Benign Gynaecology: Varian YST Ccidents

WOMEN AND NEWBORN HEALTH SERVICE
King Edward Memorial Hospital

CLINICALGUIDELINES
GYNAECOLOGY GUIDELINES
BENIGN GYNAECOLOGY
OVARIAN CYST ACCIDENTS

BACKGROUND
1
Ovarian cyst accidents refer to any of the three complications of ovarian cysts .
1. Ovarian torsion
2. Ovarian cyst haemorrhage
3. Ovarian cyst rupture
KEY POINTS:
Other gynaecological complications can present similarly to an ovarian cyst event. Consider on
examination conditions such as: ectopic pregnancy, pelvic inflammatory disease, tubo-ovarian
1
abscess, or non gynaecological issues e.g. appendicitis .
Ovarian cyst accidents will most commonly involve benign ovarian cysts.
Immediate treatment should occur if ovarian torsion is suspected as this is a gynaecologic

2
emergency .
TORSION
Ovarian torsion, or adnexal torsion; is partial or complete rotation of the ovarian vascular pedicle
1
causing obstruction to venous outflow and later arterial inflow . The incidence of ovarian torsion occurs
1, 3
mainly in women of childbearing age, it is rare and accounts for 3% of gynaecologic emergencies .
Thought to be primarily caused by a heavy ovary in conditions such as ovarian hyper stimulation or
1
teratoma; right sided ovarian torsion is more common . 10-20% of ovarian torsion can occur during
3
pregnancy; with infertility treatment being a possible risk factor . Reoccurrence can occur in polycystic
3
4
ovaries . 15% of ovarian torsion can occur in children and adolescents .
3
Diagnosis: Is based on a high index of clinical suspicion :

Signs of ovarian torsion include:
DPMS
Ref: 8432
Characterised by colicky pain in lower abdomen or pelvic tenderness which becomes constant
3
and can disappear if tissue is severely necrosed .
50% of cases present with nausea and vomiting .
The presence of an adnexal mass on USS raises the suspicion of a torted ovarian cyst.
Doppler sonography can be useful in diagnosis but normal blood flow does not exclude
5
torsion .
All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual
Page 1 of 3
MANAGEMENT OF OVARIAN TORSION
Perform laparoscopy if suspicion of ovarian torsion as soon as possible to aid in preservation

of ovarian tissue. Diagnosis can only be made at laparoscopy or laparotomy.
During surgery de-torsion only is recommended as blood resupply in 91-100% of cases will be
restored. Further surgery at a later stage should be considered for cysts deemed to be
1, 3
complex .
RUPTURE & HAEMORRHAGE

Usually this is a physiological event during the ovarian cycle involving the follicle or corpus luteum. An
1
extremely rare cause of rupture is pseudomyxoma, (mucinous cyst) . Complications can occur with
1
women with a history of coagulopathy . If a benign teratoma/ endometriotic cyst is involved be aware
1
that the ruptured cyst content can be extremely irritant for the peritoneum . Historically treatment for
functional ovarian cysts has included the oral contraceptive pill; this has not been proven to be
6
beneficial in most cases as functional ovarian cysts are likely to resolve within several months . Other
treatment such as repeated laparoscopic ovarian cystectomies for functional cysts has been shown to
reduce fertility without any added benefit to the woman.
3
Signs of rupture / Haemorrhage :
Characterised by a sudden onset of sharp then constant ache. Pain is at its worst at the time of
onset.
Most women are systemically well; mild signs of peritonism may be present on examination,
not associated with fevers, tachycardia or inflammatory markers.
Free fluid may be seen on USS.
If significant blood loss occurs the women could present with hypovolemic shock. This is a very
late sign.
MANAGEMENT
Ultrasound is the first line of investigation.
Management is usually conservative, with analgesia and observation.
Address any predisposing cause such as Factor VIII deficiency causing haemorrhage .
If pain does not improve within 48 hours consider an alternative diagnosis
If the pain persists beyond a few days then laparoscopy should be considered.
Follow up after 6 weeks with an ultrasound to confirm resolution is recommended when an

1
ovarian haemorrhagic cyst has been identified .
Date Issued: 2001

Date Revised: May 2014
Review Date: May 2017
Written by:/Authorised by: OGCCU
Review Team: OGCCU
DPMS Ref: 8432
Ovarian Cyst Accidents

Gynaecology
Clinical Guidelines
Perth Western Australia
All guidelines should be read in conjunction with the Disclaimer at the beginning of this section
Page 2 of 3
REFERENCES ( STANDARDS)
1.
Bottomley. C., Bourne. T. Diagnosis and management of ovarian cyst accidents Best Practice & Research
Clinical Obstetrics & Gynaecology. 2009;23:711-24.
2.
Ramphal. S.R. Emergency Gynaecology. Best Practice & Research Clinical Obstetrics and
Gynaecology. 2006;20(5):729-50.
3.
Ginath. S, Shalev. A, Keiday. R, Kerner. R, Condrea. A, Golan. A, et al. Differences between adnexal
torsion in pregnant and nonpregnant women The Journal of Minimally Invasive Gynaecology.
2012;19:708-14.
4.
McCloskey. K., Grover. S., Vuillermin. P., Babl. F.E. Ovarian torsion among girls presenting with abdominal
pain: a retrospective cohort study. Emergency Medical Journal. 2013;30(e11):2-5.
5.
Pea JE, Ufberg D, Cooney N, Denis AL. Usefulness of Doppler sonography in the diagnosis of ovarian
torsion. Fertility and Sterility. 2000 5//;73(5):1047-50.
6.
Grimes. D.A., Jones. L.B., Lopez. L.M., Schulz. K.F. Oral contrceptives for functional ovarian cysts The
Cochrane Library. 2011(9):1-28.
National Standards Standard 1 Clinical Practice
Legislation - Nil
Related Policies - Clinical Guidelines Ovarian Hyperstimulation Syndrome.
Other related documents Nil
RESPONSIBILITY
Policy Sponsor
Initial Endorsement
Last Reviewed
Last Amended
Review date
Date Issued: 2001

Date Revised: May 2014
Review Date: May 2017
Written by:/Authorised by: OGCCU
Review Team: OGCCU
DPMS Ref: 8432
Medical Director Gynaecology

2001
May 2014
May 2017
C.6.2 Ovarian Cyst Accidents

Section C
Clinical Guidelines
Perth Western Australia
All guidelines should be read in conjunction with the Disclaimer at the beginning of this section
Page 3 of 3

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WOMEN AND NEWBORN HEALTH SERVICE

King Edward Memorial Hospital

OVARIAN CYST ACCIDENTS

Immediate treatment should occur if ovarian torsion is suspected as this is a gynaecologic

Diagnosis: Is based on a high index of clinical suspicion :

50% of cases present with nausea and vomiting .

MANAGEMENT OF OVARIAN TORSION

Perform laparoscopy if suspicion of ovarian torsion as soon as possible to aid in preservation

RUPTURE & HAEMORRHAGE

Signs of rupture / Haemorrhage :

Free fluid may be seen on USS.

Ultrasound is the first line of investigation.

Management is usually conservative, with analgesia and observation.

If pain does not improve within 48 hours consider an alternative diagnosis

Follow up after 6 weeks with an ultrasound to confirm resolution is recommended when an

Date Issued: 2001

Ovarian Cyst Accidents

Date Issued: 2001

Medical Director Gynaecology

C.6.2 Ovarian Cyst Accidents

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