•
•
Ruptured Corpus Luteum with Hemoperitoneum
1
Diagnostic Radiology
James~McCortM.D.
Rupture of the corpus luteum in a young woman can cause massive hemoperitoneum, seen as free fluid in the flanks and pelvis on abdominal films. Radiographic examination alone cannot distinguish hemorrhage due to a ruptured corpus luteum or ectopic pregnancy from pus due to a ruptured appendix or a tubo-ovarian abscess; however, the presence of nonclotting blood on culdocentesis excludes abdominal sepsis. If these symptoms and findings occur during the latter half of the menstrual cycle in a young woman of low parity who has a normal menstrual history and a negative pregnancy test, a ruptured corpus luteum is a more likely diagnosis than ectopic pregnancy. INDEX TERMS: Corpus Luteum s Peritoneum, fluid. Peritoneum, hemorrhage. Pregnancy, ectopic Radiology 116: 65-67, July 1975
•
• (18) found that bleeding could occur at any time during the menstrual cycle, including menstruation. Corpus luteum hemorrhage occurring early in the cycle must originate in the previous cycle. All 7 patients had abdominal pain of acute onset, usually low in the abdomen, which was aggravated by motion. In 5 cases the pain subsequently radiated to one or both shoulders due to diaphragmatic extension of intraperitoneal blood and referral of pain by the phrenic nerve. Taniguchi and Kilkenny (19) and Weil (21) consider the sudden onset of abdominal pain to be characteristic of corpus luteum rupture and distinct from the more gradual onset seen in appendicitis and salpingitis. In 5 patients, abdominal pain occurred following coitus, an association reported previously by Rosenthal (15) and Speroff (18). Two patients experienced nausea and vomiting and 2 reported fainting episodes. One patient had dysuria. All patients had lower abdominal tenderness on physical examination. In 3 cases it was localized to the lower quadrant occupied by the involved ovary. Guarding was present, and bowel sounds were absent, a sign of peristaltic hypoactivity. The hematocrit was lowered in 7 patients, ranging from 30 to 37 %; in 4 it fell progressively under observation, indicating continued bleeding. In 2 patients the white blood cell count exceeded 10,000/mm 3 , with a predominance of neutrophils. Five patients had cervical and adnexal tenderness, and one had a slightly bloody cervical discharge on pelvic examination. In 4 of the 5 patients in whom culdocentesis was performed, the surgeon aspirated nonclotting blood. Speroff (18) performed culdocentesis in 19 patients with corpus luteum hemorrhage and obtained nonclotting blood in every case.
corpus luteum and intraperitoneal hemorrhage in a young woman cause acute abdominal pain and hypovolemic shock. The attending physician may suspect appendicitis, salpingitis, or twisted ovarian cyst if pain is the presenting complaint and ruptured ectopic pregnancy when the patient shows signs of blood loss. Abdominal radiography often provides diagnostic aid in such cases. UPTURE OF THE
R
MATERIAL AND METHODS
Preoperative plain films of the abdomen were evaluated in 7 patients ranging from 16 to 29 years of age who presented with a ruptured corpus luteum and hemoperitoneum. In 6, surgical excision confirmed the diagnosis of ruptured corpus luteum. In 1, the diagnosis was based on the gynecologist's findings at surgery. Culdocentesis was performed in 5. CLINICAL FINDINGS
Four of my 7 patients were nulliparous. This is in accord with other authors' observation that hemorrhage of the corpus luteum commonly involves young women of low parity (1,3,6, 14). The earliest age at which hemorrhage has been reported to occur is 12 years (5). Although hemorrhage of the corpus luteum should be more likely to occur in the latter half of the ovarian cycle and in fact began between the fifteenth and the twenty-eighth day in 4 of my 7 patients, it occurred on the seventh day of the cycle in one patient. One woman being treated with clomiphene citrate (Clomid) had experienced amenorrhea for one and one-half years, while the date of the last menstrual period was not recorded in the remaining patient. Claman (3) and Speroff
1 From the Division of Radiology (J. J. M., Chairman), Santa Clara Valley Medical Center, San Jose, Calif. Accepted for publication in February 1975. sjh
65
66
JAMES J. MCCORT
July 1975
Fig. 1 (A. T.). Blood in pelvis. This 18year-old gravida 1, Para 1 woman had abdominal pain which radiated to both shoulders. Her last menstrual period had begun 15 days earlier. The hematocrit was 31.9 with a normal white blood cell count and differential. Fullness and tenderness were found on pelvic examination. The Gravidex test was negative. Culdocentesis revealed nonclotting blood. Radiographs showed a normal-sized uterus (with an intrauterine contraceptive device) above the bladder. Fluid filled the lateral recesses of the pelvis (arrows) and was also present in the flanks, shifting when the patient was placed in the decubitus position. On celiotomy, the peritoneum was found to contain 1,000 ml of nonclotting blood as well as blood clots. A ruptured corpus luteum was excised at surgery.
