A “kiss” before conception: triggering ovulation with kisspeptin-54 may improve IVF

A 30-year-old primigravid (G1P000) female with infertility secondary to her partner’s oligospermia and her chronic anovulation presented 13 days after an oocyte retrieval for in vitro fertilization (IVF) with a positive home pregnancy test, abdominal distention, a 5-pound weight gain, nausea, shortness of breath, and reduced urinary frequency. Her IVF cycle included the usual cocktail for gonadotropin stimulation and was uncomplicated, except for excessively stimulated ovaries that led to a peak estradiol level of 6,000 pg/ml and the retrieval of 30 oocytes. Her past history was relevant only for anovulation due to polycystic ovarian syndrome (PCOS), though her preprocedure body mass index was normal at 21 kg/m². Pelvic ultrasound revealed abundant ascites and enlarged ovaries, at 8 cm average diameter. Serum human chorionic gonadotropin (hCG) concentration was 200 mIU/ml; she was hemoconcentrated (hemoglobin 16 g/dl), with normal liver function and coagulation testing. An ultrasound guided, transvaginal paracentesis removed 4 liters of straw-colored fluid, resulting in significant short-term symptom relief.The patient described above has moderate to severe ovarian hyperstimulation syndrome (OHSS), the most serious maternal complication of gonadotropin therapy. OHSS poses a significant risk of maternal morbidity and mortality as well as pregnancy loss. The patient’s risk factors for having OHSS include youth, excessive ovarian stimulation, PCOS, and a likely twin gestation. Signs and symptoms of severe OHSS include abdominal distention, compromised renal function (including renal failure) due to decreased renal perfusion secondary to pressure from tense ascites and decreased intravascular volume, respiratory compromise due to pleural effusion and pulmonary edema, thromboembolism (including stroke) due to hemoconcentration and high estrogen levels, ovarian rupture, electrolyte abnormalities, and liver dysfunction. Although most cases are mild and self limited, severe cases can result in acute respiratory distress syndrome (ARDS) or stroke and can require intensive care unit (ICU) admission to prevent death.     

留置中心静脉导管腹水引流治疗中重度卵巢过度刺激综合征合并张力性腹水的临床应用

目的回顾性分析留置中心静脉导管（CVC）腹水引流治疗中重度卵巢过度刺激综合症（OHSS）合并张力性腹水的临床疗效。方法将本中心2009年1月-2011年6月、2004年6月-2008年12月收治的中重度OHSS合并张力性腹水患者分别作为置管组（n=10）、对照组（n=15）。置管组采用CVC腹腔留置引流腹水,对照组采用传统多次腹腔穿刺引流腹水,评价临床疗效。结果置管组均一次性置管成功,引流腹水后患者腹胀明显缓解,腹围、体重、红细胞压积、尿比重均明显下降,24h尿量明显增多;与对照组比较,治疗5d患者腹围明显减小、腹水引流量及总引流次数增多、病程有所缩短,且置管组无特殊并发症。结论采用CVC腹腔留置引流治疗中重度OHSS合并张力性腹水患者效果良好,且方便、安全、经济,患者依从性好。值得推广。     

Plasminogen activators and plasminogen activator inhibitor in malignant and non-malignant ascitic fluid

Ascitic fluid from tumour patients (hepatoma, gastric cancer, gallbladder cancer, colorectal cancer, ovarian cancer) and from non-malignant diseases (liver cirrhosis, congestive heart failure) were compared with respect to their content of determinants of the fibrinolytic system, tissue-type plasminogen activator antigen (t-PAag) and activity (t-PAact), urokinase-type plasminogen activator antigen (u-PA) and plasminogen activator inhibitor activity (PAI). Furthermore, SDS-polyacrylamide slab-gel electrophoresis (SDS-PAGE) was performed to evaluate molecular weight distribution of the detectable fibrinolytic parameters. In malignant ascites, PAI activity was three to four times higher, and increased complex formation of PAI with t-PA could be demonstrated, compared with non-malignant ascitic fluid. Tissue-type plasminogen activator antigen and activity showed a similar concentration in ascites of both study groups. Urokinase-type plasminogen activator antigen was detectable neither in ascites of malignant nor in ascites of non-malignant origin. It is concluded that t-PA is the physiological plasminogen activator in ascites and that increased PAI levels followed by increased complex formation between t-PA and PAI might reflect a reaction of the peritoneum.     

