Classically, the woman with adnexal torsion complains of sharp lower abdominal pain with sudden onset that worsens intermittently over several hours. Th e pain usually is localized to the involved side, with radiation to the fl ank, groin, or thigh. Low-grade fever suggests adnexal necrosis. Nausea and vomiting frequently accompany the pain.
statistically significant correlation was found between plasma VEGF levels and certain biological characteristics of OHSS, and of capillary leakage such as leukocytosis with increasing VEGF levels
Chlorpromazine cyclizine diphenhydramine
worsening hypotension and its sequelae). Diuretics will increase blood viscosity and increase the risk of venous thrombosis,Diuretics should used in the management of pulmonary edema.
Stimulation Multiple follicles
Shift of fluid to
Pathophysiology Endo hCG
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
1. High number of medium/large follicles
2. High or rapidly rising E2 levels
Pregnancy (increase in endogenous hCG)
It occurs after 10 days oocyte retrieva
correlated to endogenous hCG produ
by implanting embryo.
Late OHSSEarly OHSS
It occurs within 9 days after
oocyte retrieval .
correlated to ovarian response to
exogenous hCG stimulation.
CriticalMild to moderate Severe
Mild to moderate OHSS
Mild to moderate abdominal pain
Tenderness in the area of ovaries
Rapid weight gain — 2.3 kilograms in one day
Severe, persistent nausea and vomiting
Sever abdominal pain
Shortness of breath
Acute renal failure
Arrhythmia(Electrolyte disturbances )
Rupture of a cyst in an ovary
Complete blood count (CBC) with differential:
Hematocrit- >55%(hemoconcentration )
Leukocyte count - >22,000 cells/µL is related to the seriousness
A positive result indicates pregnancy.
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
to assess the follicles
To measure the size of the ovaries
to evaluate ascites
may be indicated if dyspnea is present.
(follow up twice-weekly):
mild & moderate OHSS.
Inpatient management :
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
- 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.
- 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).
1.Fluids and electrolytes:
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
Treatment with diuretics (e.g., furosemide, 20 mg IV) may be
considered after an adequate intravascular volume has been
restored (hematocrit <38%).
Ascites with pain
Ascites compromised pulmonary function
oliguria/ anuria that does not improve
with appropriate fluid management
A transvaginal or transabdominal approach may be used,
under gentle ultrasound guidance
Replace plasma protein
Bilateral or severe pleural effusion
that persists after paracentesis
INTENSIVE CARE TREATMENT
adult respiratory distress syndrome
a ruptured cyst in the ovary
an internal hemorrhage
Laparoscopy(detorsion of ovaries )
Recognition of risk factors for OHSS
Ovulation induction regimens should be highly
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