Management of ovarian hyperstimulation syndrome

1. CASE PRESENTATION

3. CASE PRESENTATION
Emergency hospital scenario
• Otherwise healthy, a 31 years old female
presents with:
– nausea and vomiting
– abdominal pain
– “difficulty taking a breath in”

4. Clinical examination:
• heart rate = 115 beats / minute
• “diffusely tender abdomen”
• bedside ultrasound: free fluid in Morrison’s
pouch (hepato-renal recess).
CASE PRESENTATION

5. CASE PRESENTATION
• Seric – Beta hCG + (205 IU/L)
• Hemoglobin - 169 (elevated)
• Platelets – 474.000/mm3 (elevated)
• WBC - 16.900/mm3 (elevated)
• electrolytes - Normal
• no Arterial Gases
• Creatinine level - Normal
• Urine Analysis = +++ ketones

6. Differential Diagnosis?

8. Differential Diagnosis?
• Ectopic pregnancy
• Ovarian torsion
• Ruptured/hemorrhagic cyst
• Appendicitis
• Pelvic Inflammatory Disease
• Sepsis

10. CASE PRESENTATION
Background medical history:
• 2.5 years of primary infertility
• Attending Fertility Clinic
• Clomifen x 3 cycles
• In-vitro Fertilization (IVF) for 1 cycle

11. CASE PRESENTATION
• Most recently underwent oocyte retrieval, IVF
and embryo transfer 2 weeks prior.
• Most Likely Diagnosis????

13. OVARIAN
HYPERSTIMULATION
SYNDROME

14. OVARIAN
HYPERSTIMULATION
SYNDROME
Ovidiu Bedreag
”Victor Babes” University of Medicine and Pharmacy Timisoara
Anesthesiology and Intensive Care Department
Timisoara 2015

16. Intriguing definition of OHSS
• Iatrogenic complication (!) of “controlled” (?)
ovarian stimulation
• Potentially fatal (!)
• Risks factor
• Triggering mechanism of hCG (!)

21. Risk factors
• Polycystic ovary syndrome
• Large number of follicles
• Young age
• Low body weight
• High or steeply increasing level of estradiol before
an HCG trigger shot
• Previous episodes of OHSS
• Migraine headaches
• A multiple pregnancy

22. Fatal OHSS
• 25 years old Japanese lady
• Bilateral chest pain - dyspnoea
• Pleural effusion
• Fatal after respiratory failure
• Autopsy - massive pulmonary edema
Semba. Patol Int 2000
Fatal

23. Fatal OHSS
• 31 years old woman
• Ovarian stimulation
• Fatal adult respiratory distress syndrome
(ARDS)
Fineschi . Int J Legal Med 2006
Maternal death

24. Maternal death
In the Netherlands (1984 – 2008)
• Death to OHSS : 3 / 100 000 IVF cycles
• Respiratory distress (n : 2)
• Cerebrovascular thrombosis (n : 1)
Braat. HR 2010

25. Maternal death
Figueroa-Casas. Extraordinary ovarian reaction to
gonadotropins: fatal case. Ann Circ (Rosario): 23: 116, 1958
Schenker , Weinstein et al. Ovarian hyperstimulation syndrome:
a current survey. Fertil Steril 30: 255, 1978
Fineschi et al. An immunohistochemical study in a fatality due to
ovarian hyperstimulation syndrome. Int J Legal Med 120: 293,
2006
Madill et al. Ovarian hyperstimulation syndrome: a potentially
fatal complication of early pregnancy. J Emerg Med 35: 283,
2008

26. At random citations
• OHSS is difficult to predict, but multiple
preventive strategies and protocols are
being developed that may limit it
Patchava Minerva Ginecol 2009
• Ovarian stimulation carries a marked risk
for … ovarian hyperstimulation syndrome
Kallen Best Pract Res Clin Obstet Gynaecol 2008

27. At random citations (continued)
• Low dose hCG at the end of the follicular
phase
Nargund. RBO 2007
• Preventive administration of IV fluid
Youssef Cochrane Database Syst Rev 2011
• Continuous vaginal and thoracic fluid
drainage for management of severe
ovarian hyperstimulation syndrome
Ceyhan. Gynecol Endocrinol 2008

28. At random citations (continued)
• Severe ovarian hyperstimulation syndrome : an
intensive care disease
Humeeus . Rev Med Chil 1998
• Coasting no benefit
D’Angelo . Cochrane Database Syst Rev 2011
• Dopamine antagonist significant reduction
(DOSTINEX)
Sherwal. J Human Reprod Sci 2010
Obstetrical outcome

30. Tests and diagnosis
• Physical exam:
– weight gain
– increases in waist size
– abdominal pain
• Pelvic and abdominal ultrasound:
– ovaries bigger than normal
– large fluid-filled cysts where follicles developed
• Blood tests:
– blood concentration, kidney function

32. Complications
• Fluid collection in the abdomen + the chest
• Electrolyte disturbances (sodium, potassium)
• Blood clots in large vessels, usually in the legs
• Kidney failure
• Twisting of an ovary
• Rupture of a cyst in an ovary - serious bleeding
• Breathing problems
• Pregnancy loss
• Rarely, death

33. OHSS Management.
Hospital admission
• intolerance of oral fluids
• vomiting or diarrhoea
• hypotension
• difficulty breathing, decreased breath sounds
• tense, distended abdomen or peritonism
• thromboembolic event

