Ovarian Torsion With Ruptured Ovarian Haemorrhage With Massive Hemoperitoneum In A Case Of ITP
R Gandhi, N Bahri, H Parekh, S Chudasama, N Doshi, C Muniya
haemoperitoneum, idiopathic thrombocytopenic purpura, ovarian torsion
R Gandhi, N Bahri, H Parekh, S Chudasama, N Doshi, C Muniya. Ovarian Torsion With Ruptured Ovarian Haemorrhage With Massive Hemoperitoneum In A Case Of ITP. The Internet Journal of Radiology. 2009 Volume 11 Number 2.
Idiopathic thrombocytopenic purpura, an immune-mediated disease, usually has a relatively benign clinical course. Bleeding manifestations are mostly mucocutaneous and mild. Massive hemorrhage requiring transfusions or other interventions are rare, unless platelet counts are extremely low or other complicating conditions coexist. We describe a 24year old woman, case of chronic ITP presenting with severe abdominal pain prompting an urgent Ultrasound and MR examination which showed ovarian torsion with ruptured ovarian hemorrhage causing massive hemoperitoneum. The specific sign of torsion is demonstration of multiple follicles of uniform size (8-12 mm in diameter) in the cortical peripheral portion of a unilaterally enlarged ovary. MR imaging showed enlarged ovary with peripherally situated T2 hyperintense follicles and ruptured ovarian capsule with better demonstration of pedicle. Large amount of subacute blood noted in peritoneal cavity suggested by hyperintensity on both T1 and T2.
ITP - immune thrombocytopenic purpura; MRI - magnetic resonance imaging;
A female aged 24 years presented with severe abdominal pain with distension, hypotension and multiple petechiae. Ultrasound with Color Doppler was done which showed ovarian torsion and haemoperitoneum [fig.1, 2,3]. MR examination with 1.5 Tesla Siemens Magnetom Essenza machine is performed and T1, T2 sequences are run which showed ruptured ovarian hemorrhage and confirmed torsion and haemoperitoneum [fig.4, 5,6,7,8].
Idiopathic thrombocytopenic purpura is an immune-mediated disease that is caused by antibody mediated platelet destruction with a normal bone marrow. 
Epidemiology: - Adnexa torsion is reported to be the fifth most common gynecologic emergency in women of reproductive age with a prevalence of 2.7%. Torsion of the adnexa structure may involve both the ovary and fallopian tube. Patients of Ovarian hyperstimulation syndrome who become pregnant had a greater risk of adnexa torsion (16%). 
Acute ITP - is typically a disease of children has an abrupt onset and is usually preceded by a viral infection. Spontaneous remissions are common and relapses are rare. 
Chronic ITP - is typically a disease of young adults, mostly women. The onset is insidious and spontaneous remission is rare. Clinical course waxes and wanes, but is usually relatively benign. 
Signs and Symptoms: - Bleeding manifestations are usually mucocutaneous and mild, such as purpura, epistaxis and gingival bleeding. Haematuria and gastrointestinal bleeding are less common and intracerebral haemorrhage is rare. Torsion manifests as gradual pain or sudden onset of pain, which mimic other acute abdominal conditions. 
Color Doppler Sonography shows decreased or absent arterial and venous flow compared with the contra lateral ovary. Better demonstration of whirlpool sign is noted. The vascularity of the ovary depends on the angle of twisting. 
On Intravenous contrast agent administration, pelvis shows heterogenous non-enhancing mass unilaterally with fluid collection which is torsed ovary (lack of enhancement sign). The enhancement of ovaries is compared to that of uterus. Non enhancement of an adnexal mass, abnormal location of the uterus, adnexa or both, ascites, uterine displacement, pelvic fat infiltration, hematoma, tubal thickening and a whirlpool sign. 
Hemorrhage into ovarian cysts has been reported to be a frequent complication in women with chronic ITP and receiving anticoagulation therapy. In some cases this causes a rapid rise in intracystic pressure, cyst rupture and haemoperitoneum. Ruptured corpus luteum cyst combines MR evidence of haemoperitoneum with a large pelvic hematoma indicative of the bleeding source. 
Tubo-ovarian abscess present with fever and abdominal pain and the diagnosis is usually made clinically or with transvaginal US. MR imaging may demonstrate the abscess as a high-signal-intensity mass on T1-weighted images when its contents are complicated. Strong perilesional enhancement of a thick wall is consistent with a tubo-ovarian abscess. 
Hematosalpinx appears as a tortuous enlarged tube filled with hemorrhagic fluid. 
Both Endometrioid and Clear cell tumors are common neoplasms associated with endometriosis. Multilocularity and mural foci or nodules in the hemorrhagic cyst are features associated with malignancy and shows contrast enhancement. A hyper intense cystic tumor on both T1- and T2- weighted images with enhancing mural nodules is often seen in cases of endometriosis complicated by ovarian carcinoma. 
Rupture and haemoperitoneum are more common complications of granulosa cell tumors than of other ovarian neoplasms. Yolk sac tumors often contain blood-filled spaces that are prone to rupture. 
Is symptomatic consisting of pain-killers, transfusions of platelets, intravenous immunoglobulins or prednisone [Prednisone is a steroid medication that decreases the effects of antibodies on platelets and eventually lowers antibody production].
-remove the spleen (splenectomy) 
Discourage rough contact sports or other activities that increase the risk of trauma and immunization against childhood diseases.