Radiographic Findings: In all 7 patients, preoperative abdominal films showed fluid (later proved to be blood) filling the lateral recesses of the pelvis and the pouch of Douglas (Fig. 1). Blood also entered the lateral gutters
between the vertical segments of the colon and the lateral abdominal wall, as shown by a dense band between the properitoneal fat and the wall of the colon (Fig. 2). In the lateral decubitus 'position, blood gravitated to the dependent flank. Two patients had nonobstructive ileus. DISCUSSION
Pathogenesis
Fig. 2 (W. K.). Blood in flank. An episode of acute abdominal pain radiating to both shoulders developed in this 24-year-old nulliparous woman a short time after intercourse. She felt faint and vomited once. The abdomen was diffusely tender with guarding, and slight tenderness was noted on pelvic examination. The hematocrit was 37 with a normal white blood cell count. Abdominal films showed fluid filling both flanks (arrows) between the retroperitoneal fat and the lateral wall of the colon. The fluid shifted when the patient was placed in the decubitus position. Nonobstructive ileus was present. A contraceptive device was in place within the uterine canal. At celiotomy, more than a liter of liquid blood was encountered in the peritoneum, as well as some blood clots in the pelvis. The gynecologist ligated a ruptured and bleeding corpus luteum in the left ovary.
The mature follicle normally ruptures in the middle of the ovarian cycle, releasing the egg together with a portion of the membrana granulosa, after which it collapses inward. This is followed by proliferation of the cells of the granular layer, which become transformed into large, polyhedral cells (lutein cells). Blood vessels from the theca now invade the lutein cells (vascularization stage). The follicle is now known as the corpus luteum. A small amount of blood normally enters and distends the cavity of the corpus luteum (10). In a few young women the bleeding is excessive and the corpus luteum ruptures into the peritoneum, possibly as the result of hormonal imbalance (9, 16). The blood lost from the corpus luteum initially clots at the surface of the ovary. If bleeding continues, the blood is defibrinated and flows into the dependent portions of the peritoneum. Maximum development of the corpus luteum occurs four to six days prior to menstruation. It then regresses and the lutein cells degenerate, to be replaced by fibrous tissue. If pregnancy occurs, the corpus luteum persists. Rupture of the corpus luteum during pregnancy can also cause hemoperitoneum (2, 3, 12, 13, 17).
