SlideShare a Scribd company logo
CASE PRESENTATION
CASE PRESENTATION
Emergency hospital scenario
• Otherwise healthy, a 31 years old female
presents with:
– nausea and vomiting
– abdominal pain
– “difficulty taking a breath in”
Clinical examination:
• heart rate = 115 beats / minute
• “diffusely tender abdomen”
• bedside ultrasound: free fluid in Morrison’s
pouch (hepato-renal recess).
CASE PRESENTATION
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
Differential Diagnosis?
Differential Diagnosis?
• Ectopic pregnancy
• Ovarian torsion
• Ruptured/hemorrhagic cyst
• Appendicitis
• Pelvic Inflammatory Disease
• Sepsis
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
CASE PRESENTATION
• Most recently underwent oocyte retrieval, IVF
and embryo transfer 2 weeks prior.
• Most Likely Diagnosis????
OVARIAN
HYPERSTIMULATION
SYNDROME
OVARIAN
HYPERSTIMULATION
SYNDROME
Ovidiu Bedreag
”Victor Babes” University of Medicine and Pharmacy Timisoara
Anesthesiology and Intensive Care Department
Timisoara 2015
Intriguing definition of OHSS
• Iatrogenic complication (!) of “controlled” (?)
ovarian stimulation
• Potentially fatal (!)
• Risks factor
• Triggering mechanism of hCG (!)
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
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
Fatal OHSS
• 31 years old woman
• Ovarian stimulation
• Fatal adult respiratory distress syndrome
(ARDS)
Fineschi . Int J Legal Med 2006
Maternal death
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
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
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
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
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
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
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
OHSS Management.
Hospital admission
• intolerance of oral fluids
• vomiting or diarrhoea
• hypotension
• difficulty breathing, decreased breath sounds
• tense, distended abdomen or peritonism
• thromboembolic event
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
Treatment of OHSS
To date, there is no treatment that will shorten
the course of illness.
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
Workup in the Emergency Department
• FAST exam
• +/-ECG
• +/- CXR if examination suggestive of pleural
effusion/pneumonia etc.
• Formal Ultrasound (increased risk of
heterotopic pregnancy)
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
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
• 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
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.
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.
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
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!!
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)
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
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.
Pulmonary Complications
• Restrictive pattern of pulmonary dysfunction
secondary to combination of intra-abdominal
and pleural fluid accumulation
• Pneumonia
• ARDS
• Pulmonary embolism
Pulmonary Complications
• Pleural effusions should be drained if causing
symptoms
• Paracentesis will also improve pulmonary
restriction
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
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
Cursul National de
Ghiduri si Protocoale in
Anestezie, Terapie Intensiva si
Medicina de Urgenta
editia a XII-a
23-25 octombrie 2014
Ovarian Hyperstimulation Syndrome Case Presentation.pptx
Ovarian Hyperstimulation Syndrome Case Presentation.pptx

More Related Content

Similar to Ovarian Hyperstimulation Syndrome Case Presentation.pptx

The nursing care.pptx
The nursing care.pptxThe nursing care.pptx
The nursing care.pptx
ssuserc3993c
 
M1 f. kamwendo_-_hypertensive_disorders_in_pregnancy.ppt
M1 f. kamwendo_-_hypertensive_disorders_in_pregnancy.pptM1 f. kamwendo_-_hypertensive_disorders_in_pregnancy.ppt
M1 f. kamwendo_-_hypertensive_disorders_in_pregnancy.ppt
Spitalul Clinic Judetean de Urgenta Craiova
 
m1_f._kamwendo_-_hypertensive_disorders_in_pregnancy.ppt.pptx
m1_f._kamwendo_-_hypertensive_disorders_in_pregnancy.ppt.pptxm1_f._kamwendo_-_hypertensive_disorders_in_pregnancy.ppt.pptx
m1_f._kamwendo_-_hypertensive_disorders_in_pregnancy.ppt.pptx
Ogunsina1
 
Upper GIT Bleeding
Upper GIT BleedingUpper GIT Bleeding
Upper GIT Bleeding
Ali Najat
 
