Ovarian hyperstimulation syndrome DR E.NAGHSHINEH DR.E ARSHAD

Case presentation 31 y G1D1 Secondry infertility PMH:IVF & OHSS,IUI DH:Gonal,HMG,HCG,Metformin PSH:Laparascopy After induction ovulation :abdominal pain

Lab data CBC(WBC:18500/Hb:15.7/HCT:46.7/PLT:290) LFT:NL Na:138/k:4.5 Cr:0.9 Alb:2.7

Hospitalization Tab Dostinex daily Tab Cholorpheniramin Amp Enoxaparin Vial Alb20% TDS Tap of ascitis:4 Lit

INTRODUCTION The most serious complication of controlled ovarian hyperstimulation.

Signs and symptoms Abdominal distention and discomfort Enlarged ovaries Ascites

Pathophysiology Increased capillary permeability Loss of fluid into the third space Overexpression of VEGF leading to administration of hCG

Two clinical forms of OHSS The early-onset form (occurring on the first eight days after exogenous hCG administration) The late-onset form (occurring nine or more days after hCG administration

Clinical features Biochemical features Mild Moderate Severe Critical Abdominal distention/discomfort Mild nausea/vomiting Diarrhea Enlarged ovaries No clinically important laboratory findings Moderate Presence of mild features plus: Ultrasonographic evidence of ascites Hct >41% WBC>15,000/microL Hypoproteinemia Severe Presence of mild and moderate features plus: Clinical evidence of ascites (can be tense ascites) Severe abdominal pain Intractable nausea and vomiting Rapid weight gain (>1 kg in 24 hours) Pleural effusion Severe dyspnea Oliguria/anuria Low blood/central venous pressure Syncope Venous thrombosis Hct >55% WBC >25,000/microL Serum creatinine >1.6 mg/dL Creatinine clearance <50 mL/min (Na+ <135 mEq/L) (K+ >5 mEq/L) Elevated liver enzymes Critical Presence of severe features plus: Anuria/acute renal failure Arrhythmia Pericardial effusion Massive hydrothorax Thromboembolism Arterial thrombosis ARDS Sepsis Worsening of biochemical findings seen with severe OHSS

APPROACH TO MANAGEMENT

Mild OHSS Managed conservatively With a goal of relieving symptoms Analgesics Avoidance of heavy physical activity

Moderate OHSS Oral fluid intake of 1 to 2 liters per day. Diuretics are contraindicated Ambulate Avoid sexual intercourse Daily weights Abdominal circumference measurements Urinary output Transvaginal ultrasound (TVUS) Laboratory testing CBC, electrolytes, cr, serum albumin, and liver enzymes Daily communication with patient Ascites/culdocentesis 

Ascites/culdocentesis In women with tense ascites Orthopnea Rapid increase of abdominal fluid

The volume of fluid to be removed is not well established. After aspiration of 500 mL: patients typically report resolution of abdominal discomfort. Removal of more than 4 liters of fluid is not recommended.

Dopamine agonists (DA)  In women at high risk for OHSS Cabergolin (0.5 mg/day orally), beginning on the day of hCG administration or oocyte retrieval

Prophylaxis for thromboembolic All hospitalized patients with OHSS Outpatients with two to three additional risk factors (in addition to OHSS): Age >35 years Obesity Immobility Personal or family history of thrombosis Thrombophilias Pregnancy

Severe and critical OHSS Hospitalization  HCT >45 percent, Leukocytes >25,000/L Cr>1.6 mg/dL. Severe abdominal pain Intractable vomiting Severe oliguria/anuria Tense ascites Dyspnea or tachypnea Hypotension Dizziness or syncope Severe electrolyte imbalance Abnormal LFT

Isotonic crystalloid solutions ( normal saline, Ringer's lactat) Some clinicians use intravenous albumin in critically ill, volume-depleted patients Thromboprophylaxis Critical OHSS cases should be managed in an ICU Assessment of fluid balance (daily or more often) Weights and measurement of abdominal circumference CBC , Electrolytes ,BUN, creatinine Serum hCG measurements (to determine if patient has conceived) Invasive monitoring of central venous pressure Pelvic ultrasound as needed to evaluate ovarian size and ascites CXR and echocardiogram when pleural or pericardial effusion is suspected

Resolution and prognosis Clinical evidence of resolution includes: Normalization of hematocrit Progressive reduction of ascites on ultrasound Alleviation of clinical symptoms

PREVENTION Recognizing risk factors Using individualized ovarian stimulation regimens Modifying treatment when indicators for increasing OHSS risk develop

Thanks for attention