超促排卵并发中、重度卵巢过度刺激综合征的护理

目的探讨超促排卵治疗过程中并发中、重度卵巢过度刺激综合征(ovarian hyper-stimulation syndrome,OHSS)的护理对策。方法回顾性总结2010年6月至2011年6月在接受体外受精-胚胎移植治疗的患者中,80例因超促排卵并发中、重度卵巢过度刺激综合征患者的临床资料及护理体会。结果 80例患者经积极治疗及护理后,均全部康复,其中32例获得妊娠、48例终止妊娠。结论中、重度卵巢过度刺激综合征患者的护理重点应包括预防性监测及护理、心理护理、饮食及用药护理、腹胀及腹痛的护理、腹水引流的护理及出院后指导等。     

中重度卵巢过度刺激综合征90例临床分析

目的探讨辅助生殖技术中的卵巢过度刺激综合征(OHSS)的高危因素及临床监测与治疗。方法对四川省人民医院90例中、重度卵巢过度刺激综合征临床资料进行回顾性分析。结果 (1)OHSS发生的高危因素:年轻患者、多囊卵巢综合征、过多卵泡数目以及妊娠。(2)妊娠的OHSS患者与未妊娠患者的病程分别为(18.56±12.19)d及(8.28±3.21)d,临床治疗时间及病程明显延长;未妊娠与妊娠患者所使用清白蛋白量为(130.43±24.22)g及(257.39±64.35)g,妊娠患者症状重、清蛋白治疗用量大。(3)扩容及输注清蛋白是治疗OHSS的有效措施,严重患者穿刺引流胸腔积液和腹水可缓解症状。结论 OHSS是辅助生育技术控制性超排卵治疗引起的医源性并发症,应予以正确的防治。     

Prenatal diagnosis of bilateral cystic adenomatoid malformation of the lung

Bilateral cystic adenomatoid malformation of the lung (CAML), solid type (Stocker III), is a rare malformation that we observed sonographically in two fetuses at 23 weeks. The ultrasonic image showed an echogenic mass compressing the heart and occupying the whole thoracic cavity. Massive ascites, probably as a result of heart failure, was apparent. The prognosis is fatal. Prenatal diagnosis enables termination of pregnancy and saves the mother from invasive procedures in case of fetal distress. In unilateral, more favorable lesions, the managing physician is prepared for respiratory distress of the newborn and an emergency operation.     

Ovarian hyperstimulation syndrome: A review for emergency clinicians

IntroductionA great deal of literature has recently evaluated the prevention and management of ovarian hyperstimulation syndrome (OHSS) in the outpatient setting, but there remains a dearth of research evaluating OHSS in the emergency department (ED) and its management.ObjectiveThis narrative review evaluates the underlying pathophysiology and clinical manifestations of OHSS and discusses approaches to patient care in the ED based on current literature.DiscussionOHSS is an iatrogenic complication caused by an excessive response to controlled ovarian stimulation during assisted reproductive cycles (ART). OHSS complicates up to 30% of ART cycles, and many of these patients seek initial care in the ED. Risk factors for the development of OHSS include age < 35, history of polycystic ovarian syndrome or previous OHSS, and pregnancy. Emergency physicians will be faced with several complications including ascites, abdominal compartment syndrome, renal dysfunction, acute respiratory distress syndrome, thromboembolic disease, and hemodynamic instability. Critical patients should be evaluated in the resuscitation bay, and consultation with the primary obstetrics/gynecology team is needed, which improves patient outcomes. This review provides several guiding principles for management of OHSS and associated complications.ConclusionsOHSS occurs in up to 30% of IVF cycles and carries a high morbidity. Effective care of the OHSS patient begins with early diagnosis while evaluating for other diseases and complications. Understanding these complications and an approach to the management of OHSS is essential to optimizing patient care.     

Emergency ultrasound diagnosis of ovarian hyperstimulation syndrome: case report

Background

Ovarian hyperstimulation syndrome (OHSS) is an exaggerated response to ovulation induction therapy. It is a known complication of ovarian stimulation in patients undergoing treatment for infertility. As assisted reproductive technology and the use of ovulation induction agents expands, it is likely that there will be more cases of OHSS presenting to the Emergency Department (ED).

