Corpus Luteum and Theca Lutein Cysts
Warfarin in
reproductive age-can it cause leaking C L : Any member have ever witnessed any
case of C L cyst rupture/ continued leak from recently ruptured Dominat follicle
or say Corpus Luteum Cysts in any women reproductive age who are on blood
thinners??
Q.1: What is a Corpus luteum?? This is a kind of physiologic or functional cyst is known as a corpus luteum cyst (CL Cyst). These are less frequent than a follicular cyst but can
cause more problems and emergencies, especially internal bleeding.
Why do you need to know the difference? Because we have to distinguish between
these cysts and other cysts and the specific dangers and treatment options. These
cysts also produce different hormones that affect your body and hormone
balance. Such cysts as expected be observed in early pregnancy, which is perfectly normal. Such
preg associated C L cysts usually go away by the second trimester. Some do not,
and if they do not look suspicious on the ultrasound, it is safe to leave them
alone. In most cases, they eventually go away after pregnancy.
Q.2:-Why we should consider CL cyst
rupture as more or less as an
physiologic event ?? Ans: Each
month, a mature ovarian follicle ruptures, releasing an ovum so the process of
fertilization can begin. Occasionally, these follicles may bleed into the ovary,
causing cortical stretch and pain, or at the rupture site following ovulation.
Similarly, a corpus luteum cyst may bleed subsequent to ovulation or in early
pregnancy. As blood accumulates in the peritoneal cavity, abdominal pain and
signs of intravascular volume depletion may arise. Problem arises when there
is excessive bleeding .Quite often the etilogy of this increased bleeding is
unknown, although abdominal trauma and anticoagulation treatments may increase
the risk.
Q.3 What is the etiogenesis of
persistence of CL cyst or say rupture of a C L cyst ? What is the pathophysiology and prognosis of C L cysts?
Complications of C L cyst / rupture : No 1:-.
Most cases where rupture of C.L. cyst occurs the consequences of cyst ruptures
are self-limiting, requiring only expectant management and oral analgesics for
relief of abdominal pain. Duration of symptoms varies from a few days to
several weeks and may depend, in part, on the type (hemorrhagic vs
nonhemorrhagic) and volume of cyst fluid in the pelvis. The
patient often presents with an acute onset of abdominal pain, typically during
strenuous physical activity, such as exercise or sexual intercourse. Given that
follicular cyst rupture is more common than corpus luteal cyst rupture, the
onset tends to be midcycle. Other associated symptoms include the following:
Although circulatory
collapse, hemorrhagic shock, disseminated intravascular coagulation (DIC), and
death have been reported, these are quite rare.
Q. 4 : Symptoms of C
L cyst rupture or contd leaking??
·
Vaginal bleeding, Nausea and/or vomiting
·
Weakness
·
Syncope
·
Shoulder tenderness
Circulatory collapse/.
Q.5: Outcome of C L cysts rupture?? The most pressing issues facing clinicians
encountering patients with potential cyst rupture in the acute setting are to
rule out ectopic pregnancy, ensure adequate pain control, and rapidly assess
the patient for hemodynamic
instability to allow appropriate triage. Although most patients require
only observation, some need analgesics for pain control and laparoscopy or
laparotomy for diagnosis or to achieve hemostasis.
By the way, pelvic pain with or without ovarian cysts being present does not mean the pain is
coming from a gynaecologic organ. In other words, there are other things down
there in your pelvis. You could have appendicitis or other bowel problems,
which have nothing to do with your gynaecologic organs. If surgery is necessary
because of bleeding, it is often possible to do it through a laparoscope (band
aid surgery). Usually the ovary does not have to be removed. Only the cyst is
removed and bleeding stopped.
Q.6:
How does a rupture of CL clinically present?? Ans: It often mimick ectopic as sometimes progesterone don’t
decrease in time(continued secretion of Progesterone from C L ) . As such there
is delay in period in spite of being
nonpregnant . So both EP & CL may present as missed period followed by some
spotting, one-sided pelvic pain and a pelvic examination, which finds a tender
ovarian mass, suggest that a persistent either Ectopic or Corpus Luteal cyst .
