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deleted836128
I am an ER PA and had an ovarian cyst rupture case that concerned me. I can’t find a ton of literature on life threatening hemorrhage associated with this so I wanted to get some opinions. A few weeks ago I had a 30 year old female come in with an acute onset of abdominal and chest pain radiating into the shoulders, pleuritic in nature. When I saw her she was tachycardic (120), pale, diaphoretic, moaning. I barely grazed her abdomen and she screamed, guarded, and seemed near syncopal. The presentation gave me chills. I immediately told my attending, got her rushed to CT, notified radiologist to start looking for her scan, started fluids, hydromorphone, and cardiac monitoring. EKG confirmed sinus tachycardia. I CTed her chest (angiogram), abdomen and pelvis. While waiting for CT she passed out on a walk to the bathroom. CT showed free fluid in the pelvis and upper abdomen that looked like hemorrhage. Radiologist said ovarian cyst rupture most likely. Called GYN, she was in disbelief that all this blood could be from a cyst... she said “it could be from the stomach” (no free air noted on the CT) and asked for a pelvic US. Consulted surgery, they said this definitely sounded like an ovarian cyst and advised continued consultation with GYN. US confirmed a ruptured ovarian cyst with lots of likely blood in the pelvis. Good flow to ovaries. The patient’s hemoglobin dropped from 12.5 to 9.0 in two hours (I know serial H and H are sometimes not useful, however). She continued to be very tender. Called GYN, they evaluated her and said she was no longer tender (“her abdomen was benign” and wanted to go home. (?!) this surprised me because on six or seven abdominal examinations including one 15 minutes prior the patient was wincing, guarding, crying out. OB said this was typical of ovarian cysts. When I went back in the room she said she felt better and wanted to go home and eat food, and she was definitely tender. Still guarding and wincing/moaning when I pressed anywhere on her belly. Told GYN I was still concerned... brought her and my attending back in the room to show her my patient was still wincing in pain, GYN said if the patient didn’t want to stay she could go home. So did attending. I said I was concerned about the initial tachycardia, syncope in the department and continued peritoneal type tenderness despite multiple doses of narcotics, and that I was also concerned of continued bleeding. GYN laughed, said they all present this way and then they all the sudden look great. For the first time ever in my PA career I didn’t just listen to the attending and specialist (I know I know) and went back in the room and really tried to get the patient to stay just for observation. I did not yet feel comfortable sending her home. She continued to decline, saying she wanted to go and eat (usually a positive sign). I discharged her with strict return precautions and Percocet. On the way out she nearly passed out from severe recurrence of pain and vomited all over. Then asked to be admitted. I called GYN back and they were PISSED and basically said “this could have been prevented” although she wouldn’t clarify when asked what she meant.
When I went home and read up on this (surprisingly my usual Pepid, EMRAP, Medscape and Tintinalli don’t have as much info as I would like though) lead me to believe that significant life threatening hemorrhage from a ruptured ovarian cyst is uncommon, and that patients do often present like they’re dying with acute surgical abdomens like in this case. Question is, was I right to advocate for admission or was the OBGYN correct in this case? I only know a small fraction of what OBGYN and my ER attending know - they are physicians after all - but this is one of those cases that didn’t settle right in my gut.
When I went home and read up on this (surprisingly my usual Pepid, EMRAP, Medscape and Tintinalli don’t have as much info as I would like though) lead me to believe that significant life threatening hemorrhage from a ruptured ovarian cyst is uncommon, and that patients do often present like they’re dying with acute surgical abdomens like in this case. Question is, was I right to advocate for admission or was the OBGYN correct in this case? I only know a small fraction of what OBGYN and my ER attending know - they are physicians after all - but this is one of those cases that didn’t settle right in my gut.
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