RUPTURED CORPUS LUTEUM WITH HEMOPERITONEUM
Vol. 116
Incidence
Hemorrhage from a ruptured corpus luteum is uncommon, though the exact frequency is unknown. A small, limited hemorrhage may not produce enough pain and blood loss to cause the patient to seek medical care. Of 28,852 patients seen in the Department of Obstetrics and Gynecology of their institution over a period of five and one-half years, Taniguchi et et. (20) found only 16 who presented as emergency cases following rupture of a corpus luteum. Israel (8) noted that hemorrhage due to corpus luteum rupture was more common than bleeding from a follicular cyst and recommended conservative treatment with preservation of the ovary. Winer (22) reported a rare instance of corpus luteum hemorrhage occurring twice in the same patient over a period of four years. Differential Diagnosis
Hemorrhage from a corpus luteum in the right ovary presents the greatest difficulty in differentiation, since it simulates appendicitis. Only if the appendix ruptures and causes peritonitis do large amounts of abdominal fluid develop. In uncomplicated appendicitis, shoulder pain is rare and culdocentesis is negative. However, several authors have reported finding acute appendicitis and corpus luteum hemorrhage in the same patient (6, 7, 11,20). Ruptured ectopic pregnancy causes pain in the lower abdomen and shoulder and symptoms of blood loss. Plain films of the abdomen show free blood, while culdocentesis reveals nonclotting blood. The presence of an intrauterine contraceptive device makes corpus luteum bleeding more likely but does not exclude pregnancy. A missed period and a positive pregnancy test would indicate ectopic gestation. A ruptured salpingo-ovarian abscess may mimic corpus luteum hemorrhage. Fever, leukocytosis, marked pelvic tenderness, and cervical discharge suggest pelvic inflammatory disease. In such cases, culdocentesis will show pus instead of nonclotting blood. On the plain film, peritoneal fluid is minimal and ileus of the small and large bowel is marked. Torsion and infarction of an ovarian cyst can cause acute abdominal pain and intraperitoneal hemorrhage but is much less common than rupture of an ectopic pregnancy or corpus luteum (20). The ovarian cyst may be seen on the plain film or palpated on pelvic examination. If corpus luteum hemorrhage seems likely, Fitzgerald and Berrigan (4) recommend management by culdoscopy. They diagnosed 7 of their 9 cases by culdoscopy, thereby avoiding surgical exploration.
67
Diagnostic Radiology
REFERENCES 1. Bachmann F: IntraperitoneaIe Blutung aus einem Corpus luteum. Zentralbl GynaekoI77:1915-1918, 1955 2. Case records of the Massachusetts General Hospital. Case 83-1962. N Engl J Med 267:1258-1262, 13 Dec 1962 3. Claman AD: Bleeding from the ovary: graafian follicle and corpus luteum. Can Med Assoc J 76:1036-1040,15 Jun 1957 4. Fitzgerald JA, Berrigan MV: Accurate diagnosis of "ovarian vascular accidents." Review of 32 instances, with clinical conclusion. Obstet GynecoI13:175-180, Feb 1959 5. Foisie PS: Hemorrhage from a ruptured corpus luteum. Report of a case in a twelve-year-old girl. N Engl J Med 227:45-46, 9 Jul1942 6. Grise RF, Morton CB: Acute abdominal symptoms from the bleeding ovary. Analysis of eighty-four proved cases. Surgery 29: 117-123, Jan 1951 7. Hoyt WF, Meigs JV: Rupture of the graafian follicle and corpus luteum. Surg Gynecol Obstet 62: 114-117, Jan 1936 8. Israel SL: Ovarian rupture causing intraperitoneal hemorrhage. With report of ten cases. Am J Obstet Gynecol 33:30-38, Jan 1937 9. Koskela 0: Intraperitoneal ovarian hemorrhages not connected with ectopic pregnancy. Ann Chir Gynaecol Fenn 55:103108, 1966 10. Novak ER, Jones GS, Jones HW Jr: Novak's Textbook of Gynecology. Baltimore, Williams & Wilkins, 8th Ed, 1970, pp 20-27 11. O'Gorman F: Acute appendicitis associated with intraperitoneal haemorrhage from rupture of the corpus luteum. Br Med J 1: 148,31 Jan 1942 12. Ottoway JP: Ruptured hemorrhagic ovarian cysts during pregnancy. Report of two cases of massive hemoperitoneum. Obstet GynecoI21:379-383, Mar 1963 13. Pecman J: Hemoperitoneum