These are the two most common diag which one should keep in mind possible
diagnois but one should be cautious about C L Cyst rupture. . It is important
to make sure, however, that a pregnancy test is ordered, because these same
findings may be there for an ectopic pregnancy (tubal pregnancy). An ultrasound may not be
able to tell these two apart and the treatment would be completely different.
There is another no physiologic cyst, which can cause similar symptoms, called
an "endometrioma" that one (specially sonologist) need to be familiar with. That is treated in
yet another way, often involving surgery, and is a whole separate topic.
Q. 7: Can
there be rupture of a pathological, cyst in mid menst period and can confuse
us??
Ans: Not impossible either. Such no physiologic cysts are cystadenoma and mature cystic teratoma
(dermoid cysts),and Thecal L cyst associated
with molar pregancy. Such cysts may, in rare cases, rupture and cause
symptoms. In addition to hemorrhage, significant pain can accompany rupture of
a dermoid cyst, presumably from spillage of sebaceous fluid, resulting in a
diffuse chemical peritonitis.
Q. 8 : How do you know that your Pt. is having a C L
Cyst ? Ans: A ruptured
ovarian cyst is a common phenomenon, with presentation ranging from no symptoms
to symptoms mimicking an acute abdomen. Sequelae of CL cyst rupture varies. Menstruating
women have rupture of a follicular cyst every cycle, which is either
asymptomatic or with mild transient pain (mittelschmerz).
In less usual circumstances, the rupture can be associated with significant
pain. In very rare circumstances, intraperitoneal hemorrhage and even death may occur. While some hemorrhage associated with
ovarian cyst rupture has unclear etilogy, there are recognized risk factors.
These include abdominal trauma and anticoagulation therapy. The condition most commonly occurs in
reproductive-aged women of 18-35 years.
·
Q.9: What to expect
from Physical Examination??
Vital signs are
usually within normal range. Physical findings can range from mild unilateral
lower abdominal tenderness to those of an acute abdomen with severe tenderness,
guarding, rebound, and peritoneal signs. Low-grade fever is sometimes observed,
and an adnexal mass may be palpable, although absence of such findings on
examination has no diagnostic value as many cysts decompress after rupture.
Orthostatic changes are consistent with a sizable hemorrhage. Abdominal Trauma can rarely be a predisposing a factor for
rupture,
Q. 10 :
How to diagnose C L cyst ?? Ultrasonography
is the preferred imaging modality for assessing gynecologic structures, given
its low cost, availability, and sensitivity in recognizing adnexal cysts and haemoperitoneum. Despite this, there remain instances in which
the ultrasound findings are nonspecific, particularly after rupture and
decompression of a cyst in the setting of apparent physiologic levels of fluid
in the pelvis.
Q. 11:--What then if USG diag / Report is
inconclusive?? Ans: CT
is the answer. If ultrasound yields ambiguous results in a patient with
significant pain, computed tomography (CT) of the pelvis with contrast should
be performed. CT features of corpus luteum cysts have been more or less specific.
What is the Role of
culdocentesis as of 2020?? Ans: No . Although commonly
performed in the past, culdocentesis has been largely abandoned in favor of
ultrasonography and CT scanning,
as both can readily identify fluid collections in the cul-de-sac. Culdocentesis
is still acceptable, however, in locations where imaging is not
available.
Patients with
presumed cyst rupture are typically managed conservatively.
Q. 12 : How to persist or drag conservative treatement of
CL?? Ans:-Conservative
medical care may consist of outpatient treatment with oral analgesics in the
stable patient, or if the clinical picture is evolving, admission and
anticipatory management with serial abdominal examinations and laboratory
testing, repeat imaging, and pain relief with an analgesic of choice. Medical therapy consists of appropriate pain
relief. Pain relief medications can include acetaminophen, nonsteroidal
anti-inflammatory drugs (NSAIDs), narcotics, or an analgesic of choice.
Medications may range
from oral acetaminophen to intravenous tramadol, paracetamol, or via
patient-controlled analgesia (PCA) infusion pumps. If continued bleeding is a
concern or if the patient is unstable haemodynamically, one should proceed with
surgery.
Surgical care may
entail laparoscopy or laparotomy, depending on clinical presentation,
amount of blood in the abdomen, patient stability, and operator skill. Most
bleeding can be stopped with suturing, cautery, cystectomy, or wedge resection.
