
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
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An opinion on the benefits of concomitant oral contraceptive therapy in premenopausal women treated with oral anticoagulants. Thromb Res 2018; 165:14-17. [DOI: 10.1016/j.thromres.2018.03.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 03/06/2018] [Accepted: 03/07/2018] [Indexed: 12/11/2022]
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The management of gynecological hemoperitoneum found to be associated with a ruptured corpus luteum cyst. ACTA ACUST UNITED AC 2016. [DOI: 10.1007/s10397-016-0951-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Gupta A, Gupta S, Manaktala U, Gupta MM, Solanki V. Conservative management of corpus luteum haemorrhage in patients on anticoagulation: a report of three cases and review of literature. Arch Gynecol Obstet 2014; 291:427-31. [DOI: 10.1007/s00404-014-3394-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 07/22/2014] [Indexed: 12/01/2022]
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Deffieux X, Thubert T, Huchon C, Demoulin G, Rivain AL, Faivre E, Trichot C. [Complications of presumed benign ovarian tumors]. ACTA ACUST UNITED AC 2013; 42:816-32. [PMID: 24210240 DOI: 10.1016/j.jgyn.2013.09.036] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The main risk factor of adnexal torsion is a previous adnexal torsion (LE3). There is no clinical, biological or radiological sign that may exclude the diagnosis of adnexal torsion (LE3). The presence of flow at color Doppler imaging does not allow exclusion of the diagnosis (LE2). An emergent laparoscopy is recommended for adnexal untwisting (Grade B), except in postmenopausal women where oophorectomy is recommended (grade C). A persistent black color of the adnexa after untwisting is not an indication for systematic oophorectomy (grade C), since a functional recovery is possible (LE3). Ovariopexy is not routinely recommended following adnexal untwisting (grade C). The clinical signs of intra-cystic hemorrhage and those of rupture of the corpus luteum are not specific (LE4). MRI is not recommended to confirm the diagnosis of intra-cystic hemorrhage (grade C). Malignant transformation of an ovarian cyst is very rare. The presence of a benign ovarian cyst is not associated with an increased risk of ovarian cancer at long-term follow-up (LE2). For these women, an ultrasound follow-up is not recommended (grade C). Dermoid ovarian cyst containing nerve tissue can trigger the production of pathogenic auto-antibody-anti-NMDA, leading to encephalitis. A high proportion of thyroid tissue in a mature teratoma (struma ovarii) may cause hyperthyroidism.
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Affiliation(s)
- X Deffieux
- Service de gynécologie-obstétrique et médecine de la reproduction, hôpital Antoine-Béclère, AP-HP, 157, rue de la Porte-de-Trivaux, 92140 Clamart, France; Faculté de médecine, université Paris-Sud, 91405 Orsay, France.
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Hackethal A, Ionesi-Pasacica J, Kreis D, Litzlbauer D, Tinneberg HR, Oehmke F. Feasibility of laparoscopic management of acute haemoperitoneum secondary to ruptured ovarian cysts in a haemodynamically unstable patient. MINIM INVASIV THER 2010; 20:46-9. [DOI: 10.3109/13645706.2010.497001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Sönmezer M, Atabekoğlu C, Cengiz B, Dökmeci F, Cengiz SD. Depot-medroxyprogesterone acetate in anticoagulated patients with previous hemorrhagic corpus luteum. EUR J CONTRACEP REPR 2009; 10:9-14. [PMID: 16036292 DOI: 10.1080/13625180400020952] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To investigate the safety of depot-medroxyprogesterone acetate (DMPA) in women of reproductive age with prosthetic heart valves, as well as the impact of DMPA on the prevention of hemorrhagic corpus luteum in these patients with previous bleeding events. METHODS In this prospective study we enrolled 13 patients who were receiving chronic anticoagulation for prosthetic heart valves, and who suffered from ovarian bleeding. After the initial bleeding episode(s), DMPA was initiated with the intent of preventing recurrent bleeding events by means of ovulation suppression. Follow-up included close monitoring of anticoagulation intensity, lipid profile, measurement of systolic and diastolic blood pressures and weight, and a general physical and gynecological examination. RESULTS Of the participating 13 patients, one stopped DMPA after the third injection because she wanted to have a child. Among the remaining 12 women, over a mean follow-up of 39.9 months all patients were well and no hemorrhagic corpus luteum was observed. During the follow-up, anticoagulation intensity, assessed by the international normalized ratio (INR), was in the optimum therapeutic ranges at all times (range 2.5-3.5), except for values of 4.6, 5.8 and 5.9 in three patients at 9, 12 and 24 months, respectively. With regard to lipid profile, we observed a significant decrease in high-density lipoprotein cholesterol levels at 12 months, and significant increases in total cholesterol and triglyceride levels after 30 months compared to baseline serum levels. No significant changes were observed in serum low-density lipoprotein cholesterol levels. Mean body weight was higher at months 12 and 30, compared with baseline values (p > 0.05). CONCLUSION DMPA, which is an effective contraceptive agent, can be used to prevent bleeding from the corpus luteum by means of ovulation suppression in anticoagulated patients with prosthetic heart valves. However, meticulous surveillance should be provided during the follow-up, including close monitoring of anticoagulation intensity and lipid profile.