from rupture of the corpus luteum. Report of a case of ruptured corpus luteum of pregnancy. Pa Med J 50:1161-1163, Aug 1947 14. Pedlow EB: Massive intraperitoneal hemorrhage caused by a rupture of a hemorrhagic corpus luteum. Ohio State Med J 43: 168-169, Feb 1947 15. Rosenthal AH: Rupture of the corpus luteum, including four cases of massive intraperitoneal hemorrhage. Am J Obstet Gynecol 79:1008-1011, May 1960 16. Rossi G, Cusmano L: La patologia del corpo luteo come fattore causale di emoperitoneo. Minerva Ginecol 8:545-552, 15 Jul 1956 (Ital) 17. Sarram M: Severe intra-abdominal hemorrhage from bilateral lutein cysts in Rh-isoimmunized pregnancy. Obstet Gynecol 17: 366-370, Mar 1961 18. Speroff L: The bleeding corpus luteum. Analysis of 40 confirmed cases. Obstet GynecoI28:416-420, Sep 1966 19. Taniguchi T, Kilkenny GS: Rupture of corpus luteum with production of hemoperitoneum. Report of nineteen cases. JAMA 147:1420-1424,8 Dec 1951 20. Taniguchi T, Klieger JA, Kuhn MJ: Surgical emergencies resulting from corpus luteum cysts and hematomas. Arch Surg 64: 516-524, Apr 1952 21. Weil AM: Ruptured graafian follicle and corpus luteum with intra-abdominal hemorrhage simulating acute appendicitis and ruptured ectopic pregnancy. Am J Obstet Gynecol 38:288-295, Aug 1939 22. Winer HJ: Recurrent massive hemorrhage due to bleeding corpus luteum cyst. Obstet GynecoI18:239-240, Aug 1961 Division of Radiology Santa Clara Valley Medical Center 751 S. Bascom Ave. San Jose, Calif. 95128
•
Ruptured Corpus Luteum with Hemoperitoneum
1
Diagnostic Radiology
James~McCortM.D.
Rupture of the corpus luteum in a young woman can cause massive hemoperitoneum, seen as free fluid in the flanks and pelvis on abdominal films. Radiographic examination alone cannot distinguish hemorrhage due to a ruptured corpus luteum or ectopic pregnancy from pus due to a ruptured appendix or a tubo-ovarian abscess; however, the presence of nonclotting blood on culdocentesis excludes abdominal sepsis. If these symptoms and findings occur during the latter half of the menstrual cycle in a young woman of low parity who has a normal menstrual history and a negative pregnancy test, a ruptured corpus luteum is a more likely diagnosis than ectopic pregnancy. INDEX TERMS: Corpus Luteum s Peritoneum, fluid. Peritoneum, hemorrhage. Pregnancy, ectopic Radiology 116: 65-67, July 1975
•
• (18) found that bleeding could occur at any time during the menstrual cycle, including menstruation. Corpus luteum hemorrhage occurring early in the cycle must originate in the previous cycle. All 7 patients had abdominal pain of acute onset, usually low in the abdomen, which was aggravated by motion. In 5 cases the pain subsequently radiated to one or both shoulders due to diaphragmatic extension of intraperitoneal blood and referral of pain by the phrenic nerve. Taniguchi and Kilkenny (19) and Weil (21) consider the sudden onset of abdominal pain to be characteristic of corpus luteum rupture and distinct from the more gradual onset seen in appendicitis and salpingitis. In 5 patients, abdominal pain occurred following coitus, an association reported previously by Rosenthal (15) and Speroff (18). Two patients experienced nausea and vomiting and 2 reported fainting episodes. One patient had dysuria. All patients had lower abdominal tenderness on physical examination. In 3 cases it was localized to the lower quadrant occupied by the involved ovary. Guarding was present, and bowel sounds were absent, a sign of peristaltic hypoactivity. The hematocrit was lowered in 7 patients, ranging from 30 to 37 %; in 4 it fell progressively under observation, indicating continued bleeding. In 2 patients the white blood cell count exceeded 10,000/mm 3 , with a predominance of neutrophils. Five patients had cervical and adnexal tenderness, and one had a slightly bloody cervical discharge on pelvic examination. In 4 of the 5 patients in whom culdocentesis was performed, the surgeon aspirated nonclotting blood. Speroff (18) performed culdocentesis in 19 patients with corpus luteum hemorrhage and obtained nonclotting blood in every case.
