Treatment of OHSS

1. Aboubakr Elnashar

2. Background
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3. Define
Systemic disease resulting from vasoactive products released by hyperstimulated ovaries.
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4. Pathophysiology
Inc cap permeability:
leakage of fluid from vas compartment:
- 3rd space fluid accumulation
-IV dehydration.
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5. Morbidity Thrombosis Renal& liver dysfunction ARDS Mortality
•True incidence: unknown
•Causes
1.ARDS
2.Cerebral infarction
3.Hepatorenal failure
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6. Incidence
•Mild: common, up to 33% of IVF Mod to Severe: 3–8% of IVF cycles
•Varies:
1.Treatments: IVF, CC, Gnt 2. Patient 3. Classification schemes
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7. Diagnosis
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8. Women at risk
1.Previous OHSS.
2.PCO
3.Young: <30 y
4.ART written information risks, symptoms, what action to take& a 24-h contact number with prompt access to a clinician 5. Ovarian stimulation written information. 6. Use of GnRHa 7. Exposure to LH/hCG 8. Development of multiple follicles during tt
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9. Fiedler and Ezcurra, 2012
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10. Based on cl criteria
Hx of ov stimulation followed by
Ab distension,
Ab pain,
N&V.
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11. DD
1.Complicated ov cyst (torsion, hge)
2.Pelvic infection,
3.Intra-abdominal hge,
4.Ectopic pregnancy
5.Appendicitis.
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12. Assessing severity
•Severity could worsen over time
•TT is guided by the severity
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13. Critical
Severe
Moderate
Mild
•Tense ascites
•Oligo/anuria
•Thromboembolism
•ARDS
• Ascites
•Oliguria
•Mod ab pain
•N± V
•Ab bloating
•Mild ab pain
Cl
•large hydrothorax
•±hydrothorax
•Ov›12 cm*
•Ascites
•Ov: 8–12 cm*
Ov: ‹8 cm*
US
•Hct›55%
•WCC›25 000/ml
•Hct ›45%
•Hypoproteinaemia
Lab
•ICU
•In pt
•Out pt
•In pt:
1.unable to
control pain
2.N with oral tt,
3.Difficulties in
monitoring
Out pt
TT
Mathur, 2oo5
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14. Aboubakr Elnashar

15. Types
Late
Early
After 9 d of HCG
Within 9 d of HCG
Endogenous HCG of early pregnancy.
Exogenous HCG
More severe& last longer
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16. Outpatient management Indications
1.Mild OHSS
2.Many of moderate OHSS.
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17. Assessment & monitoring I. Cl: Wt Ab girth US {ov size, ascites}.
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18. II. Lab:
1.Hgb
2.Hct
3.Serum creatinine
4.Liver function tests.
5.Electrolytes
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19. III. Review
/2–3 d
If pregnant: prolonged monitoring
If not pregnant: resolution by the time of the withdrawal bleeding.
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20. Treatment
I.Reassurance
II.Analgesia: Paracetamol or codeine NSAID should not be used {precipitate R failure by inhibiting R PG which maintains RBF despite hypovolemia}. III. Continue progesterone luteal support but hCG luteal support is inappropriate.
Aboubakr Elnashar