34. OHSS Management.
Intensive care admission
• Renal failure (oligoanuria) or failure to respond to fluid
management or paracentesis as patient may require
dialysis
• Respiratory failure not responding to diuresis or
paracentesis, patient may require ventilation
• Clinical appearance of acute respiratory distress syndrome
(ARDS)
• Thromboembolism
• Tense ascites or large hydrothorax
• Haematocrit > 55%
• WCC > 25,000/ml

36. Treatment of OHSS
To date, there is no treatment that will shorten
the course of illness.

37. Treatment of OHSS
• Most cases are managed as outpatients
• ASK: can they keep themselves hydrated
orally? Will they be able to cope at home?
• Often will only need simple IV rehydration,
analgesics and anti-emetics in the Emergency
Department prior to discharge

38. Workup in the Emergency Department
• FAST exam
• +/-ECG
• +/- CXR if examination suggestive of pleural
effusion/pneumonia etc.
• Formal Ultrasound (increased risk of
heterotopic pregnancy)

39. OHSS Management
• Supportive management:
– Prevention of thromboembolism (TE)
– Hydration
– Drainage of ascites
– Pain relief
OVARIAN HYPERSTIMULATION SYNDROME (OHSS) DIAGNOSIS AND MANAGEMENT.
Institute of Obstetricians and Gynaecologists, Royal College of Physicians of Ireland.
Revision date: April 2014

40. Prevention of thromboembolism (TE):
- thromboembolic deterrent stockings
- prophylactic anticoagulant therapy with low
molecular weight heparin
OHSS Management
OVARIAN HYPERSTIMULATION SYNDROME (OHSS) DIAGNOSIS AND MANAGEMENT.
Institute of Obstetricians and Gynaecologists, Royal College of Physicians of Ireland.
Revision date: April 2014

42. • A challenge due to the porous nature of the vascular
bed
• Drink to thirst rather than to excess
• If cannot tolerate oral fluids, intravenous (IV) fluids
such as normal saline should be commenced
• The volume should be titrated using the hematocrit as
indicator of the state of hydration
• Excess i.v. fluids could make the condition worse.
• Constant monitoring of the input/output balance is
mandatory.
OHSS Management. Hydration

43. OHSS Management. Hydration
• Diuretics are contraindicated in case of
haemoconcentration
• Diuretics can be used only where renal output
is decreased on a background of normal
haematocrit.
• Women with severe haemoconcentration (Hb
>14g/dl); Htc >45%) require a bolus of 500 ml
fluids intravenous (IV) on admission.

44. OHSS Management. Hydration
Albumin
• administration should be kept for a later stage,
• in case of hypo-albuminaemia
• administration is important during drainage of
ascites.
• daily dose: 25 - 75g (100 – 300 ml) per day
according to the severity of hypoalbuminaemia
and the total volume of ascetic fluid drained.

45. Treatment of Complications
Ovarian enlargement:
• Grade III ovarian cysts are extremely large and
brittle
• Recommended surgery avoided unless torsion
or rupture with hemorrhage
• In the 50s, attempts at cystectomy would
inevitably lead to oophorectomy

46. Treatment of Complications
Ascites:
• Initial weight gain of >3kg following hCG
admin is a warning that OHSS is developing
• Women can gain as much as 20kg over 5
days!!

47. Treatment of Complications
Ascites
Leads to multitude of complications
• Pain (can be severe)
• Hypovolemia
• Decrease diaphragmatic excursion
• Compression of Renal Vessels (essentially
abdominal compartment syndrome)

48. Paracentesis
• Effect of paracentesis of ascitic fluids on
urinary output and blood indices in patients
with severe ovarian hyperstimulation
syndrome.
Ishai Levin, Benny Almog, Amiram Avni, Amiram Baram, Joseph
B. Lessing, Ronni Gamzu. Fertility and Sterility 2002 77: 986

49. Paracentesis
• Practice locally is to perform paracentesis in
patients complaining of dyspnea, or pain with
tense ascites.
• Similar to ascites in liver disease, patients feel
good for a short time, prior to reaccumulation.

50. Pulmonary Complications
• Restrictive pattern of pulmonary dysfunction
secondary to combination of intra-abdominal
and pleural fluid accumulation
• Pneumonia
• ARDS
• Pulmonary embolism

51. Pulmonary Complications
• Pleural effusions should be drained if causing
symptoms
• Paracentesis will also improve pulmonary
restriction

52. Thromboembolic Events
• Recommended that moderate-severe OHSS should
receive prophylaxis for 1-2 months beyond the
resolution of symptoms (Chan, 2009)
• Guidelines - low dose ASA from start of cycle until
pregnancy confirmed or OHSS subsides
• Admitted patients or those requiring paracentesis
receive LMWH prophylaxis
• Confirmed DVT/PE treated with LMWH

53. CONCLUSION
• Ovarian Hyperstimulation Syndrome occurs
most commonly in patients undergoing IVF
• May see 1-2 per month in the Emergency Dept.
• Severe cases can present with tense ascites,
hypovolemic shock and thromboembolic
events.
• Treatment is largely supportive care

55. Cursul National de
Ghiduri si Protocoale in
Anestezie, Terapie Intensiva si
Medicina de Urgenta
editia a XII-a
23-25 octombrie 2014