corpus luteum and intraperitoneal hemorrhage in a young woman cause acute abdominal pain and hypovolemic shock. The attending physician may suspect appendicitis, salpingitis, or twisted ovarian cyst if pain is the presenting complaint and ruptured ectopic pregnancy when the patient shows signs of blood loss. Abdominal radiography often provides diagnostic aid in such cases. UPTURE OF THE
R
MATERIAL AND METHODS
Preoperative plain films of the abdomen were evaluated in 7 patients ranging from 16 to 29 years of age who presented with a ruptured corpus luteum and hemoperitoneum. In 6, surgical excision confirmed the diagnosis of ruptured corpus luteum. In 1, the diagnosis was based on the gynecologist's findings at surgery. Culdocentesis was performed in 5. CLINICAL FINDINGS
Four of my 7 patients were nulliparous. This is in accord with other authors' observation that hemorrhage of the corpus luteum commonly involves young women of low parity (1,3,6, 14). The earliest age at which hemorrhage has been reported to occur is 12 years (5). Although hemorrhage of the corpus luteum should be more likely to occur in the latter half of the ovarian cycle and in fact began between the fifteenth and the twenty-eighth day in 4 of my 7 patients, it occurred on the seventh day of the cycle in one patient. One woman being treated with clomiphene citrate (Clomid) had experienced amenorrhea for one and one-half years, while the date of the last menstrual period was not recorded in the remaining patient. Claman (3) and Speroff
1 From the Division of Radiology (J. J. M., Chairman), Santa Clara Valley Medical Center, San Jose, Calif. Accepted for publication in February 1975. sjh
65
66
JAMES J. MCCORT
July 1975
Fig. 1 (A. T.). Blood in pelvis. This 18year-old gravida 1, Para 1 woman had abdominal pain which radiated to both shoulders. Her last menstrual period had begun 15 days earlier. The hematocrit was 31.9 with a normal white blood cell count and differential. Fullness and tenderness were found on pelvic examination. The Gravidex test was negative. Culdocentesis revealed nonclotting blood. Radiographs showed a normal-sized uterus (with an intrauterine contraceptive device) above the bladder. Fluid filled the lateral recesses of the pelvis (arrows) and was also present in the flanks, shifting when the patient was placed in the decubitus position. On celiotomy, the peritoneum was found to contain 1,000 ml of nonclotting blood as well as blood clots. A ruptured corpus luteum was excised at surgery.
Radiographic Findings: In all 7 patients, preoperative abdominal films showed fluid (later proved to be blood) filling the lateral recesses of the pelvis and the pouch of Douglas (Fig. 1). Blood also entered the lateral gutters
between the vertical segments of the colon and the lateral abdominal wall, as shown by a dense band between the properitoneal fat and the wall of the colon (Fig. 2). In the lateral decubitus 'position, blood gravitated to the dependent flank. Two patients had nonobstructive ileus. DISCUSSION
Pathogenesis
Fig. 2 (W. K.). Blood in flank. An episode of acute abdominal pain radiating to both shoulders developed in this 24-year-old nulliparous woman a short time after intercourse. She felt faint and vomited once. The abdomen was diffusely tender with guarding, and slight tenderness was noted on pelvic examination. The hematocrit was 37 with a normal white blood cell count. Abdominal films showed fluid filling both flanks (arrows) between the retroperitoneal fat and the lateral wall of the colon. The fluid shifted when the patient was placed in the decubitus position. Nonobstructive ileus was present. A contraceptive device was in place within the uterine canal. At celiotomy, more than a liter of liquid blood was encountered in the peritoneum, as well as some blood clots in the pelvis. The gynecologist ligated a ruptured and bleeding corpus luteum in the left ovary.