Lower gi cirrhosis - marques schwartz - feb 2014
Lower gi   cirrhosis - marques schwartz - feb 2014Lower gi   cirrhosis - marques schwartz - feb 2014
Lower gi cirrhosis - marques schwartz - feb 2014
Marques Schwartz
 
acutepancreatitis-160326205412.pdf
acutepancreatitis-160326205412.pdfacutepancreatitis-160326205412.pdf
acutepancreatitis-160326205412.pdf
HosamAlhussin
 
acute pancreatitis
acute pancreatitisacute pancreatitis
acute pancreatitis
ssn zhd
 
Obstetric good Emergencies and treatmentpptx
Obstetric good Emergencies and treatmentpptxObstetric good Emergencies and treatmentpptx
Obstetric good Emergencies and treatmentpptx
sanjay07vp
 
gastrointestinal bleeding.pptx
gastrointestinal bleeding.pptxgastrointestinal bleeding.pptx
gastrointestinal bleeding.pptx
DR Venkata Ramana
 
Pulmonery oedema in pregnancy case reporet
Pulmonery oedema in pregnancy case reporetPulmonery oedema in pregnancy case reporet
Pulmonery oedema in pregnancy case reporet
Waled Abohatab
 
Surgical emergencies in newborn
Surgical emergencies in newbornSurgical emergencies in newborn
Surgical emergencies in newborn
Abhijeet Deshmukh
 
Upper gi bleeding
Upper gi bleedingUpper gi bleeding
Upper gi bleeding
niteshpansari
 
uppergibleeding-150402032909-conversion-gate01.pdf
uppergibleeding-150402032909-conversion-gate01.pdfuppergibleeding-150402032909-conversion-gate01.pdf
uppergibleeding-150402032909-conversion-gate01.pdf
DakaneMaalim
 
Obstetrics Emergencies by Dr KD DELE
Obstetrics Emergencies by Dr KD DELEObstetrics Emergencies by Dr KD DELE
Obstetrics Emergencies by Dr KD DELE
Kemi Dele-Ijagbulu
 
HYPERTENSIVE DISORDER IN PREGNANCY (1).pptx
HYPERTENSIVE DISORDER IN PREGNANCY  (1).pptxHYPERTENSIVE DISORDER IN PREGNANCY  (1).pptx
HYPERTENSIVE DISORDER IN PREGNANCY (1).pptx
AjayHalder5
 
Hyperemesis gravidarum by ruhila
Hyperemesis gravidarum by ruhilaHyperemesis gravidarum by ruhila
Hyperemesis gravidarum by ruhila
ruhila bhat
 
Liver
LiverLiver
Liver
HI HI
 
Hyperemesis gravidarum and its management
Hyperemesis gravidarum and its managementHyperemesis gravidarum and its management
Hyperemesis gravidarum and its management
sunil kumar daha
 
Ohss
OhssOhss
1.hyperemesisgravidarum
1.hyperemesisgravidarum1.hyperemesisgravidarum
1.hyperemesisgravidarum
AhmedAdamMohamud
 

Similar to Ovarian Hyperstimulation Syndrome Case Presentation.pptx (20)

The nursing care.pptx
The nursing care.pptxThe nursing care.pptx
The nursing care.pptx
 
M1 f. kamwendo_-_hypertensive_disorders_in_pregnancy.ppt
M1 f. kamwendo_-_hypertensive_disorders_in_pregnancy.pptM1 f. kamwendo_-_hypertensive_disorders_in_pregnancy.ppt
M1 f. kamwendo_-_hypertensive_disorders_in_pregnancy.ppt
 
m1_f._kamwendo_-_hypertensive_disorders_in_pregnancy.ppt.pptx
m1_f._kamwendo_-_hypertensive_disorders_in_pregnancy.ppt.pptxm1_f._kamwendo_-_hypertensive_disorders_in_pregnancy.ppt.pptx
m1_f._kamwendo_-_hypertensive_disorders_in_pregnancy.ppt.pptx
 
