Ovarian hyperstimulation syndrome: Difference between revisions
 
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==Background==
==Background==
*Fertility treatments causing development of multiple follicles at once
*Fertility treatments causing development of multiple follicles at once
*Fluid shifts out of vasculature
**Exaggerated ovarian response to ovulation induction (esp in IVF when HCG is used to stimulate)
*Fluid shifts out of vasculature (third spacing)
*Typically 5-10d after 1st dose
*Ranges in severity from mild to severe multiorgan dysfunction, relating in part to massive intravascular fluid shifts


==Clinical Features==
==Clinical Features==
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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 Imbalances]]
*[[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]]
*[[Pulmonary embolism in pregnancy]]


{{Pelvic pain DDX}}
{{Pelvic pain DDX}}


==Diagnosis==
==Evaluation==
[[File:Vaginal ultrasonography in mild ovarian hyperstimulation syndrome - sagittal.jpg|thumb|Pelvic ultrasound (sagittal) in woman with OHSS showing ascites and enlarged ovary (diameter = 6.5mm)]]
===Workup===
===Workup===
*Urine pregnancy
*Urine or serum pregnancy
*Pelvic ultrasound
**'''[[Beta-HCG]] may be positive if [[beta-HCG]] injection given as part of fertility treatment, consider obtaining beta quantitative instead of qualitative'''
*CBC
*CBC
*Chem 10
*Chem 10
*CXR
*Progesterone level
*Estradiol level
*PT/PTT
*PT/PTT
*Fibrinogen
*[[Pelvic ultrasound]]
*'''[[Beta-HCG]] may be positive if [[beta-HCG]] injection given as part of fertility treatment'''
*Consider:
**[[CXR]] (rule out [[pleural effusion]])
**Cardiac [[ultrasound]] (rule out [[pericardial effusion]])
**Progesterone level
**Estradiol level
**Fibrinogen (rule out [[DIC]])


===Evaluation<ref>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</ref>.===
===Evaluation<ref>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</ref>.===
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*Ultrasonographic evidence of [[ascites]]
*Ultrasonographic evidence of [[ascites]]
||
||
*Elevated Hct (>41%)  
*Elevated hematocrit (>41%)  
*Elevated WBC (>15,000/mL)  
*Elevated WBC (>15,000/mL)  
*Hypoproteinemia
*Hypoproteinemia
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*[[Venous thrombosis]]
*[[Venous thrombosis]]
||
||
*Hemoconcentration (Hct >55%)  
*Hemoconcentration (hematocrit >55%)  
*WBC >25,000/mL  
*WBC >25,000/mL  
*Serum creatinine >1.6 mg/dL  
*Serum creatinine >1.6mg/dL  
*Creatinine clearance <50 mL/min  
*Creatinine clearance <50 mL/min  
*[[Hyponatremia]] (Na+ <135 mEq/L)  
*[[Hyponatremia]] (Na+ <135 mEq/L)  
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||Worsening findings
||Worsening findings
|}
|}


==Management==
==Management==
''Pregnant patients must be followed very closely, as they are likely to worsen''
''Pregnant patients must be followed very closely, as they are likely to worsen''
*Urgent GYN consultation
*Urgent GYN consultation for all


===Mild===
===Mild===
*Acetaminophen
*Pain control
*Avoidance of heavy physical activity
**[[Acetaminophen]], [[Norco]], or [[morphine]]
**Return for
*Encourage oral fluids (1-2 liters/day)
***Worsening abdominal pain
*Ambulate, but avoid other physical activity. Avoid sexual intercourse
***Weight gain (>1 kg/day)
***Increasing abdominal girth


===Moderate===
===Moderate===
*Encourage oral fluids (1-2 liters/day)
*[[IV fluids]] (e.g normal saline)
*Ambulate, but avoid other physical activity. Avoid sexual intercourse
*Therapeutic [[paracentesis]] if [[ascites]] (aspirate 0.5-4 L)
*Daily weights, abdominal circumference measurements, and urinary output recordings
*Thromboembolic prophylaxis (e.g. [[LMWH]])
*Ascites/culdocentesis or paracentesis  
**Aspirate 0.5-4 L
*Prophylaxis for thromboembolic events (e.g. [[LMWH]])
**All hospitalized patients
**All hospitalized patients
*Outpatients with 2-3 risk factors
**Outpatients with 2-3 risk factors:
**Age >35 years
***Age >35 years
**Obesity
***Obesity
**Immobility
***Immobility
**Personal or family history of thrombosis
***Personal or family history of thrombosis
**Thrombophilias
***Thrombophilias
**pregnancy
***Pregnancy


===Severe===
===Severe===
*Maintain intravascular blood volume (e.g normal saline)
*As above + consider need to drain [[pleural effusion|pleural]] or [[pericardial effusion]]
*Relieve ascites, hydrothorax, and/or pericardial effusion
*Prevent thromboembolism (e.g. [[LMWH]])


===Critical===
===Critical===
*As for severe + resuscitation care
*As above + resuscitative care


==Disposition==
==Disposition==
*Mild: outpatient
*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)
*Moderate: outpatient if close follow-up (discuss with GYN)
*Severe: admit
*Severe: admit
*Critical: ICU
*Critical: ICU
==Disposition==
*May require ICU admission for third spacing
*Admit all but most mild cases to monitored setting


==Complications==
==Complications==
*Ovarian torsion
*[[Ovarian torsion]]
*Thromboembolism
*[[Venous thromboembolism]]
*[[Hydrothorax]]
*[[Pericardial effusion]]
*Arterial thrombosis
*[[Pulmonary embolism]]
*[[Sepsis]]
*[[Acute renal failure]]
*[[Acute respiratory distress syndrome]] (ARDS)
*[[Disseminated intravascular coagulation]] (DIC)


==See Also==
==See Also==

Latest revision as of 19:06, 15 April 2020

Background

  • Fertility treatments causing development of multiple follicles at once
    • Exaggerated ovarian response to ovulation induction (esp in IVF when HCG is used to stimulate)
  • Fluid shifts out of vasculature (third spacing)
  • Typically 5-10d after 1st dose
  • Ranges in severity from mild to severe multiorgan dysfunction, relating in part to massive intravascular fluid shifts

Clinical Features

Differential Diagnosis

Acute Pelvic Pain

Differential diagnosis of acute pelvic pain

Gynecologic/Obstetric

Genitourinary

Gastrointestinal

Musculoskeletal

Vascular

Evaluation

Pelvic ultrasound (sagittal) in woman with OHSS showing ascites and enlarged ovary (diameter = 6.5mm)

Workup

Evaluation[2].

Classification Clinical features Lab findings
Mild Normal
Moderate Above plus:
  • Ultrasonographic evidence of ascites
  • Elevated hematocrit (>41%)
  • Elevated WBC (>15,000/mL)
  • Hypoproteinemia
Severe Above plus:
  • Hemoconcentration (hematocrit >55%)
  • WBC >25,000/mL
  • Serum creatinine >1.6mg/dL
  • Creatinine clearance <50 mL/min
  • Hyponatremia (Na+ <135 mEq/L)
  • Hyperkalemia (K+ >5 mEq/L)
  • Elevated liver enzymes
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
  • 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

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

See Also

References

  1. ↑ Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
  2. ↑ 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
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