Ovarian hyperstimulation syndrome "OHSS"

• Serious and potentially life-threatening complication of • Women undergoing fertility ttt and abdominal
induction of ovulation or superovulation during infertility ttt bloating, discomfort/pain, N&V, pyrexia.
(excess numbers of follicles develop in response to FSH • Presence of risk factors
then HCG administration to trigger release of oocytes).  Polycystic ovarian syndrome.
• Characterized by ovarian enlargement and a shift of fluid
 Elevated baseline AMH.
from the intravascular to the extravascular space due to
Suspect  Increased ovarian volume and high antral follicle
increased capillary permeability leading to accumulation of
fluid in peritoneal, pleural and rarely pericardial cavities, count (AFC) on baseline scan.
intravascular fluid depletion and haemoconcentration.  Age <30 ys & Low BMI
• Early’ OHSS usually presents within 7 ds of hCG injection  Previous OHSS & High doses of FSH
and is usually associated with an excessive ovarian  Large number of oocytes collected (>25)
response. ‘Late’ OHSS typically presents >10 ds after  Rapidly rising + high oestradiol (>17,000 pmol/l)
hCG injection and is usually the result of endogenous
hCG derived from an early pregnancy. The preceding
Symptoms are not specific & no diagnostic tests ----
ovarian response in these women may be unremarkable.
Late OHSS tends to be more prolonged and severe. Exclude other serious conditions that may present in
• The pathophysiology of the syndrome is unclear. There a similar manner but require different management
are suggestions that VEGF (vascular endothelial growth (pelvic inf., abscess, appendicitis, ovarian torsion or
factor), the renin-angiotensin-aldosterone system, LH, + cyst rupture, bowel perforation and ectopic
histamine, prostaglandins or ovarian prorenin might play a pregnancy especially if there is severe pain).
role in the development of OHSS. Ph E ------ assess for:
• General: volume status, oedema (pedal, vulval and
General measures sacral); record HR, RR, bl pr, UOP, b w.
• Intercourse --- restricted (risk of cyst rupture). • Abdominal: ascites Women with severe OHSS can
• Avoid impact-type activities or strenuous exertion. gain as much as 15 - 20 kg over 5 - 10 ds", palpable
Mild & Moderate “supportive” ---outpatient mass, peritonism; measure girth.
• Observation, bed rest, analgesia (avoid NSAIs (Level • Respiratory: pleural effusion, pneumonia, pulmonary
Confirm
III-B), adequate fluids oedema ARDS, pneumonia, ALI, and VTE
Workup
• Sono-graphic monitoring of cyst size. • Thromboembolic complications "in internal jugular,
• Progesterone leuteal support. subclavian, axillary, and mesenteric vessels".
• Monitor fluid balance Lab.
• Alarming signs --- intractable pain or vomiting, calf • CBC, Haematocrit (Hemoconcentration), CRP
pain, progressive dyspnea, positive balance > 1000 • Urea and electrolytes (hyppnatremia, hyperkalemia)
ml/d, UOP < 1000ml/d, Ht > 0.55 (Level IV). • Serum osmolality (hypo-osmolality)
Severe & Critical ---- inpatient + • LFT (elevated enzymes and reduced albumin)
• Maintaining bl volume & correct disturbed fluid , • Coagulation (high fibrinogen and low antithrombin)
electrolyte balance, and normal UOP (>30ml/hr). • hCG (determine outcome of ttt cycle) if appropriate
• Encourage oral fluids if not vomiting. Where oral US scan: ovarian size, pelvic and abdominal fluid.
cannot be maintained expand intravascular Investigation for complications
compartment with a minimum of 2-3 litres of NS. • ABGs, ECG/echo, CXR in hypoxemia, or collapse
• Women with persistent haemoconcentration or UOP • D-dimers CTPA or V/Q scan if emboli suspected
<0.5mL/kg/hr may benefit from colloid in form of Intervene • Ovarian Doppler if torsion suspected
20% human albumin (40-100 g over 4 hrs and / 4-
12 hr) &Invasive monitoring & Ht / 4 hrs; stop <38 %.
Classification
• Oral Indomethacin” blocks prostaglandin synthesis
Mild
and reduces capillary permeability”.
• Abdominal bloating, mild abdominal pain.
• Diuretic ---- not recommended (remove fluid from
• Ovarian size usually < 8 cm
vascular compartment only). Have a role if oliguria
Moderate
persists despite adequate fluid replacement and
• Moderate abdominal pain, N&V.
drainage of ascites
• US evidence of ascites
• Drainage of ascites, pleural effusion ---- if there is
• Ovarian size usually 8-12 cm
significant ascites with significant discomfort or
respiratory distress or persistent oliguria despite Severe
• Clinical ascites (± hydrothorax)
fluid replacement. Should only be done under US + • Oliguria (< 300 mL/d or < 30 mL/hr)
guidance (avoid damage to bowel or ovaries). A
continuous drainage tube can be left in situ. Colloid • Haematocrit > 0.45
should be considered for large volumes drainage. • Hyponatraemia , hypo-osmolality
Pleural effusion drainage less commonly indicated. • Hyperkalaemia, hypoproteinaemia
• VTE prophylaxis (II-2B). • Ovarian size usually > 12 cm
• Laparotomy ----- catastrophic complications" Critical
ovarian torsion or rupture and internal hge”. • Tense ascites/large hydrothorax
• GnRH antagonist, Dopamine agonists --- unclear • Haematocrit > 0.55
evidence. • WBCs > 25 000/mL
• Oliguria/anuria, thromboembolism, ARDS
• In most women, the condition resolves over of 7–10 NOTE
❖ Ovarian size may not correlate with severity of OHSS in cases of
ds. If conception occurs, endogenous hCG can lead
assisted reproduction because of the effect of follicular aspiration.
to a worsening of OHSS, whereas, in absence of Women demonstrating any feature of severe or critical OHSS should
pregnancy, recovery is usually complete by the time Outcome be classified in that category.
of the withdrawal bleed (Level III). ❖ Mild forms of OHSS affect up to 33% of IVF cycles. Moderate to
severe OHSS has been reported in 3-8%.
• Pregnancies complicated by OHSS may be at
increased risk of pre-eclampsia and preterm
delivery.