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.


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


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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Recurrent hemorrhage from corpus luteum during anticoagulant therapy.

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...
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