What is the recommended management for a hemodynamically stable reproductive‑age woman with a ruptured ovarian cyst presenting with mild‑to‑moderate abdominal pain?

Management of Ruptured Ovarian Cyst in Hemodynamically Stable Reproductive-Age Women

Conservative management with analgesics and observation is the recommended approach for hemodynamically stable reproductive-age women with ruptured ovarian cysts presenting with mild-to-moderate abdominal pain, as the vast majority (84.7%) resolve spontaneously without surgical intervention. 1, 2

Initial Assessment and Diagnosis

Ultrasound is the first-line imaging modality to confirm the diagnosis of ruptured ovarian cyst and assess the amount of free fluid in the pelvis. 1 The typical ultrasound findings include:

• Evidence of a hemorrhagic cyst with characteristic reticular pattern or retracting clot 3
• Free fluid in the pelvis (hemoperitoneum) 2, 4
• Absence of features suggesting ovarian torsion (enlarged ovary, peripheral follicles, whirlpool sign, abnormal venous flow) 5

Hemorrhagic corpus luteum cysts are the most common type associated with rupture in reproductive-age women. 2, 6 These typically occur in the second half of the menstrual cycle and may be precipitated by intercourse or minor trauma. 6

Conservative Management Protocol

For hemodynamically stable patients with mild-to-moderate pain:

• Analgesics for pain control (NSAIDs are typically sufficient) 1, 2
• Observation for 24-48 hours to ensure hemodynamic stability is maintained 2
• Serial hemoglobin monitoring if there is concern for ongoing bleeding 4
• Follow-up ultrasound in 8-12 weeks to confirm cyst resolution 1, 3

If the cyst persists or enlarges on follow-up imaging, referral to a gynecologist is warranted for further evaluation. 1

Indications for Surgical Intervention

Surgery is indicated in only 15.4% of cases and should be reserved for: 2

• Hemodynamic instability despite resuscitation efforts 3, 2
• Large ovarian cysts (significantly larger than those managed conservatively) 2
• Large volume of free fluid on imaging (>500mL or extending beyond the pelvis) 2, 4
• Persistent or worsening pain despite adequate analgesia 7
• Diagnostic uncertainty when other acute abdominal pathology cannot be excluded 7

Laparoscopy is the preferred surgical approach when intervention is necessary, allowing for peritoneal washout, hemostasis, and cyst wall removal if needed. 4, 6, 7

Prevention of Recurrence

For women with recurrent cyst rupture or hemorrhage, suppression of ovulation with combined oral contraceptives is recommended to prevent future episodes. 7 This is particularly important for women who have experienced multiple symptomatic episodes.

Critical Pitfalls to Avoid

• Do not assume hemodynamic stability will persist - serial vital signs and hemoglobin monitoring are essential in the first 24 hours 2, 4
• Do not miss ovarian torsion - while ruptured cysts and torsion can both present with acute pelvic pain, torsion requires immediate surgical intervention and normal arterial flow on Doppler does not exclude the diagnosis 5, 7
• Do not perform unnecessary surgery - the overwhelming majority of ruptured cysts in hemodynamically stable patients resolve with conservative management 2
• Do not forget follow-up imaging - failure to document cyst resolution may miss a persistent complex mass requiring further evaluation 1, 3

Special Considerations

In postmenopausal women, a more thorough evaluation is required due to increased risk of malignancy, even with ruptured cysts. 1 However, the question specifically addresses reproductive-age women where functional cysts are the predominant etiology and carry minimal malignancy risk. 2, 6

Pregnancy must be excluded as ectopic pregnancy can mimic ruptured ovarian cyst, and corpus luteum cysts can occur with intrauterine pregnancy and must be preserved. 6