Objectives

OHSS has a broad spectrum of clinical manifestations, from mild abdominal pain to severe cases where there is increased vascular permeability leading to significant fluid accumulation in body cavities and interstitial space. Severe cases may present to the ED with ascites, pericardial effusions, pleural effusions, and lower extremity edema. Through a case report, we review OHSS with an emphasis on early diagnosis by Emergency Physician (EP)-performed bedside ultrasonography.

Case Report

We present a case of a patient undergoing treatment for infertility who presented to the ED with shortness of breath and abdominal pain. The diagnosis of severe OHSS was made, largely based on EP-performed bedside ultrasonography showing peritoneal free fluid and bilateral pleural effusions, as well as multiple ovarian follicles.

Conclusions

This report reviews the pathophysiology of OHSS, its clinical features, and pertinent diagnostic and management issues. This report emphasizes the importance of early EP-performed bedside ultrasonography.     

超声对卵巢过度刺激综合征的诊断价值

目的探讨超声对卵巢过度刺激综合征的诊断价值.方法收集我院自1999年来诊治的7例卵巢过度刺激综合征病例进行回顾分析.结果 7例患者的卵巢增大,3例伴腹水,1例腹水伴胸水.结论超声是诊断卵巢过度刺激综合征的首选方法.     

卵巢过度刺激综合征77例临床分析

目的：探讨多囊卵巢综合征（OHSS）治疗的临床特征和治疗方法。方法：回顾性分析77例OHSS住院患者的临床资料。结果：77例OHSS患者均发生在超促排卵周期的第9～22 d,其中50例患者发生在体外受精胚胎移植（IVF-ET）术后。经过监护、扩容、补液、注射黄体酮及腹腔、胸腔穿刺引流后,患者在6～43d内病情缓解并出院,77例患者妊娠47例,其中一例终止妊娠。结论：OHSS的治疗主要是对症支持治疗,严密监护OHSS的病情发展,扩容是治疗的关键,治疗严重的难以控制的OHSS,终止妊娠是最有效的手段。     

肝硬化腹腔动脉血流动力学改变的超声多普勒研究

本文应用彩色多普勒探测４２例肝硬化患者及１５例正常人脾动脉（ＳＡ）、肠系膜上动脉（ＳＭＡ）血流参数，研究肝硬化腹腔动脉血流动力学变化与上消化道出血及腹水的关系。结果表明肝硬化食管静脉曲张上消化道出血患者脾动脉阻力指数（ＳＡＲＩ）较无出血组及对照组明显增高，提示ＳＡＲＩ与肝硬化门脉高压密切相关，可作为预测食管静脉曲张上消化道出血的一项无创性新指标；此外大量腹水的出现有可能减低门脉压力，减少食管静脉曲张上消化道出血的发生     

Ovarian hyperstimulation syndrome (OHSS): diagnosis and management

Objective: To present our experience and the current knowledge about pathophysiology, diagnosis, and management of the ovarian hyperstimulation syndrome (OHSS). Design: Retrospective study concerning clinical and laboratory findings of severe OHSS. Setting: General ICU at a maternity-surgical hospital. Patients: Ten patients suffering from severe OHSS. Interventions: Supportive and preventive therapeutic measures applied are described. Measurements and results: Admission and discharge data as well as worst values during disease course were recorded. Clinical and laboratory findings showed third space fluid shift leading to weight gain, generalized tissue edema, ascites, hydrothorax, abdominal distension and pain, chest discomfort, hypovolemia, dehydration, ovaries enlargement, electrolyte disturbances, hypoalbuminemia, high hematocrit, urea, and WBC. Conclusions: OHSS is an iatrogenic complication of assisted conception of unknown pathogenesis, with potentially life-threatening sequelae due to hemoconcentration such as circulatory shock, ARDS, hepato-renal failure, thromboembolic phenomena, and multi-organ dysfunction syndrome. Gynecologists and intensivists must be aware of the diagnosis and management of the syndrome because of the widely used reproductive techniques for assisted conception. Received: 8 July 1999 Final revision received: 3 January 2000 Accepted: 15 February 2000     

Ovarian overstimulation syndrome: problem of intensive care

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic complication, the basis for which is a hyperergic uncontrolled ovarian response to gonadotropins in the ovulation stimulation cycles and assisted procreation programs. The clinical picture of OHSS is characterized by a broad spectrum of clinical and laboratory manifestations: increased vascular permeability resulting in the excess release of liquid into the third space and its storage with the development of hypovolemia, hemoconcentration, oliguria, hypoproteinemia, electrolyte imbalance, polyserositis; in severe cases, acute renal failure, thromboembolic events, and adult respiratory distress syndrome develop. The goal of treatment is to prevent the development of multiply organ dysfunctions. Its leading methods are infusion therapy with colloid-crystalloid solutions and anticoagulant therapy. Whether diuretics and other drugs are administered is under consideration. Indications for laparocentesis and peritoneal transudate evacuation are discussed. Complications requiring surgery are identified.     