Occasionally, salpingo-oophorectomy is necessary.
Q. 13 : What may be the D/D? Ans: Acute app, UTI, pelvic inflammatory disease, renal
stone, urereteric colic. Diagnois
mainly by imaging and one has to utilize the D/D , as mentioned .
A)
The possible diag are Ectopics, appendicitis, Rupture of Dermoid, Solid Ov
tumour, UTI, Ureteric colic, Diverticulitis, Renal stone, If concerned
regarding possible hemorrhage, monitor the hematocrit (serially, if necessary)
to ensure there is no continued bleeding.
Estimate urine
pregnancy test. If the pregnancy test is positive, make sure to rule out an
ectopic pregnancy. Evaluate for ovarian torsion before discharge. If a
diagnosis of bleeding ruptured ovarian cyst is considered, make sure the
haemoglobin level is stable before discharging the patient. It is appropriate
to admit the patient for observation and pain control.
Perform a diagnostic laparoscopy and/or laparotomy if the
patient is haemodynamically unstable or if a specific diagnosis is unclear, yet
a definitive diagnosis is necessary.
Q. 14 : Can there be repeated rupture
of CL cyst almost every month?? Ans:
Very rare indeed. For the patient with multiple episodes of
ruptured physiologic cysts or following a single severe episode, it is
reasonable to consider suppression of ovulation with oral hormonal
contraception, as this may help reduce the risk of recurrence of ovarian cysts.
Q. 15:-Take home
message on C L cyst :Accurate diagnois :-- 1) Serum or urine pregnancy testing should
be performed. In the case of a positive result, the patient should be evaluated
for ectopic pregnancy. If
the diagnosis is unclear, 2) urinalysis
should be performed to identify a possible urinary tract infection or renal or
bladder stones. 3) Routine :blood,
urine, and cervical cultures may also be indicated rule out pelvic inflammatory
disease or urinary tract infections.
Blood type and cross-match are
indicated in patients with significant peritoneal signs or hemodynamic
instability, because such patients may require surgical intervention or blood
transfusion.
B)
Pain control Pain control is
essential to quality patient care. These medications ensure patient comfort and
have sedating properties, which are beneficial in the treatment of pain. Acetaminophen is the drug of choice for
pain in patients with documented hypersensitivity to aspirin or nonsteroidal
anti-inflammatory drugs; those with upper GI disease; or those who are taking
oral anticoagulants.
Morphine sulfate: Not nowadays used. But earlier Morphine sulfate was the drug of choice for narcotic analgesia,
owing to its reliable and predictable effects, safety profile, and ease of
reversibility with naloxone. In the decades
of fifties/ Sixties Intravenous morphine administration may be dosed in a number of
ways and commonly is titrated until desired effect is obtained.
.
C) Purchase time no jumping for Laparoscopy!!! That is all about non rupture of CL. But what happens when there is C L ruptures, S/S depends on the amount of bleeding and/or pain may cause this to be a surgical emergency. This is unusual, but there are medications ( blood thinners -anticoagulants) that one is taking that could make it much worse. In particular, these include aspirin, non-steroidal anti-inflammatory drugs (e.g. ibuprofen), Vitamin E . Therefore all women reproductive should ideally basically stay away from anything that may "thin the blood" and cause easy bruising or bleeding including vain surfaces , unless specially indicated ? It is duty of doctor to enquire all the medications, she might be taking .Unfortunately, one third of women (33%) who have a problem with bleeding from a CLC will have it happen again, possibly over and over. So knowing what to avoid can save more than one trip to the operating room or possibly even your life. If the cyst is NOT ruptured, and there is no bleeding or torsion, it is reasonable to avoid surgery and “wait it out." Why? Because surgery, no matter how small, causes scars or adhesions to form. Doctor should try to avoid surgery .
