1. Ovarian hyperstimulation syndrome
DR E.NAGHSHINEH
DR.E ARSHAD

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

3. 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

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

5. INTRODUCTION
The most serious complication of controlled ovarian hyperstimulation.

6. Signs and symptoms Abdominal distention and discomfort
Enlarged ovaries
Ascites

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

8. 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

9. 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

10. APPROACH TO MANAGEMENT

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

12. 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 

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

14. 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.

15. 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

16. 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

17. 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

18. 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

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

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

21. Thanks for attention