Endometriosis is a well established cause of female infertility and may be associated with early pregnancy losses. Association of endometriosis with pregnancy is rare. Ruptured endometriotic cyst presenting as acute abdomen in pregnancy is even a rarer presentation. We present hereby a rare and interesting case, presented in our hospital, of Spontaneous rupture of endometiotic Cyst in 3rd trimester of pregnancy and its subsequent management.

1. Spontaneous rupture of en
ndometrio
pregnancy
of p
otic cyst i
y
in 3rd trimester

2. Apollo Medicine 2012 September
Volume 9, Number 3; pp. 246e248 Case Report
Spontaneous rupture of endometriotic cyst in 3rd trimester
of pregnancy
Sarat Battinaa,*, Bhushan Ramesh Murkeyb, Shiva Singh Shekhawatc
ABSTRACT
Endometriosis is a well established cause of female infertility and may be associated with early pregnancy losses.
Association of endometriosis with pregnancy is rare. Ruptured endometriotic cyst presenting as acute abdomen in
pregnancy is even a rarer presentation.
We present hereby a rare and interesting case, presented in our hospital, of Spontaneous rupture of endometiotic
Cyst in 3rd trimester of pregnancy and its subsequent management.
Copyright © 2012, Indraprastha Medical Corporation Ltd. All rights reserved.
Keywords: Rupture of endometriotic cyst, 3rd trimester of pregnancy, Endometrioma
INTRODUCTION
Endometriosis is an enigmatic disease mostly seen in
women in their reproductive period. It is a fascinating entity
because of diverse clinical presentation and discordance
between severity of lesions and symptoms. It is a well
established cause of female infertility (15e25% incidence)1
and may be associated with early pregnancy losses. Not
much data is available regarding its coexistence or associa-tion
with more advanced pregnancy.
CASE REPORT
d Mrs JS, 28 year old lady, first visit in July 2010. She was
married for 3 years and was anxious to conceive. Cycles
were regular, average flow, associated with severe
dysmenorrhea. H/O Bronchial Asthma since childhood,
no H/O of any other major medical illness. In surgical
past history, she had H/O acute pain abdomen and vom-iting
in Jan 2008 for which she visited her doctor and an
Emergency Laparoscopy was done in view of sus-pected
torsion of ovary/suspected ruptured chocolate
cyst/suspected Rare possibility ovarian abscess. Opera-tive
findings were: Omentum fixed to the pelvic cavity.
Uterus, tubes and ovaries could not be made out clearly.
Pus aspirated and peritoneal lavage done.
Husband e Mr. S, 29 yrs old. No H/O any major medical
or surgical illness. No H/O smoking/alcohol. No H/O any
drug intake. No H/O retrograde ejaculation. Normal sexual
life. Husband Semen Analysis: Normozoospermia.
TVS (July2010): Uterus Normal size, anteverted, Endo-metrial
thickness e 7 mm. Right Ovary contained
a cyst 6.8 4.6 cm with low level internal echoes. Left
Ovary contained a cyst e 5.0 4.7 cm with low level
internal echoes. Both ovaries adherent to each other sugges-tive
of Bilateral Endometriotic cysts.
d In view of previous laparoscopy findings and anticipated
pelvic adhesions decided to go ahead with ART (IVF/
ICSI) instead of laparoscopy.
d In viewof large endometriomas, Ultrasound guided aspi-ration
of endometriotic cysts was done first in August
2010. Decided to put her on ultra long protocol for ICSI.
d Inj Zoladex 3.6 mg sc monthly were given for 3 doses
and decided to review in November 2010 with TVS
report for ultra long protocol for ICSI.
aHOD, bRegistrar, cSenior Resident, Apollo Hospitals, Chennai 600006, India.
* Corresponding author. email: drsarat_b@apollohospitals.com
Received: 5.6.2012; Accepted: 2.7.2012; Available online: 7.7.2012
Copyright 2012, Indraprastha Medical Corporation Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.apme.2012.07.006

