This document discusses ovarian hyperstimulation syndrome (OHSS) and various ovarian emergencies. It describes the grading of OHSS from mild to severe based on clinical features and outlines preventive measures. Prevention of OHSS includes use of metformin in PCOS patients, cabergoline administration after retrieval, cryopreservation of all embryos, and coasting. Differential diagnosis, management, and prognosis of ruptured ovarian cysts, ectopic pregnancies, abscesses, and torsion are also covered.

1. OVARY &
EMERGENCY
LAKSHMI SUJANI.CH
Alluri Sitaramaraju Academy Of
Medical Sciences

2. OVARIAN
HYPERSTIMULATION
SYNDROME

3. GRADING OHSS
DEGREE GRADE CLINICAL FEATURES
MILD GRADE 1
GRADE 2
Abdominal distention, pain.
Vomiting ,diarrhea, ovary enlargement less than 5
cms, weight gain less than 3kg.
MODERATE GRADE 3 Mild OHSS + Ultrasound evidence of ascites,
electrolyte disturbances, ovarian size upto
10cms,weight gain of 10lbs.
SEVERE GRADE 4
GRADE 5
GRADE 6
Moderate OHSS + ovary size > 12cm, weight gain >
5kg.
Grade 4 + tense ascites, hydrothorax.
Grade 5 + haemoconcenteration , coagulation
abnormalities, renal dysfunction, respiratory failure

4. PREVENTION OF OHSS
Adjunctive use of metformin in
PCOS patient¹. (GRADE-A evidence)
Cabergoline : 0.5 mg daily x 7
days following retrieval². (GRADE A
evidence)
- dopamine antagoinst
- reduces VEGF production
- Long term use causes
valvular heart defect
¹Tso LO , Costello MF, Albuquerque LE , et al.Metformin treatment before and during IVF and ICSI in women with
PCOD. Cochraine database Syst Rev 2009;2;CD006105
² Garcia-Velasco JA. How to avoid ovarian hyperstimulation syndrome: a new indication for dopamine agonists.
Reprod Biomed Online 2009;18(Suppl 2): 71-75

5. PREVENTION OHSS
Cryopreservation of all
embryos without transfer
will prevent late onset
OHSS¹
(GRADE B evidence)
IN VITRO OOCYTE
MATURATION completely
obviates the need to
stimulate ovaries by
gonadotrophins.²
¹Aboulghar M. Symposium: update on prediction and management of OHSS. Reprod Biomed Online
2009;19:33-42
²Siristatidis CS, Maheshwari A, Bhattacharya S. Invitro maturation in subfertile women PCOD undergoing
assisted reproduction. Cochrane Database Syst Rev 2009;19:2005-2013

6. PREVENTION OHSS
COASTING is considered when
estradiol levels are less than
4500pg/ml and 15 to 30 mature
follicles are present .¹( level B evidence)
- Gonadotropin stimulation is withheld and
estradiol levels are checked daily
-patient is triggered when estradiol levels fall
below 3500pg/ml.
Alteration of trigger in high risk
patients.¹
LOW dose FSH use starting from
150IU.(grade A evidence)
Reintroduction of gonadodropin
antagonists following retrieval.¹
¹ Garcia-Velasco JA. How to avoid ovarian hyperstimulation syndrome: a new
indication for dopamine agonists. Reprod Biomed Online 2009;18(Suppl 2):
71-75

7. Reducing the risk of OHSS-what
does not work
Intravenous albumin.
(level A evidence)
Follicle aspiration.
(level A evidence )
Using recombinant LH
instead of HCG .
(level A evidence)
Using recombinant HCG
instead of urinary
HCG.(level A evidence)
NOTE: Usage of letrozole
is banned in india since
2011

8. PREDICTION OF OHSS
Estradiol
concenteration more
than 3500pg/ml at time
if trigger. (1.5% severe OHSS
risk)
More than 20
preovulatory follicles.
(15% severe OHSS risk)
Doppler changes

9. RUPTURE OVARIAN PREGNANCY
3% of ectopics &
most common non tubal ectopic.¹
Increased incidence in IUCD
users. 1 out of 9 ectopics in IUCD
users is ovarian ectopic.²
Not associated with PID or
infertility¹
Classical triad of pain, bleeding
and amenorrhoea absent in
ovarian ectopic.²
¹ Jonathan S. Berek. Berek & Novak’s Gynaecology,2012
²John A.Rock , Howard w. Jones . TeLinde’s OPERATIVE GYNECOLOGY.

10. Differential diagnosis hemoperitonium
with ovarian mass
ruptured ovarian
ectopic
ruptured luteal
hematoma
ruptured ovarian
endometrioma

11. Rupture ovarian cyst
• Traumatic rupture common
in functional cysts &
dermoid cyst.
• Spontaneous rupture in
rapidly growing ovarian
neoplasm.(mucious
epithelial neoplasms)
• Rupture corpus luteal cyst
dd.ovarian ectopic
- Hcg levels fall in ectopic
n not in lueteal cyst.
- D&C reveals chorionic
villi in corpus leuteal cyst.¹
¹John A.Rock , Howard w. Jones . TeLinde’s OPERATIVE GYNECOLOGY

12. Ruptured chocolate cyst
Diagnosed by a typical CT
picture showing,¹
Bilateral mutilocular
ovarian cysts with thick wall
Loculated ascites confined
to pelvic cavity
Pelvic fat infiltration.
HAS EXTREMELY HIGH
CA 125 LEVELS
MIMICKING
CARCINOMA.
¹Young Rae Lee, MD. CT Imaging Findings of Ruptured Ovarian Endometriotic
Cysts: Emphasis on the Differential Diagnosis with Ruptured Ovarian
Functional Cysts. Korean J Radiol. 2011 Jan-Feb; 12(1): 59–65.
Published online Jan 3, 2011. doi: 10.3348/kjr.2011.12.1.59

13. Rupture ovarian
abscess
Primary ovarian abscess is
rare however it can be life
threatening.(Wetcher and Dunn
, 1985)
Early surgical intervention
recommended to salvage
the ovary (Stubblefield,1991)
Even after proper periop
care, mortality is as high as
7.1 %.¹
Prescence of subphrenic pus and
bowel injury are poor prognostic
factors.¹
¹ROBERT G. FORMAN

14. Torsion ovarian cyst
→ 3% gynaecological
emergencies.¹
→ NORMAL VASCULARITY
DOESNOT EXCULDE
TORSION AS OVARY HAS
DUAL SUPPLY FROM
UTERINE AND OVARIAN
ARTERIES.¹
→ Inflammatory cysts and
malignant cysts rarely
undergo torsion due to
adhesions.²
¹ http://en.wikipedia.org/wiki/Ovarian_torsion²
²Jonathan S. Berek. Berek & Novak’s
Gynaecology,2012

15. Thankyo
u