What is the management plan for a ruptured ovarian cyst?

Management of Ruptured Ovarian Cyst

Conservative management is the first-line approach for most ruptured ovarian cysts, with surgical intervention reserved only for cases with hemodynamic compromise or large hemoperitoneum. 1

Initial Assessment

• Ultrasound is the first-line imaging modality to characterize the ruptured cyst and assess the amount of free fluid in the pelvis 2, 3
• Evaluate vital signs with particular attention to diastolic blood pressure, as dBP ≤70 mmHg is a significant risk factor for requiring surgical intervention 4
• Assess the depth of total pelvic fluid collection, as fluid collection ≥5.6 cm on imaging is associated with higher likelihood of requiring surgery 4

Management Algorithm

Conservative Management (Appropriate for 80-85% of cases)

• Indicated for hemodynamically stable patients with minimal to moderate free fluid 1
• Components include:
  • Pain management with appropriate analgesics 5
  • Serial clinical assessments to monitor for hemodynamic changes 4
  • Follow-up ultrasound in 8-12 weeks to ensure resolution 2

Surgical Intervention (Required in 15-20% of cases)

• Indications for surgical management:
  • Hemodynamic instability (particularly diastolic BP ≤70 mmHg) 4
  • Large amount of free fluid in pelvis (≥5.6 cm depth on imaging) 4
  • Persistent or worsening symptoms despite conservative management 1
  • Suspicion of adnexal torsion or other complications 5
• Laparoscopy is the preferred surgical approach with minimal complications 1, 6

Special Considerations

• Patients with both diastolic BP ≤70 mmHg and pelvic fluid ≥5.6 cm have approximately 78% likelihood of requiring surgical intervention 4
• Hemorrhagic corpus luteum cysts are the most common type of ruptured ovarian cysts 1
• For recurrent cyst rupture or hemorrhage, consider suppression of ovulation with combined oral contraceptives 5

Follow-up

• For patients managed conservatively, follow-up ultrasound in 8-12 weeks is recommended 2
• If the cyst persists or enlarges during follow-up, referral to a gynecologist for further evaluation is warranted 2
• Consider annual ultrasound surveillance for patients with history of recurrent cyst rupture 2

Pitfalls and Caveats

• Adnexal torsion can present similarly to ruptured ovarian cyst and requires immediate surgical intervention with de-torsion of the affected adnexa 5
• Postmenopausal women with ruptured ovarian cysts require more thorough evaluation due to increased risk of malignancy 2, 3
• Sepsis is a rare but potentially life-threatening complication of ruptured ovarian cysts that requires prompt surgical intervention and antibiotic therapy 7