The mature follicle normally ruptures in the middle of the ovarian cycle, releasing the egg together with a portion of the membrana granulosa, after which it collapses inward. This is followed by proliferation of the cells of the granular layer, which become transformed into large, polyhedral cells (lutein cells). Blood vessels from the theca now invade the lutein cells (vascularization stage). The follicle is now known as the corpus luteum. A small amount of blood normally enters and distends the cavity of the corpus luteum (10). In a few young women the bleeding is excessive and the corpus luteum ruptures into the peritoneum, possibly as the result of hormonal imbalance (9, 16). The blood lost from the corpus luteum initially clots at the surface of the ovary. If bleeding continues, the blood is defibrinated and flows into the dependent portions of the peritoneum. Maximum development of the corpus luteum occurs four to six days prior to menstruation. It then regresses and the lutein cells degenerate, to be replaced by fibrous tissue. If pregnancy occurs, the corpus luteum persists. Rupture of the corpus luteum during pregnancy can also cause hemoperitoneum (2, 3, 12, 13, 17).
RUPTURED CORPUS LUTEUM WITH HEMOPERITONEUM
Vol. 116
Incidence
Hemorrhage from a ruptured corpus luteum is uncommon, though the exact frequency is unknown. A small, limited hemorrhage may not produce enough pain and blood loss to cause the patient to seek medical care. Of 28,852 patients seen in the Department of Obstetrics and Gynecology of their institution over a period of five and one-half years, Taniguchi et et. (20) found only 16 who presented as emergency cases following rupture of a corpus luteum. Israel (8) noted that hemorrhage due to corpus luteum rupture was more common than bleeding from a follicular cyst and recommended conservative treatment with preservation of the ovary. Winer (22) reported a rare instance of corpus luteum hemorrhage occurring twice in the same patient over a period of four years. Differential Diagnosis
Hemorrhage from a corpus luteum in the right ovary presents the greatest difficulty in differentiation, since it simulates appendicitis. Only if the appendix ruptures and causes peritonitis do large amounts of abdominal fluid develop. In uncomplicated appendicitis, shoulder pain is rare and culdocentesis is negative. However, several authors have reported finding acute appendicitis and corpus luteum hemorrhage in the same patient (6, 7, 11,20). Ruptured ectopic pregnancy causes pain in the lower abdomen and shoulder and symptoms of blood loss. Plain films of the abdomen show free blood, while culdocentesis reveals nonclotting blood. The presence of an intrauterine contraceptive device makes corpus luteum bleeding more likely but does not exclude pregnancy. A missed period and a positive pregnancy test would indicate ectopic gestation. A ruptured salpingo-ovarian abscess may mimic corpus luteum hemorrhage. Fever, leukocytosis, marked pelvic tenderness, and cervical discharge suggest pelvic inflammatory disease. In such cases, culdocentesis will show pus instead of nonclotting blood. On the plain film, peritoneal fluid is minimal and ileus of the small and large bowel is marked. Torsion and infarction of an ovarian cyst can cause acute abdominal pain and intraperitoneal hemorrhage but is much less common than rupture of an ectopic pregnancy or corpus luteum (20). The ovarian cyst may be seen on the plain film or palpated on pelvic examination. If corpus luteum hemorrhage seems likely, Fitzgerald and Berrigan (4) recommend management by culdoscopy. They diagnosed 7 of their 9 cases by culdoscopy, thereby avoiding surgical exploration.
