Recurrent hemorrhage from corpus luteum during anticoagulant

Recurrent hemorrhage from corpus luteum
during anticoagulant therapy
K.P. WONG, MB, BS; P.G. GILLETT, MD, CM, FRCS[C], MRCOG
A 43-year old woman had recurrent
massive intraperitoneal hemorrhage
from rupture of a hemorrhagic corpus
iuteum in two successive menstrual
cycles while receiving anticoagulant
therapy. Left oophorectomy was
performed on the first occasion and
right salpingo-oophorectomy with left
saipingectomy on the second. While
the precise incidence cannot be
determined, rupture from a hemorrhagic
corpus luteum appears to be a
rare but potentially catastrophic
complication of anticoagulant therapy.
Hence possible ovarian hemorrhage
should be considered in women of
reproductive age receiving heparin or
sodium warfarin therapy.
Une femme de 43 ans a subi des
hemorragies intrap6ritoneaies massives
r6petee par rupture d'un corps jaune
hemorragique au cours de deux cycles
menstruels consecutifs alors qu'elle
etait sous traitement anticoagulant. A
Ia premiere occasion on a proced6
a une ovariectomie gauche et, a Ia
deuxieme, A une salpingo-ovariectomie
droite avec saipingectomie gauche.
Bien que Ia fr6quence ne puisse en
Atre determin6e avec pr6cision, Ia
rupture d'un corps jaune h6morragique
sembie Atre une complication rare
mais possiblement catastrophique du
traitement anticoagulant. On devrait
donc envisager Ia possibilite d'une
hemorragie ovarienne chez les femmes
en Age d'enfanter recevant un
traitement A l'heparine ou A Ia warfarine
sodique.
Anticoagulation is well recognized as
a valuable treatment for thromboembolic disease. Abnormal bleeding from
a wide variety of sites is the main complication and may occur despite careful
control. An uncommon complication is
rupture of a hemorrhagic corpus luteum cyst. We report a case of rupture
of a hemorrhagic corpus luteum of the
left and right ovary in succeeding menstrual cycles in a patient who was receiving anticoagulant therapy.
Case report
A 43-year-old Mohawk Indian woman,
gravida I, para 1, was seen in the emerFrom the department of obstetrics and
gynecology, Montreal General Hospital
Reprint requests to: Dr. P.G. Gillett, Department
of obstetrics and gynecology, Montreal General
Hospital, 1650 Cedar Ave., Montreal, PQ
H3G 1A4
gency room Sept. 22, 1975 complaining
of lower abdominal pain of 5 hours' duration with sudden onset. Her last normal
menstrual period had begun 13 days before and her menstrual cycles had occurred regularly every 30 days and lasted
5 days. The patient was not currently
having intercourse or using oral contraceptives. Because of recurrent pulmonary embolism since November 1974 she had
been taking sodium warfarin orally, 15
mg/d 5 days a week and 20 mg/d 2 days
a week. Prothrombin time on admission
was 16 s (control time, 10 s).
The patient looked ill. Her blood pressure was 140/90 mm Hg and her pulse
rate, 110 beats/mm. She was afebrile. Her
abdomen was distended and tender and
the bowel sounds were decreased. Pelvic
examination revealed fullness in the culde-sac, and abdominal paracentesis yielded
blood that did not clot. Her hematocrit,
initially 36%, decreased to 23% after
admission.
Laparotomy was performed the next
day after 10 mg of vitamin K had been
given intramuscularly. The abdominal
cavity contained about 2 1 of blood, which
apparently had come from a hemorrhagic
corpus luteum of the left ovary. Pathologic examination confirmed this suspicion
and left oophorectomy was performed.
The patient received 4 units of blood.
Postoperatively pulmonary embolism
developed; this was confirmed by serial
lung scans. Heparin, 6000 U intravenously
(IV) q4h, was given initially, then sodium
warfarin, 20 mg/d orally was substituted.
On the 26th postoperative day the patient complained of right lower quadrant
pain. The pain increased during 3 days
of observation. On the 3rd day evidence
of peritoneal irritation was elicited and
pelvic examination revealed a tender mass
in the right adnexal area. Her hematocrit
had decreased from 40% to 35%. Partial
thromboplastin time was 48.5 s (control
time, 30.7 s) and prothrombin time was
16.9 s.
Laparotomy was performed that day, 6
hours after IV administration of vitamin
K, 10 mg, and discontinuation of heparin.