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Affiliation(s)
- M Sönmezer
- Department of Obstetrics and Gynecology, Ankara University Faculty of Medicine, Ankara, Turkey
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Hoffman R, Brenner B. Corpus Luteum Hemorrhage in Women with Bleeding Disorders. WOMENS HEALTH 2009; 5:91-5. [DOI: 10.2217/17455057.5.1.91] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Bleeding into the corpus luteum following ovulation rarely has clinical significance in healthy women, but may lead to life-threatening hemorrhage in women with congenital or acquired bleeding disorders. Women who are at an increased risk for corpus luteum hemorrhage (CLH) can be divided in two categories; first, those taking anticoagulants because of a thrombotic disorder; and second, women with congenital bleeding disorders. The management and prevention of CLH is still unsettled and the literature dealing with this problem is based on case reports only. This review focuses on the pathophysiology, clinical presentation, diagnosis and treatment options of an acute bleeding event and prevention modalities of CLH in women with bleeding disorders.
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Affiliation(s)
- Ron Hoffman
- Ron Hoffman, MD, Thrombosis & Haemostasis Unit, POB 9602, Rambam, Health Care Campus, Haifa, Israel, Tel.: +972 4854 3520, Fax: +972 4865 3886,
| | - Benjamin Brenner
- Benjamin Brenner, Bat Galim, Haifa, Thrombosis & Haemostasis Unit, Rambam, Health Care Campus, Israel, Tel.: +972 4854 3520, Fax: +972 4854 3886,
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Girolami A, Lombardi AM, Candeo N, Scarparo P, Paternoster A. Control of ovulation-induced hemoperitoneum by oral contraceptives in a patient with congenital hypoprothrombinemia and in another with congenital factor V deficiency. Acta Haematol 2008; 119:236-40. [PMID: 18583905 DOI: 10.1159/000141782] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2008] [Accepted: 04/11/2008] [Indexed: 11/19/2022]
Abstract
Hemoperitoneum is a serious and often life-threatening bleeding manifestation. This is particularly true for women who carry congenital bleeding disorders. We describe here a hemoperitoneum occurring in 1 patient with congenital prothrombin deficiency and another with congenital factor V deficiency. Both patients have been followed by us for many years. The patient with prothrombin deficiency underwent laparoscopy but was treated consecutively with whole blood, plasma transfusions and 1,000 units of prothrombin complex concentrates. Response was good and she was then placed on oral contraceptives (OC) which prevented any recurrence. The patient with factor V deficiency presented several episodes of ovulation-related bleeding which required hospitalization and fresh frozen plasma transfusions. On the fifth occasion, the patient had to undergo surgery, and a left oophorectomy was carried out. After this last episode, she was also placed on OC which were very effective in preventing further recurrences. Both patients tolerated the medications very well which, in addition, were able to control menometrorrhagia with a consequent decrease over time in transfusional needs. OC are the treatment of choice in congenital bleeding disorders to control both the menorrhagia and, more importantly, ovulation-related hemoperitoneum.
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Affiliation(s)
- A Girolami
- Department of Medical and Surgical Sciences, Northeastern Italy Association for the Study of Coagulation Disorders, Padua, Italy.
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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; 33:376-80. [PMID: 17578371 DOI: 10.1111/j.1447-0756.2007.00540.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Women taking anticoagulants or those with a clotting factor deficiency are at increased risk of corpus luteum rupture due to coagulation abnormalities and three such cases are described here. Case 1 was a 35-year-old woman with prosthetic mitral valve replacement who was on anticoagulant therapy, in whom hemoperitoneum secondary to ruptured corpus luteum was seen. Emergency laparotomy revealed 1.2 L of massive hemoperitoneum. Left salpingo-oophorectomy was performed. Case 2 was two episodes of hemoperitoneum from luteal cyst rupture in a young patient with the rare congenital factor X deficiency. This patient was managed conservatively with fresh frozen plasma and blood transfusion. This is the first case of congenital factor X deficiency manifested as luteal rupture to be managed conservatively. Case 3 was two episodes of hemoperitoneum from luteal cyst rupture in a patient with antiphospholipid antibody syndrome who was on oral anticoagulants. Laparotomy was done twice with left salpingo-oophorectomy in the first instance and partial excision of the right ovary in the second instance. Hemoperitoneum secondary to rupture of the corpus luteum should be considered in the differential diagnosis of acute abdominal pain in women with congenital and acquired coagulation deficiencies.
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Affiliation(s)
- Nupur Gupta
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India.
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Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2002; 11:621-36. [PMID: 12462142 DOI: 10.1002/pds.663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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