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ovarian hyperstimulation syndrome


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etiology,pathophysiology,clinical presentation

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ovarian hyperstimulation syndrome

  1. 1. Ovarian Hyperstimulation Syndrome (OHSS) Prepared By: Hemin Jamal
  2. 2. Definition  Ovarian hyperstimulation syndrome (OHSS) is an exaggerated response to ovulation induction therapy
  3. 3. Causes  Fertility drugs  Injections  Gonadotropins( anovulation and ovarian stimulation)  Human chorionic gonadotropin(maturation of egg)  Gonadotropin-releasing hormone(to suppress the LH surge)  Oral  Clomiphene citrate (anovulation and ovarian stimulation)
  4. 4.  Spontaneous OHSS (without medication)  Hydatiform mole  multiple pregnancy  Hypothyroidism
  5. 5. F F F F F F F F F F F Stimulation Multiple follicles VEGF VEGF VEGF VEGF VEGF Bloodvessel Ovary enlargement t Production of VEGF Increase permeability Shift of fluid to 3rd space edema ascites Effects Risk factors Pathophysiology Endo hCG Upregulate F F F F F F F Mature Mature Mature Mature Mature VEGF Mature
  6. 6. Risk factors Primary risk factors (patient-related): 1. Young age 2. Previous OHSS 3.polycystic ovary syndrome (PCOS) 4.Low body weight Secondary risk factors ( ovarian response related); On day of hCG trigger: 1. High number of medium/large follicles 2. High or rapidly rising E2 levels Pregnancy (increase in endogenous hCG)
  7. 7. Clinical presentation  It occurs after 10 days oocyte retrieva  correlated to endogenous hCG produ by implanting embryo. Onset Late OHSSEarly OHSS  It occurs within 9 days after oocyte retrieval .  correlated to ovarian response to exogenous hCG stimulation.
  8. 8. Clinical presentation Severity CriticalMild to moderate Severe
  9. 9. Mild to moderate OHSS  Mild to moderate abdominal pain  Abdominal bloating  Nausea  Vomiting  Diarrhea  Tenderness in the area of ovaries
  10. 10. Severe OHSS  Rapid weight gain — 2.3 kilograms in one day  Severe, persistent nausea and vomiting  Sever abdominal pain  Shortness of breath  Dark urine  Dizziness/syncope  Hemodynamic instability  Edema  Ascites
  11. 11. Critical  Acute renal failure  Arrhythmia(Electrolyte disturbances )  Thromboembolism(hemoconcentration)  Pericardial effusion  Massive hydrothorax  Adult RDS  Ovarian torsion  Rupture of a cyst in an ovary
  12. 12. Diagnosis Laboratory investigations:  Complete blood count (CBC) with differential:  Hematocrit- >55%(hemoconcentration )  Leukocyte count - >22,000 cells/µL is related to the seriousness of OHSS  Beta-hCG concentration  A positive result indicates pregnancy.
  13. 13.  Estradiol levels  Estradiol levels are increased  estradiol >2000 pg/mL  Complete metabolic panel  Liver function test: AST, ALT , and ALP  Renal function test: blood urea and creatinine  Albumin and protein levels are decreased.  Electrolyte imbalances: hyperkalemia and acidosis may be present.
  14. 14. Imaging  Ultrasonography  to assess the follicles  To measure the size of the ovaries  to evaluate ascites  Chest radiography  may be indicated if dyspnea is present.
  15. 15. Treatment Outpatient management (follow up twice-weekly):  mild & moderate OHSS.  Severe OHSS Inpatient management :
  16. 16. Conservative  Education  Fluid: the patient should receive plenty of of fluid (not less than 1 liter).  Activity: the patient should avoid vigorous activities  Weight: should be recorded daily,  urine output: the frequency and/or volume
  17. 17.  Pain relief: - Symptomatic relief of abdominal pain can be achieved with acetaminophen and if necessary oral or parenteral opiates.  Nausea and/or vomiting Antiemetic agents considered to be safe in early pregnancy should be used to alleviate nausea and/or vomiting.
  18. 18. - Hospitalized patients should be considered at risk of thrombosis secondary to hemo-concentration and immobilization. - Full-length venous support stockings are recommended Daily prophylactic doses of low-molecular weight heparin (e.g., dalteparin sodium 5000 IU/day). Thromboprophylaxis:
  19. 19. 1.Fluids and electrolytes:  Hypovolemia correction  Rapid initial hydration may be accomplished with a bolus of IV fluid (500–1,000 mL). normal saline is preferable to lactated Ringer’s solution.  Albumin (25%) in doses of 50–100 g, infused over 4 hours and, is an effective plasma expander when infusion of normal saline fails
  20. 20.  Volume overload Treatment with diuretics (e.g., furosemide, 20 mg IV) may be considered after an adequate intravascular volume has been restored (hematocrit <38%).  Hyperkalemia  calcium gluconate  insulin  sodium bicarbonate  Kayexelate
  21. 21. 2.Paracentesis  Indication  Ascites with pain  Ascites compromised pulmonary function  oliguria/ anuria that does not improve with appropriate fluid management  Procedure  A transvaginal or transabdominal approach may be used, under gentle ultrasound guidance  Replace plasma protein
  22. 22. 3- Pleuracentesis:  Bilateral or severe pleural effusion that persists after paracentesis INTENSIVE CARE TREATMENT renal failure thromboembolism adult respiratory distress syndrome
  23. 23. surgery  Indications  ovarian torsion  a ruptured cyst in the ovary  an internal hemorrhage  Approach  Laparoscopy(detorsion of ovaries )  Laparotomy  Preserve ovaries
  24. 24. prevention  Recognition of risk factors for OHSS  Ovulation induction regimens should be highly individualized  Use the minimum dose and duration of gonadotropin therapy necessary to achieve the therapeutic goal.  Monitoring(E2 and ultrasoography) and prophylactic treatment with volume expanders