Upper GIT Bleeding
Upper GIT BleedingUpper GIT Bleeding
Upper GIT Bleeding
 
Lower gi cirrhosis - marques schwartz - feb 2014
Lower gi   cirrhosis - marques schwartz - feb 2014Lower gi   cirrhosis - marques schwartz - feb 2014
Lower gi cirrhosis - marques schwartz - feb 2014
 
acutepancreatitis-160326205412.pdf
acutepancreatitis-160326205412.pdfacutepancreatitis-160326205412.pdf
acutepancreatitis-160326205412.pdf
 
acute pancreatitis
acute pancreatitisacute pancreatitis
acute pancreatitis
 
Obstetric good Emergencies and treatmentpptx
Obstetric good Emergencies and treatmentpptxObstetric good Emergencies and treatmentpptx
Obstetric good Emergencies and treatmentpptx
 
gastrointestinal bleeding.pptx
gastrointestinal bleeding.pptxgastrointestinal bleeding.pptx
gastrointestinal bleeding.pptx
 
Pulmonery oedema in pregnancy case reporet
Pulmonery oedema in pregnancy case reporetPulmonery oedema in pregnancy case reporet
Pulmonery oedema in pregnancy case reporet
 
Surgical emergencies in newborn
Surgical emergencies in newbornSurgical emergencies in newborn
Surgical emergencies in newborn
 
Upper gi bleeding
Upper gi bleedingUpper gi bleeding
Upper gi bleeding
 
uppergibleeding-150402032909-conversion-gate01.pdf
uppergibleeding-150402032909-conversion-gate01.pdfuppergibleeding-150402032909-conversion-gate01.pdf
uppergibleeding-150402032909-conversion-gate01.pdf
 
Obstetrics Emergencies by Dr KD DELE
Obstetrics Emergencies by Dr KD DELEObstetrics Emergencies by Dr KD DELE
Obstetrics Emergencies by Dr KD DELE
 
HYPERTENSIVE DISORDER IN PREGNANCY (1).pptx
HYPERTENSIVE DISORDER IN PREGNANCY  (1).pptxHYPERTENSIVE DISORDER IN PREGNANCY  (1).pptx
HYPERTENSIVE DISORDER IN PREGNANCY (1).pptx
 
Hyperemesis gravidarum by ruhila
Hyperemesis gravidarum by ruhilaHyperemesis gravidarum by ruhila
Hyperemesis gravidarum by ruhila
 
Liver
LiverLiver
Liver
 
Hyperemesis gravidarum and its management
Hyperemesis gravidarum and its managementHyperemesis gravidarum and its management
Hyperemesis gravidarum and its management
 
Ohss
OhssOhss
Ohss
 
1.hyperemesisgravidarum
1.hyperemesisgravidarum1.hyperemesisgravidarum
1.hyperemesisgravidarum
 

Recently uploaded

GIT BS.pptx about human body their structure and
GIT BS.pptx about human body their structure andGIT BS.pptx about human body their structure and
GIT BS.pptx about human body their structure and
MuzafarBohio
 
Know Latest Hiranandani Hospital Powai News.pdf
Know Latest Hiranandani Hospital Powai News.pdfKnow Latest Hiranandani Hospital Powai News.pdf
Know Latest Hiranandani Hospital Powai News.pdf
Dr. Sujit Chatterjee CEO Hiranandani Hospital
 
FACIAL NERVE
FACIAL NERVEFACIAL NERVE
FACIAL NERVE
aditigupta1117
 
Sectional dentures for microstomia patients.pptx
Sectional dentures for microstomia patients.pptxSectional dentures for microstomia patients.pptx
Sectional dentures for microstomia patients.pptx
SatvikaPrasad
 
NURSING MANAGEMENT OF PATIENT WITH EMPHYSEMA .PPT
NURSING MANAGEMENT OF PATIENT WITH EMPHYSEMA .PPTNURSING MANAGEMENT OF PATIENT WITH EMPHYSEMA .PPT
NURSING MANAGEMENT OF PATIENT WITH EMPHYSEMA .PPT
blessyjannu21
 