21. IV. Instruct the patient to
1.Drink to thirst, rather than to excess. Drink at least 1,000 ml of fluid per day 3 litres per day, in the form of protein rich drinks, eg. milk, if possible 2. Avoid: a. Strenuous exercise b. Sexual intercourse {fear of injury or torsion of hyperstimulated ovaries}. Complete bed rest (Increase DVT) 3. Urgent clinical review:
A.increasing severity of pain
B.increasing ab distension
C.shortness of breath
D.reduced u output. <1.01 (given 3 litre intake)/24 h
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22. Inpatient management
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23. Indications 1. Severe OHSS. keep under review until resolution. 2. Moderate OHSS
a.Unable to achieve control of pain
b.N with oral tt
c.Difficulties in monitoring
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24. Who should provide care to women with OHSS?
•Multidisciplinary care: Experienced in OHSS 1. Gynecologist 2. Intensivest
3.Anaesthesia
4.Medical
•Critical OHSS: intensive care.
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25. Assessment & monitoring
Investigations
His& Exam
•/4-8 H
Hct while titrating vol status
•Daily:
CBC (Hgb, hct, WCC)
Electrolytes
•Baseline
Liver function tests
Urea
Clotting studies
US: ascites, ov size
Chest X-ray or US (if res sym)
ECG& echocardiogram (if suspect pericardial effusion)
•/4H
V signs,
Intake& output
Pain
Breathlessness
•Daily
Wt
Ab girth
Ascites
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26. •Worsening OHSS:
1.Increasing: ab pain Wt gain girth 2. Breathlessness 3. Oliguria U output<1000 ml/d Persistent Positive fluid balance.
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27. •Severe pain Torsion, rupture or hge in the enlarged ovaries. Ectopic pregnancy.
•Haemoconcentration: measure of the severity of OHSS measured by raised hgb& hct.
•WCC increase: An ongoing systemic stress response.
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28. •Hyponatraemia: 55% of severe OHSS ±dilutional {ADH hypersecretion}.
•Oliguria 1/3 of severe OHSS {reduced R perfusion 2ndry to hypovolaemia or tense ascites} ARF is rare.
•Abnormal liver function tests: 1/3 of severe OHSS usually normalise with resolution of the disease.
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29. •Chest X-ray: Indication
1.Resp symptoms
2.Signs suggestive of hydrothorax, pulm infection or pulm embolism. Findings: increased size in the cardiac shadow, with the heart appearing globular or pear shaped.
•Chest US: diagnosis of hydrothorax.
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30. •ECG
Indication pulm embolism or pericardial effusion is suspected.
•Echocardiography confirms the diagnosis of pericardial effusion.
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31. Treatment I. Treatment of symptoms II Fluid balance 1. Oral intake: 2. IV crystalloids: 3. 1 liter N saline over 1h: 4. Colloids: 5. Paracentesis: III. Treatment of ascites or effusions IV. Thrompoprophylaxis V. Surgical tt
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32. I. Treatment of symptoms
1.Reassurance
2.Pain relief:
•Paracetamol
•Opiates: oral or parenteral. care should be taken to avoid constipation
•NSAID: not recommended {compromise R function}. 3. Antiemetics:
•Prochlorperazine
•Metoclopramide
•Cyclizine.
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33. II Fluid balance
1.Oral intake: Allowing women to drink acc to their thirst: {the most physiological approach, avoid risk of hypervolaemia& worsening ascites that may occur with vigorous IV therapy} Antiemetics & analgesics {enable to tolerate oral fluid intake satisfactorily}.
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34. 2. IV crystalloids:
•Where oral intake cannot be maintained Crystalloid of choice NS but D5NS can be given but not Ringer Fluid intake: 2–3 lit/24 h Guided by a strict fluid balance chart. Ringer=lactated Ringer {Nacl: 6.5 g, Kcl:0.42 g, Ca cl: 0.25 g, 1 mol of Na bicarbonate is dissolved in 1 liter of distilled water
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35. 3. 1 liter NS over 1h:
• Haemoconcentration (hgb>14g/dl, hct>45%) Assess change in Hct & u output response after 1 h: u output response is adequate & Hct normalizes: switch to IV D5NS & run at maintenance rate of 125-150 ml/h while closely monitoring input & output/4 h. Only NS should be used as infusion fluid {Hyponatraemia & hyperkalemia are typical of the synd} (McManus & McClure,2002)
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36. 4. Colloids:
•Indication Persistent haemoconcentration u output <0.5ml/kg/ h
•Human albumin, Hydroxyethylstarch (HES) Dextran Mannitol Haemaccel Few comparative data to support the use of any one of these over the other
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37. Human albumin (25%)
•200 ml at 50 ml/h over 4 hs. Hct /4 h Repeat until Hct is 36%-38% (Hopkins protocol)
•50–100 g is infused over 4 h Repeat at 4-12-h intervals as necessary to reverse haemoconcentration
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38. HES (6%): non-biological origin HES Vs Albumin higher M wt higher mean daily u output, fewer paracenteses shorter hospital stay Dose: 500ml infused over 4 h Repeat at 4-12-h intervals as necessary to reverse haemoconcentration. NB :In Egypt HES is available as HAES Sterile= HES(6%) in isotonic saline or Voluven 500 ml (68 EP)
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39. IV 500 ml 6% HES was given over 4 h then repeated/8 h
After 24 hour of HES the patient was evaluated
Vomiting & abdominal discomfort are improved
Bp: 120/75 puls: 76 Hct: 38%
Urine output within 24 h improved: 850ml =0.65 ml/kg/h
 U/S ascites is regressing
HES is continued for other 2 days
Urine output 24h:1L
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40. •Hyperkalemia (>5mEqu/L or tall peaked T waves in ECG): Calcium gluconate.
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41. 5. Paracentesis: Haemoconcentration &/or oliguria persist despite colloids
•Further fluid management guided by CVP monitoring Anesthetists should be involved.
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42. Diuretics
•Avoided {deplete IV volume}, oliguria {reduced bl vol &decreased R perfusion}
•Indication: rare Oliguria persists despite adequate rehydration& a normal intraabdominal pressure.
•Requirements
1.invasive haemodynamic monitoring
2.senior multidisciplinary involvement
3.usually after paracentesis
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43. III. Treatment of ascites or effusions Paracentesis Indication
1.Distress (significant discomfort or res embarrassment) due to abd distension
2.Oliguria persists despite adequate vol replacement {relief of intraabdominal pressure may promote R perfusion& improve u output}.
•Intraabdominal pressure: measured via a u catheter >20 mmHg suggestive of the need for decompression
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44. How?
1.US guidance {avoid puncture of vascular ovaries distended by large luteal cysts}. Transabdominal aspiration is better tolerated than vaginal. 2. Rate of ascitic fluid drainage should be controlled {avoid cardiovascular collapse from massive fluid shifts}, 3. Blood pressure& pulse should be monitored. 4. IV colloid replacement should be considered for women who have large volumes of ascitic fluid drained. 5. Repeated paracenteses may be avoided by the use of pigtail (that is used for nephrostomy) or suprapubic catheter that can be left in place.
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45. Hydrothorax Drainage of ascites alone may suffice to resolve hydrothorax Persistent symptomatic hydrothorax despite abdominal paracentesis: Direct drainage
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46. IV. Thromboprophylaxis
•Indications all women admitted to hospital.
•Duration At least until discharge from hospital& possibly longer, depending on other risk factors. -Not pregnant: discontinued with resolution of OHSS. -Pregnant: {The risk of thrombosis appears to persist into the first trimester of pregnancy} until the end of 1st trim, or even longer, depending on the presence of risk factors& course of the OHSS.
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47. How?
1.Full-length venous support stockings
2.Prophylactic heparin therapy. Heparin: 5000 u twice daily SC 3. Intermittent pneumatic compression device is helpful when symptoms prevent ambulation& confine the patient to bed.
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48. Thrombosis with OHSS
•Incidence 0.7% and 10% Sites: preponderance of upper body sites frequent involvement of the arterial system.
•Mechanisms
1.Haemoconcentration
2.Altered coagulation system
3.Reduced venous return {enlarged ovaries, ascites and immobility}
4.Personal or family history of thromboembolic events, thrombophilia or vascular anomalies.
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49. Suspicion Unusual neurological symptomatology following ovarian stimulation TT
1.If thromboembolism is suspected: Therapeutic anticoagulation Arterial blood gases Ventilation/perfusion scan.
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50. V. Surgical management Indications:
1.Adnexal torsion
2.Co-incident problems requiring surgery Torsion: Risk factor: Pregnancy Suspicion: Further ovarian enlargement Worsening particularly unilateral pain, N, leucocytosis& anemia. Diagnosis: Color Doppler assessment of ovarian blood flow TT: Laparoscopy or laparotomy: Untwisting of the twisted adnexa followed by observation of improved color: favorable prognosis for ovarian function.
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51. Risks associated with pregnancy& OHSS Data are inconclusive 1. Pregnancy may continue normally despite OHSS 2. No evidence of an increased risk of cong abnormalities. 3. High rates of miscarriage, PIH& PTL: not confirmed by controlled studies.
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52. Thank you
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53. Out patient management Indications: Mild OHSS Assessment & monitoring Cl: Wt, Ab girth, US {ov size, ascites}. Lab: Hgb, Hct, Serum creatinine, Liver function tests, Electrolytes Review: /2–3 d Treatment I. Reassurance II. Analgesia: Paracetamol or codeine III. Continue progesterone luteal support IV. Instruct the patient to 1. Drink to thirst, rather than to excess. Drink at least 1,000 ml of fluid/d 2. Avoid: Strenuous exercise, Sexual intercourse, complete bed rest 3. Urgent cl review: increasing severity of pain, abdominal distension, shortness of breath, reduced u output.
Aboubakr Elnashar