67
Diagnostic Radiology
REFERENCES 1. Bachmann F: IntraperitoneaIe Blutung aus einem Corpus luteum. Zentralbl GynaekoI77:1915-1918, 1955 2. Case records of the Massachusetts General Hospital. Case 83-1962. N Engl J Med 267:1258-1262, 13 Dec 1962 3. Claman AD: Bleeding from the ovary: graafian follicle and corpus luteum. Can Med Assoc J 76:1036-1040,15 Jun 1957 4. Fitzgerald JA, Berrigan MV: Accurate diagnosis of "ovarian vascular accidents." Review of 32 instances, with clinical conclusion. Obstet GynecoI13:175-180, Feb 1959 5. Foisie PS: Hemorrhage from a ruptured corpus luteum. Report of a case in a twelve-year-old girl. N Engl J Med 227:45-46, 9 Jul1942 6. Grise RF, Morton CB: Acute abdominal symptoms from the bleeding ovary. Analysis of eighty-four proved cases. Surgery 29: 117-123, Jan 1951 7. Hoyt WF, Meigs JV: Rupture of the graafian follicle and corpus luteum. Surg Gynecol Obstet 62: 114-117, Jan 1936 8. Israel SL: Ovarian rupture causing intraperitoneal hemorrhage. With report of ten cases. Am J Obstet Gynecol 33:30-38, Jan 1937 9. Koskela 0: Intraperitoneal ovarian hemorrhages not connected with ectopic pregnancy. Ann Chir Gynaecol Fenn 55:103108, 1966 10. Novak ER, Jones GS, Jones HW Jr: Novak's Textbook of Gynecology. Baltimore, Williams & Wilkins, 8th Ed, 1970, pp 20-27 11. O'Gorman F: Acute appendicitis associated with intraperitoneal haemorrhage from rupture of the corpus luteum. Br Med J 1: 148,31 Jan 1942 12. Ottoway JP: Ruptured hemorrhagic ovarian cysts during pregnancy. Report of two cases of massive hemoperitoneum. Obstet GynecoI21:379-383, Mar 1963 13. Pecman J: Hemoperitoneum from rupture of the corpus luteum. Report of a case of ruptured corpus luteum of pregnancy. Pa Med J 50:1161-1163, Aug 1947 14. Pedlow EB: Massive intraperitoneal hemorrhage caused by a rupture of a hemorrhagic corpus luteum. Ohio State Med J 43: 168-169, Feb 1947 15. Rosenthal AH: Rupture of the corpus luteum, including four cases of massive intraperitoneal hemorrhage. Am J Obstet Gynecol 79:1008-1011, May 1960 16. Rossi G, Cusmano L: La patologia del corpo luteo come fattore causale di emoperitoneo. Minerva Ginecol 8:545-552, 15 Jul 1956 (Ital) 17. Sarram M: Severe intra-abdominal hemorrhage from bilateral lutein cysts in Rh-isoimmunized pregnancy. Obstet Gynecol 17: 366-370, Mar 1961 18. Speroff L: The bleeding corpus luteum. Analysis of 40 confirmed cases. Obstet GynecoI28:416-420, Sep 1966 19. Taniguchi T, Kilkenny GS: Rupture of corpus luteum with production of hemoperitoneum. Report of nineteen cases. JAMA 147:1420-1424,8 Dec 1951 20. Taniguchi T, Klieger JA, Kuhn MJ: Surgical emergencies resulting from corpus luteum cysts and hematomas. Arch Surg 64: 516-524, Apr 1952 21. Weil AM: Ruptured graafian follicle and corpus luteum with intra-abdominal hemorrhage simulating acute appendicitis and ruptured ectopic pregnancy. Am J Obstet Gynecol 38:288-295, Aug 1939 22. Winer HJ: Recurrent massive hemorrhage due to bleeding corpus luteum cyst. Obstet GynecoI18:239-240, Aug 1961 Division of Radiology Santa Clara Valley Medical Center 751 S. Bascom Ave. San Jose, Calif. 95128