Sexual Disorders.gender identity disorderspptx
Sexual Disorders.gender identity  disorderspptxSexual Disorders.gender identity  disorderspptx
Sexual Disorders.gender identity disorderspptx
Pupayumnam1
 
Innovative Minds France's Most Impactful Healthcare Leaders.pdf
Innovative Minds France's Most Impactful Healthcare Leaders.pdfInnovative Minds France's Most Impactful Healthcare Leaders.pdf
Innovative Minds France's Most Impactful Healthcare Leaders.pdf
eurohealthleaders
 
DELIRIUM BY DR JAGMOHAN PRAJAPATI.......
DELIRIUM BY DR JAGMOHAN PRAJAPATI.......DELIRIUM BY DR JAGMOHAN PRAJAPATI.......
DELIRIUM BY DR JAGMOHAN PRAJAPATI.......
DR Jag Mohan Prajapati
 
一比一原版(EUR毕业证)鹿特丹伊拉斯姆斯大学毕业证如何办理
一比一原版(EUR毕业证)鹿特丹伊拉斯姆斯大学毕业证如何办理一比一原版(EUR毕业证)鹿特丹伊拉斯姆斯大学毕业证如何办理
一比一原版(EUR毕业证)鹿特丹伊拉斯姆斯大学毕业证如何办理
gjsma0ep
 
VEDANTA AIR AMBULANCE SERVICES IN REWA AT A COST-EFFECTIVE PRICE.pdf
VEDANTA AIR AMBULANCE SERVICES IN REWA AT A COST-EFFECTIVE PRICE.pdfVEDANTA AIR AMBULANCE SERVICES IN REWA AT A COST-EFFECTIVE PRICE.pdf
VEDANTA AIR AMBULANCE SERVICES IN REWA AT A COST-EFFECTIVE PRICE.pdf
Vedanta A
 
CHAPTER 1 SEMESTER V COMMUNICATION TECHNIQUES FOR CHILDREN.pdf
CHAPTER 1 SEMESTER V  COMMUNICATION TECHNIQUES FOR CHILDREN.pdfCHAPTER 1 SEMESTER V  COMMUNICATION TECHNIQUES FOR CHILDREN.pdf
CHAPTER 1 SEMESTER V COMMUNICATION TECHNIQUES FOR CHILDREN.pdf
Sachin Sharma
 
Management of Post Operative Pain: to make doctors conscious about the benefi...
Management of Post Operative Pain: to make doctors conscious about the benefi...Management of Post Operative Pain: to make doctors conscious about the benefi...
Management of Post Operative Pain: to make doctors conscious about the benefi...
Nilima65
 
Mental Health and Physical Wellbeing.pdf
Mental Health and Physical Wellbeing.pdfMental Health and Physical Wellbeing.pdf
Mental Health and Physical Wellbeing.pdf
shindesupriya013
 
R3 Stem Cell Therapy: A New Hope for Women with Ovarian Failure
R3 Stem Cell Therapy: A New Hope for Women with Ovarian FailureR3 Stem Cell Therapy: A New Hope for Women with Ovarian Failure
R3 Stem Cell Therapy: A New Hope for Women with Ovarian Failure
R3 Stem Cell
 
chatgptfornlp-230314021506-2f03f614.pdf. 21506-2f03f614.pdf
chatgptfornlp-230314021506-2f03f614.pdf. 21506-2f03f614.pdfchatgptfornlp-230314021506-2f03f614.pdf. 21506-2f03f614.pdf
chatgptfornlp-230314021506-2f03f614.pdf. 21506-2f03f614.pdf
marynayjun112024
 
Friendly Massage in Ajman - Malayali Kerala Spa Ajman
Friendly Massage in Ajman - Malayali Kerala Spa AjmanFriendly Massage in Ajman - Malayali Kerala Spa Ajman
Friendly Massage in Ajman - Malayali Kerala Spa Ajman
Malayali Kerala Spa Ajman
 