54. Inpatient management Indications: 1. Severe OHSS. 2. Moderate OHSS Assessment & monitoring Cl: /4H: V signs, Intake& output, Pain, Breathlessness Daily: Wt, Ab girth, Ascites Investigations /4-8 H: Hct while titrating vol status Daily: CBC (Hgb, hct, WCC), Electrolytes Baseline: Liver function tests, Urea, clotting studies, US: ascites, ov size, Chest X-ray or US (if res sym), ECG& echocardiogram (if suspect pericardial effusion) I. TT of symptoms Reassurance Pain relief: Paracetamol, Opiates: oral or parenteral. Antiemetics: Prochlorperazine, Metoclopramide, Cyclizine.
Aboubakr Elnashar

55. II Fluid balance 1. Oral intake: drink according to her thirst 2. IV crystalloids: Where oral intake cannot be maintained. Crystalloid of choice: NS but 5%dextrose saline can be given but not Ringer. Fluid intake: 2–3 L/24 h. Guided by a strict fluid balance chart. 3. 1L NS over 1h: indication: Haemoconcentration (hgb>14g/dl, hct>45%). Assess change in Hct & urine output response after 1 h 4. Colloids: Indication: Persistent haemoconcentration or u output <0.5ml/kg/ h. Human albumin (25%) 200 ml at 50 ml/h over 4 hs. Hct /4 h, Repeat until Hct is 36%-38%. 5. Paracentesis: indication Haemoconcentration &/or oliguria persist despite colloids
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56. III. TT of ascites or effusions: Paracentesis Indication: 1. Distress (significant discomfort or res embarrassment) due to abdominal distension. 2. Oliguria persists despite adequate vol replacement Direct drainage: Persistent symptomatic hydrothorax despite abdominal paracentesis IV. Thromboprophylaxis: Indication: all women admitted to hospital with OHSS. V. Surgical management Indications: Adnexal torsion, Co-incident problems requiring surgery
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