Ovarian hyperstimulation syndrome: Difference between revisions
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*Movement of fluid out of vasculature | *Movement of fluid out of vasculature | ||
**[[Ascites]] | **[[Ascites]] | ||
**Pleural effusions | **[[Pleural effusions]] | ||
**Pericardial effusion | **[[Pericardial effusion]] | ||
**[[Hypotension]] | **[[Hypotension]] | ||
*[[Electrolyte | *[[Electrolyte imbalances]] | ||
*[[DIC]] | *[[DIC]] | ||
*[[Thromboembolism]] | *[[Thromboembolism]] | ||
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==Differential Diagnosis== | ==Differential Diagnosis== | ||
*[[Ectopic Pregnancy]] | *[[Ectopic Pregnancy]] | ||
*Molar Pregnancy | *[[Molar Pregnancy]] | ||
*[[Sepsis]] | *[[Sepsis]] | ||
*[[PE]] | *[[PE]] | ||
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*Chem 10 | *Chem 10 | ||
*PT/PTT | *PT/PTT | ||
*Pelvic ultrasound | *[[Pelvic ultrasound]] | ||
*Consider: | *Consider: | ||
**[[CXR]] (rule out [[pleural effusion]]) | **[[CXR]] (rule out [[pleural effusion]]) | ||
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===Moderate=== | ===Moderate=== | ||
*[[IV fluids]] (e.g normal saline) | *[[IV fluids]] (e.g normal saline) | ||
* | *Therapeutic [[paracentesis]] if [[ascites]] (aspirate 0.5-4 L) | ||
*Thromboembolic prophylaxis (e.g. [[LMWH]]) | *Thromboembolic prophylaxis (e.g. [[LMWH]]) | ||
**All hospitalized patients | **All hospitalized patients | ||
Revision as of 14:27, 14 September 2019
Background
- Fertility treatments causing development of multiple follicles at once
- Fluid shifts out of vasculature
Clinical Features
- Ovarian enlargement
- Movement of fluid out of vasculature
- Electrolyte imbalances
- DIC
- Thromboembolism
- Both venous and arterial
- Hypervolemic hyponatremia
Differential Diagnosis
Acute Pelvic Pain
Gynecologic/Obstetric
- Normal variants may be noted on exam but generally do not cause pain or other symptoms
- Nabothian cysts: Epithelial cells within mucous glans that appear as yellow inclusions on the cervix
- Cervical Ectropion: Edothelial cells on the exterior of the cervix
- Parous cervix: The is no longer round but may have multiple shapes after birth
- Pregnancy-related
- Ectopic pregnancy
- Spontaneous abortion, threatened or incomplete
- Septic abortion
- Pelvic organ prolapse
- Acute Infections
- Vulvovaginitis
- Adnexal Disorders
- Hemorrhage/rupture of ovarian cyst
- Ovarian torsion
- Twisted paraovarian cyst
- Other
- Myoma (degenerating)
- Genitourinary trauma
- Ovarian hyperstimulation syndrome
- Sexual assault
- Recurrent
- Mittelschmerz
- Primary/Secondary Dysmenorrhea
- Pelvic Congestion Syndrome
- Endometriosis
Genitourinary
Gastrointestinal
- Gastroenteritis
- Appendicitis
- Bowel obstruction
- Perirectal abscess
- Diverticulitis
- Inflammatory bowel disease
- Irritable bowel syndrome
- Mesenteric adenitis
Musculoskeletal
- Abdominal wall hematoma
- Psoas hematoma, psoas abscess
- Hernia
Vascular
- Pelvic thrombophlebitis
- Abdominal aortic aneurysm
- Ischemic bowel (Mesenteric Ischemia)
Evaluation
Workup
- Urine pregnancy
- CBC
- Chem 10
- PT/PTT
- Pelvic ultrasound
- Consider:
- CXR (rule out pleural effusion)
- Cardiac ultrasound (rule out pericardial effusion)
- Progesterone level
- Estradiol level
- Fibrinogen (rule out DIC)
Evaluation[2].
| Classification | Clinical features | Lab findings |
| Mild |
|
Normal |
| Moderate | Above plus:
|
|
| Severe | Above plus:
|
|
| Critical | Above plus:
|
Worsening findings |
Management
Pregnant patients must be followed very closely, as they are likely to worsen
- Urgent GYN consultation for all
Mild
- Pain control
- Acetaminophen, Norco, or morphine
- Encourage oral fluids (1-2 liters/day)
- Ambulate, but avoid other physical activity. Avoid sexual intercourse
Moderate
- IV fluids (e.g normal saline)
- Therapeutic paracentesis if ascites (aspirate 0.5-4 L)
- Thromboembolic prophylaxis (e.g. LMWH)
- All hospitalized patients
- Outpatients with 2-3 risk factors:
- Age >35 years
- Obesity
- Immobility
- Personal or family history of thrombosis
- Thrombophilias
- Pregnancy
Severe
- As above + consider need to drain pleural or pericardial effusion
Critical
- As above + resuscitative care
Disposition
- Mild: outpatient
- Avoid heavy physical activity
- Return for
- Worsening abdominal pain
- Weight gain (>1 kg/day)
- Increasing abdominal girth
- Moderate: outpatient if close follow-up (discuss with GYN)
- Severe: admit
- Critical: ICU
Complications
- Ovarian torsion
- Venous thromboembolism
- Hydrothorax
- Pericardial effusion
- Arterial thrombosis
- Pulmonary embolism
- Sepsis
- Acute renal failure
- Acute respiratory distress syndrome (ARDS)
- Disseminated intravascular coagulation (DIC)
See Also
References
- ↑ Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
- ↑ Navot D, Bergh PA, Laufer N. Ovarian hyperstimulation syndrome in novel reproductive technologies: prevention and treatment. Fertil steril 1992; 58:249. From: Fiedler K, Ezcurra D. Predicting and preventing ovarian hyperstimulation syndrome (OHSS): the need for individualized not standardized treatment. Reprod Biol Endocrinol 2012; 10:32. Copyright © 2012 Fiedler and Ezcurra. Reproduced from BioMed Central Ltd