Monopoly PCD Pharma Franchise in Tripura
Monopoly PCD Pharma Franchise in TripuraMonopoly PCD Pharma Franchise in Tripura
Monopoly PCD Pharma Franchise in Tripura
SKG Internationals
 
nhs fpx 4000 assessment 4 analyzing a current health care problem or issue.pdf
nhs fpx 4000 assessment 4 analyzing a current health care problem or issue.pdfnhs fpx 4000 assessment 4 analyzing a current health care problem or issue.pdf
nhs fpx 4000 assessment 4 analyzing a current health care problem or issue.pdf
Carolyn Harker
 
一比一原版(USF毕业证)旧金山大学毕业证如何办理
一比一原版(USF毕业证)旧金山大学毕业证如何办理一比一原版(USF毕业证)旧金山大学毕业证如何办理
一比一原版(USF毕业证)旧金山大学毕业证如何办理
40fortunate
 
leprosy Case detection and diagnosis.pptx
leprosy Case detection and diagnosis.pptxleprosy Case detection and diagnosis.pptx
leprosy Case detection and diagnosis.pptx
habtegirma
 

Recently uploaded (20)

GIT BS.pptx about human body their structure and
GIT BS.pptx about human body their structure andGIT BS.pptx about human body their structure and
GIT BS.pptx about human body their structure and
 
Know Latest Hiranandani Hospital Powai News.pdf
Know Latest Hiranandani Hospital Powai News.pdfKnow Latest Hiranandani Hospital Powai News.pdf
Know Latest Hiranandani Hospital Powai News.pdf
 
FACIAL NERVE
FACIAL NERVEFACIAL NERVE
FACIAL NERVE
 
Sectional dentures for microstomia patients.pptx
Sectional dentures for microstomia patients.pptxSectional dentures for microstomia patients.pptx
Sectional dentures for microstomia patients.pptx
 
NURSING MANAGEMENT OF PATIENT WITH EMPHYSEMA .PPT
NURSING MANAGEMENT OF PATIENT WITH EMPHYSEMA .PPTNURSING MANAGEMENT OF PATIENT WITH EMPHYSEMA .PPT
NURSING MANAGEMENT OF PATIENT WITH EMPHYSEMA .PPT
 
Sexual Disorders.gender identity disorderspptx
Sexual Disorders.gender identity  disorderspptxSexual Disorders.gender identity  disorderspptx
Sexual Disorders.gender identity disorderspptx
 
Innovative Minds France's Most Impactful Healthcare Leaders.pdf
Innovative Minds France's Most Impactful Healthcare Leaders.pdfInnovative Minds France's Most Impactful Healthcare Leaders.pdf
Innovative Minds France's Most Impactful Healthcare Leaders.pdf
 
DELIRIUM BY DR JAGMOHAN PRAJAPATI.......
DELIRIUM BY DR JAGMOHAN PRAJAPATI.......DELIRIUM BY DR JAGMOHAN PRAJAPATI.......
DELIRIUM BY DR JAGMOHAN PRAJAPATI.......
 
一比一原版(EUR毕业证)鹿特丹伊拉斯姆斯大学毕业证如何办理
一比一原版(EUR毕业证)鹿特丹伊拉斯姆斯大学毕业证如何办理一比一原版(EUR毕业证)鹿特丹伊拉斯姆斯大学毕业证如何办理
一比一原版(EUR毕业证)鹿特丹伊拉斯姆斯大学毕业证如何办理
 
VEDANTA AIR AMBULANCE SERVICES IN REWA AT A COST-EFFECTIVE PRICE.pdf
VEDANTA AIR AMBULANCE SERVICES IN REWA AT A COST-EFFECTIVE PRICE.pdfVEDANTA AIR AMBULANCE SERVICES IN REWA AT A COST-EFFECTIVE PRICE.pdf
VEDANTA AIR AMBULANCE SERVICES IN REWA AT A COST-EFFECTIVE PRICE.pdf
 
CHAPTER 1 SEMESTER V COMMUNICATION TECHNIQUES FOR CHILDREN.pdf
CHAPTER 1 SEMESTER V  COMMUNICATION TECHNIQUES FOR CHILDREN.pdfCHAPTER 1 SEMESTER V  COMMUNICATION TECHNIQUES FOR CHILDREN.pdf
CHAPTER 1 SEMESTER V COMMUNICATION TECHNIQUES FOR CHILDREN.pdf
 
Management of Post Operative Pain: to make doctors conscious about the benefi...
Management of Post Operative Pain: to make doctors conscious about the benefi...Management of Post Operative Pain: to make doctors conscious about the benefi...
Management of Post Operative Pain: to make doctors conscious about the benefi...
 