The abdominal cavity contained about
500 ml of old blood and blood clots. The
right ovary was obscured by an organized
blood clot, 4 x 4 cm. Because of the
extensive ovarian destruction by hemorrhage, in addition to her age and parity,
ovarian cystectomy was precluded. Right
salpingo-oophorectomy and left salpingectomy were performed. Hysterectomy
was not considered because of her serious
medical condition. Inferior vena cava
plication with a de Weese clip was carried out at the same time in view of her
recurrent episodes of pulmonary embolism. Pathologic examination of the right
ovary revealed a ruptured corpus luteum
cyst.
3S8 CMA JOURNAL/FEBRUARY 19, 1977/VOL. 116
Discussion
There are many reports of bleeding
from a corpus luteum causing massive
intraperitoneal hemorrhage in premenopausal women; Fitzgerald and Martin'
have referred to this event as an "ovarian vascular accident". The formation
of the corpus luteum begins with the
release of an ovum from a ripe follicle.
According to Novak and Woodruff2
bleeding does not normally occur from
the stigma because it becomes plugged
with fibrin. Ovulation is followed by
a stage of proliferation or hyperemia,
consisting of follicular collapse and
luteinization of the granulosa layer,
which is devoid of blood vessels. The
lumen of the corpus still contains no
blood. The stage of vascularization then
occurs: the granulosa layer is penetrated by blood vessels that pass vertically towards the cavity of the corpus
luteum, filling the cavity with blood.
If this corpus luteum hematoma ruptures, intraperitoneal hemorrhage may
occur, especially if the woman's clotting
mechanisms are depressed by anticoagulant therapy.
The complications of anticoagulant
therapy, which was introduced in the
late 1930s, are infrequent but can
be extremely serious. Gurewich and
Thomas3 listed the more common complications as gastrointestinal bleeding,
hematuria, cerebral hemorrhage, subcutaneous ecchymosis, epistaxis and
hemoptysis, and the rare complications
as spontaneous spinal epidural hematoma, bilateral adrenal hemorrhage,
hemopericardium, hematoma of the
rectus abdominis and intraperitoneal
hemorrhage of ovarian origin. We were
able to find only six reports in the
English literature, published between
1957 and 1976, of massive intraperitoneal hemorrhage originating from the
corpus luteum in 10 women who were
taking anticoagulants for various reasons.44 The exact incidence of this
complication cannot be determined but
this small number of reports suggests
that it occurs infrequently.
Because it is a potentially life-threatening complication, hemorrhage from
a ruptured corpus luteum cyst should
be considered in any woman of reproductive age who is given anticoagulant
therapy. Consideration should be given
to stopping the therapy when ovarian
enlargement is detected. Hemoperitoneum should be sought by culdocentesis
in such patients who present with an
acute abdomen, and if it is detected
laparotomy should be undertaken immediately. The definitive surgical procedure should be determined by the
operative findings and the circumstances of the individual patient. Before
operation anticoagulation should be reversed with protamine sulfate if heparin
was the anticoagulant administered,
and vitamin K if it was sodium warfarm.
References
1. FITZGERALD JA, MARTIN VB: Accurate diagnosis of ovarian vascular accidents". Gb-
2. stet Gynecol 13: 175, 1959
NOVAK ER, WOODRuFF JD: Novak's Gynecologic & Obstetric Pathology: With Clinical
& Endocrine Relations, 7th ed, Philadelphia,
Saunders, 1974, p 335
3. GUREWICH V, THOMAS D: Massive intraperitoneal hemorrhage from ruptured corpus
luteum. A rare complication of long-term
anticoagulant therapy. N Engi I Med 263:
909, 1960
4. WESELEY AC, NEU5TADTER MI, LEVINE W:
Massive mtraperstoneal hemorrhage of ovarian foflicular origin during anticoagulant therapy. Am J Obstet Gynecol 73: 683, 1957
5. DAcus RM III: Massive intraperitoneal hemorrhage from a corpus luteum hematoma in
women taking anticoagulants. Report of 2
cases. Obstet Gynecol 31: 471, 1968
S..
6. WALTON LA: Bleeding corpus luteum from
anticoagulant therapy. N Engl I Med 263:
450, 1969
7. MANNY J, MERIN G, ROZIN RR, et al: Ovarian hemorrhage complicating anticoagulant
therapy. Obstet Gynecol 41: 512, 1973
8. MAT5EOANE S, BAx-rs JA JR, MANDEvILLE
EO: Ovarian hemorrhage complicating warfarm sodium anticoagulant therapy. Am I
Obstet Gynecol 124: 755, 1976
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