Presentation
Reason for exam: Abdominal pain, unspecified. History per chart review: Nulligravida with right breast invasive ductal carcinoma presents after controlled ovarian hyperstimulation and undergoing oocyte retrieval earlier in the day having two syncopal episodes.
Patient Data
There is moderate volume intraperitoneal fluid, some of which in the lower abdomen and pelvis measures higher attenuation.
The ovaries are enlarged and heterogeneous consistent with recent ovarian hyperstimulation. There is a focus of high attenuation contrast blush at the periphery of the right ovary that dissipates to the right on delayed phase. There is an additional blush of contrast in the periphery of the left ovary that is less prominent and is not definitely representative of active extravasation given that it is not well seen on the delayed phase.
Both ovaries are enlarged. The left measures 6.6 x 4.6 x 5.9 cm (92 mL volume). The right measures 7.2 x 5.6 x 6.9 cm (144 mL). Arterial flow to both ovaries is detected.
There is moderate volume free intraperitoneal fluid. There is layering echogenic hematoma anterior to the ovaries and uterus.
Case Discussion
This case demonstrates hemoperitoneum complicating oocyte retrieval, presenting as syncope. Imaging showed sentinel clot in the pelvis and active bleeding from the right ovary, on a background of ascites and ovarian enlargement related to iatrogenic ovarian hyperstimulation. As part of the syncope workup, in the setting of known malignancy, a CT pulmonary angiogram (not shown) was also obtained and negative for pulmonary embolism. Bloodwork showed an acute drop in hematocrit from 40% at preprocedure baseline to 33% on presentation and then serially declining to 26% over the next 12 hours.
Oocyte retrieval is an invasive component of assisted reproduction therapy, requiring ovarian puncture under transvaginal ultrasound guidance. Ovarian hemorrhage with hemoperitoneum is a rare complication but in severe cases may necessitate hospitalization, transfusion, or even surgical hemostasis 1. This patient was hospitalized for a day and treated with 4 units of packed red blood cells.
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