Mental Health and Physical Wellbeing.pdf
Mental Health and Physical Wellbeing.pdfMental Health and Physical Wellbeing.pdf
Mental Health and Physical Wellbeing.pdf
 
R3 Stem Cell Therapy: A New Hope for Women with Ovarian Failure
R3 Stem Cell Therapy: A New Hope for Women with Ovarian FailureR3 Stem Cell Therapy: A New Hope for Women with Ovarian Failure
R3 Stem Cell Therapy: A New Hope for Women with Ovarian Failure
 
chatgptfornlp-230314021506-2f03f614.pdf. 21506-2f03f614.pdf
chatgptfornlp-230314021506-2f03f614.pdf. 21506-2f03f614.pdfchatgptfornlp-230314021506-2f03f614.pdf. 21506-2f03f614.pdf
chatgptfornlp-230314021506-2f03f614.pdf. 21506-2f03f614.pdf
 
Friendly Massage in Ajman - Malayali Kerala Spa Ajman
Friendly Massage in Ajman - Malayali Kerala Spa AjmanFriendly Massage in Ajman - Malayali Kerala Spa Ajman
Friendly Massage in Ajman - Malayali Kerala Spa Ajman
 
Monopoly PCD Pharma Franchise in Tripura
Monopoly PCD Pharma Franchise in TripuraMonopoly PCD Pharma Franchise in Tripura
Monopoly PCD Pharma Franchise in Tripura
 
nhs fpx 4000 assessment 4 analyzing a current health care problem or issue.pdf
nhs fpx 4000 assessment 4 analyzing a current health care problem or issue.pdfnhs fpx 4000 assessment 4 analyzing a current health care problem or issue.pdf
nhs fpx 4000 assessment 4 analyzing a current health care problem or issue.pdf
 
一比一原版(USF毕业证)旧金山大学毕业证如何办理
一比一原版(USF毕业证)旧金山大学毕业证如何办理一比一原版(USF毕业证)旧金山大学毕业证如何办理
一比一原版(USF毕业证)旧金山大学毕业证如何办理
 
leprosy Case detection and diagnosis.pptx
leprosy Case detection and diagnosis.pptxleprosy Case detection and diagnosis.pptx
leprosy Case detection and diagnosis.pptx
 

Ovarian Hyperstimulation Syndrome Case Presentation.pptx

  • 2.
  • 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
  • 7.
  • 8. Differential Diagnosis? • Ectopic pregnancy • Ovarian torsion • Ruptured/hemorrhagic cyst • Appendicitis • Pelvic Inflammatory Disease • Sepsis
  • 9.
  • 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????
  • 12.
  • 14. OVARIAN HYPERSTIMULATION SYNDROME Ovidiu Bedreag ”Victor Babes” University of Medicine and Pharmacy Timisoara Anesthesiology and Intensive Care Department Timisoara 2015
  • 15.
  • 16. Intriguing definition of OHSS • Iatrogenic complication (!) of “controlled” (?) ovarian stimulation • Potentially fatal (!) • Risks factor • Triggering mechanism of hCG (!)
  • 17.
  • 18.
  • 19.
  • 20.
  • 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
  • 29.
  • 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
  • 31.
  • 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
  • 35.
  • 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
  • 41.
  • 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
  • 54.
  • 55. Cursul National de Ghiduri si Protocoale in Anestezie, Terapie Intensiva si Medicina de Urgenta editia a XII-a 23-25 octombrie 2014