What research is
due?? How informative is CRP & plasma
D-dimer levels ?? Ans: 1) A study by Shiite et al indicated that
C-reactive protein (CRP) levels can be used preoperatively to differentiate a
ruptured ovarian cyst from ovarian torsion. In a retrospective evaluation of 98
patients diagnosed with a benign ovarian cyst, it was found that 21 patients
with a ruptured cyst and 77 patients with ovarian torsion had mean preoperative
CRP levels of 6.6 and 0.9 mg/dL, respectively; the mean size of the ovarian
cysts also differed significantly between the two groups (6.7 cm and 9.7 cm,
respectively). The investigators mentioned another study, however, that
indicated that patients with ovarian
torsion who present over 10 hours after the onset of acute abdomen with
elevated CRP levels are at risk of necrosis. They suggested, therefore,
that by taking into account imaging findings, CRP levels, and time of acute
abdomen onset, clinicians can preoperatively differentiate ovarian cyst rupture
from ovarian torsion.
Tanaka et al suggest that plasma D-dimer levels may
be markers for endometriotic ovarian cyst rupture. In their
study of 6 patients with emergent endometriotic cyst rupture and 16 control
patients with unruptured endometriotic cysts, significantly elevated plasma D-dimer levels were seen in
the group with the ruptured cysts. The investigators also noted that
differences in white blood cell count and serum CRP levels between the two
groups were statistically significant.
Theca Lutein Cysts
The least common type of physiologic or functional cysts are called "theca lutein cysts" . The key difference is that
these are usually multiple, on both ovaries, and occur all at the same time.
Each of these cysts can be 1cm to 10cm in size, so if there are multiple cysts,
the ovaries can be massively enlarged: up to 20 to 30cm (about 10 inches or
more) on both sides.
Corpus luteum cyst
A Corpus
luteum cyst is a type of ovarian
cyst which appears
after ovulation-extrusion of oocyte along with cumulus. C L may, fill with fluid
or blood, causing the corpus luteum to expand into a cyst, and stay in the
ovary. Usually, this cyst is on only one side, and does not produce any
symptoms .Occasionally such physiological cyst may rupture at any time after
ovulation. By and large C L cyst is of considerable size may take up to three months to disappear entirely.
A corpus luteum cyst usually cant occurs after menopause. Corpus luteum cysts
may contain blood and other fluids. The ruptured follicle begins
producing large quantities of estrogen and progesterone in preparation. The physical shape of a corpus luteum
cyst may appear as an enlargement of the ovary itself, rather than a distinct
mass -like growth on the surface of the ovary.
In
women of reproductive age cysts with a diameter of less than 5 cm are
common, clinically inconsequential, and almost always a physiological condition
rather than a cancer or other disease condition. What can be the largest possible
size of normal CL?? Ans:-It can, however, grow to almost 10 cm (4 inches)
in diameter and has the potential to bleed into itself or twist the ovary,
causing pelvic or abdominal pain. If it fills with blood, the cyst may rupture,
causing internal bleeding and sharp pain. This pain disappears within a few
days of the rupture. Rarely, it may cause the ovary to twist around the ovarian
ligament and can cut off the blood flow to the ovary. This is known as ovarian
torsion and causes pain and other symptoms In postmenopausal women the
threshold for concern is 1 cm. Any cyst > 10 mm in psmeno should be viewed with concern . Although ovarian
cancer is cystic, it does not arise from benign corpus luteum cysts. Medical specialty professional organizations recommend no follow-up imaging for cysts which are
clinical inconsequential.
Corpus luteum cyst
with bleeding, whereof fresh blood is visualized as anechoic (dark), with a protrusion of
coagulated blood is seen in top part of image. Theca Lutein
Cysts
The least common type of physiologic or functional cysts are called "theca lutein cysts" . The key difference is that
these are usually multiple, on both ovaries, and occur all at the same time.
Each of these cysts can be 1cm to 10cm in size, so if there are multiple cysts,
the ovaries can be massively enlarged: up to 20 to 30cm (about 10 inches or
more) on both sides. Etiology of Theca
Lutein Cysts??
How does this happen? Ans: This is the answer
is simply hormonal overstimulation of the ovaries due to pregnancy. Most often
this occurs due to very high beta-hCG levels (a hormone of pregnancy) often
seen with twins or abnormalities called "molar pregnancy," where the
placenta develops but the fetus does not. This is a highly oversimplified
explanation, but the point is that high levels of hCG stimulate the ovary. The
reason for this overstimulation should be evaluated. Sometimes these cysts can
even look like cancer to the untrained eye. Quite a scare, but usually you just
need to ask the right questions and in most cases it is not cancer.
No comments:
Post a Comment