3. Spontaneous rupture of endometriotic cyst Case Report 247
d But patient returned in Jan 2011.
d TVS (Jan2011): Right ovaryea cyst measuring
6.4 4.5 cm with low level internal echoes and one
small follicle. Left ovary e cysts measuring
3.8 3.7 cm and 1.7 1.4 cm filled with internal
echoes and a clear cyst measuring 3.0 1.9 cm and
one follicle. Imp: Bilateral Endometriotic cysts.
d Ultrasound guided aspiration of the endometriotic cysts
was done again.
d As patient reported late and started mensturating again,
patient was put on long protocol for ICSI
d Repeat ultrasound guided aspiration of the endo-metriotic
cysts was done on the day 3 of the cycle.
16 oocytes retrieved, 13 oocytes were of good quality.
All were inseminated. 13 good quality embryos were ob-tained.
3 embryos transferred. 10 embryos frozen
d She conceived in first cycle of ICSI.
d The early pregnancy (at 7 wk gestation) e Transvaginal
ultrasound showed a Heterotopic pregnancy
The left tubal pregnancy aborted spontaneously at 8 wk
gestation.
First Trimester Screening was normal. First trimester
scan e Menstrual age e 12 wk 2 days, Gestational age e
11 wk 2 days. Cystic structure suspected endometriotic cyst
in right adnexa 9.3 6.3 cm. Placenta e posterior and is
covering the internal os. Nuchal translucency e 1.2 mm.
At 15 wk þ 4 days e Cyst measuring 7.8 5.6 cm per-sisted
in right adnexa. Placenta e posterior and covering
the internal os (she remained asymptomatic for both).
GTT Fasting 80 mg/dl 1 hr 192 mg/dl, 2 hr 205 mg/dl. Dia-betologist
opinion sought and she was started on Insulin.
d Second trimester scan e No anomaly detected in fetus
but continued to have complete Placenta Previa and
Endometriotic cyst e 7.7 5.1 cm. All other parame-ters
were within normal limits.
d Her pregnancy faired well till 29 wk gestation.
Suddenly, she presented in the labor room at 3AMwith c/o
acute pain abdomen since 1 h. No H/O bleeding or leaking per
vaginum, No H/Odysuria or fever, No H/Odischarge per vag-inum,
NoH/Ofall or trauma, Perceiving fetalmovementswell.
General condition was fair, Hydration adequate, Temp e
98.4 F, PR e 82/min, regular, good volume, BP e 130/
90 mm of Hg. No pallor/icterus/cyanosis. Mild pedal edema
was present. RS e B/L NVBS heard, CVS e S1,
S2 þ CNS e No focal neurological deficit. Per Abdomen e
Fundal height : 28e30 week gestation, suspected longitudinal
lie, Mild contractions present, FHSþ/regular/good. No leak-ing
or bleeding per vaginum. Inj. Betamethasone 12 mg im
given. Continuous CTG monitoring was done. Vitals were
monitored. She was kept NBM, was Catheterized. Preterm
labor was suspected provisionally. Ultrasound showed e
Single live intrauterine gestation 29e30 wk, Breech,
Complete placenta previa, AFI 10.5. A 11 7 cm heteroge-nous
echogenic lesion extending to either adnexa with no color
uptake. Impressione?haemorrhagic/suspected endometriotic
cyst/suspected torsion of cyst.
d Patient continued to have pain with increased intensity
and FHR showed decelerations at 11:45 AM.
d Decided to take up for Emergency LSCS in view of
suspected abruptio placenta. Per Operative Findings
were Massive intraperitoneal bleeding was present.
Central placenta previa. Liquor e Clear. Baby delivered
as breech, didn’t cry at birth, handed over to pediatrician,
could not be resuscitated. Ruptured left ovarian endo-metrioma
adherent to the posterior wall of the uterus.
Raw bleeding areas were present at the posterior
surface of the uterus, same cauterized. Hemostasis was
ensured. 3 units of PRCs transfused preoperatively.
She was shifted to ICU where patient was put on venti-lator.
1 unit of PRC and 4 units of FFP transfused. CBC,
renal functions and coagulation profile done. HB e
9.9 gm% .Other investigations and coagulation profile
was WNL. Hematologist opinion taken.
Post operative day 1 e Patient extubated, NBM, Urine
output adequate, HB 7.8 gm%, TLC 28,000, DIC profile
normal.
Post operative day 2 e Shifted to the ward. Orally
allowed, Foleys removed, Dressing was changed. Pallor
was present. Mobilized out of the bed.
Post operative day 3 e Repeat Hb e 6.3 gm%. Two
units of PRCs transfused. Patient improved symptomati-cally.
Her Hb became 9.6 gm%. She was discharged on
post operative day 5.
DISCUSSION
Association of endometriosis with pregnancy is rare.
Ruptured endometriotic cyst presenting as acute abdomen
in pregnancy is even a rarer presentation.1
Pregnancy is known to favor retrogression of endometri-osis.
In fact endometriosis has been linked with female
infertility (15e25% incidence)2 and recurrent pregnancy
looses (38e52 L Pittway, Groll).3
Possible causes of rupture:
- Increasing pressure by the fluid inside the cyst
- Adhesions causing increased tension as the uterus
enlarges and its anatomical position is altered
- Decreased abdominal space as pregnant uterus
occupies the abdomen and cyst ruptures
- Increased blood flow during pregnancy can induce
enlargement of cyst and perhaps bleeding into the
cyst itself and eventually rupture
- Secondary to softening of lesion due to stromal
decidualisation.

4. 248 Apollo Medicine 2012 September; Vol. 9, No. 3 Battina et al.
Hence it poses a diagnostic problem when it coexists
with advanced pregnancy. As signs of ruptured endometri-otic
cyst are not localized to lower abdomen with advanced
pregnancy, the acute abdomen is often attributed to surgical
causes like appendicitis etc. Hence, in our patient also, we
could only diagnose this entity intraoperatively followed by
histopathological confirmation.
CONFLICTS OF INTEREST
All authors have none to declare.
REFERENCES
1. Puri M, Jain S, Thomas S, Trivedi SS. Acute abdomen in preg-nancy
e ruptured endometrioma e a rare cause. Indian J Med
Sci. 2000;54:246e248.
2. Bie Nkiewicz A, Kazimierak W. Spontaneous rupture of an
endometriotic cyst in pregnancy near term. Ginekol Pol.
1996;67:160e162.
3. Bulot F, Eroukhnanoff P. Rupture of an edometriotic
cyst during pregnancy (letter). Presse Med. 1991;20:1786.

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