诱发排卵时卵巢过度刺激综合征44例临床分析

目的：回顾性分析44例卵巢过度刺激综合征(OHSS)，提出预防和治疗的措施。方法：293个超排卵周期中，44个周期发生OHSS。分析OHSS的年龄、体重指数、促排方案、临床表现、以及治疗结果。结果：轻度和部分中度患者，未作任何处理自动缓解；9例给予人体血清白蛋白；6例给予人体血清白蛋白，并放腹水，3～55天内缓解；28例中、重度患者，住院监测后缓解。结论：B超预览双侧卵巢状态，以发现多囊卵巢(PCO)征象病人；白蛋白是扩容的首选，可预防性和治疗性用药；适当抽腹水、胸水以改善循环功能。     

Continuous monitoring of blood gases during hypercapnia in a patient with severe acute lung failure

We report about our first experiences with a new device for continuous intra-arterial monitoring of blood gases in a patient with severe acute respiratory failure. This device facilitated continuous monitoring of PaO₂, PaCO₂ and pH while weaning the patient from extracorporeal membrane oxygenation (ECMO). Although sufficient oxygenation at FIO₂ 0.45 could be achieved after disconnection from ECMO, carbon dioxide elimination remained inadequate and resulted in severe respiratory acidosis. Within six hours, PaCO₂ increased to 95 mmHg. Continuous monitoring of pH and PaCO₂ helped to monitor CO₂ retention and assisted the decision making process for reinstitution of ECMO.     

Diagnostic value of adenosine deaminase in ascites for tuberculosis ascites: a meta-analysis

The diagnosis of tuberculosis (TB) ascites using standard diagnostic tools is difficult. The aim of the present meta-analysis was to establish the overall diagnostic accuracy of adenosine deaminase (ADA) levels in ascites for diagnosing TB ascites. A systematic review was performed of English language publications prior to April 2013. Sensitivity, specificity, and other measures of the accuracy of ADA for the diagnosis of TB ascites using ascites fluid were summarized using a random-effects model or a fixed-effects model. Receiver operating characteristic curves were used to summarize overall test performance. Seventeen studies involving 1797 subjects were eligible for the analysis. The summary estimates of sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and the area under cure of overall analysis were: 0.93, 0.94, 13.55, 0.11, 169.83, and 0.976, respectively; the results of sensitivity analysis of studies that used Giusti method were 0.94, 0.94, 12.99, 0.08, 183.18, and 0.977, respectively. Our results suggest that ADA in the ascites can be a sensitive and specific target and a critical criterion for the diagnosis of TB ascites.     

Ovarian hyperstimulation syndrome in the emergency department: A case report

The Ovarian Hyperstimulation Syndrome (OHSS) is a complication of ovulation enhancing technologies that is becoming more prevalent with increasing use of these techniques in infertile women. In this report, we describe a 36-year-old woman who presented to the Emergency Department with hemodynamic compromise secondary to OHSS. The OHSS is characterized by ovarian enlargement, ascites, electrolyte disturbances, hypotension, and thromboembolic events. This case illustrates a serious complication of techniques used to enhance fertility.     

A case of liver cirrhosis complicated with endotoxemia and disseminated intravascular coagulation: a case report

A 59-year-old female was admitted to our hospital because of massive ascites and increasing jaundice, suggesting a severe decompensated state of liver cirrhosis. On the third hospital day, she was diagnosed as disseminated intravascular coagulation (DIC) from a coagulofibrinolytic study and developed renal failure. Continuous drip infusion of gabexate mesilate, a synthetic inhibitor of serine-protease, was found to be successful in managing DIC, followed by the restoration of renal function. During the clinical course, blood endotoxin, assayed by the chromogenic method, was initially 11 pg/ml and increased, in accordance with the elevation of serum FDP, to a level of 110 pg/ml when renal failure occurred. A proportional relationship was observed between changes in blood endotoxin and serum FDP throughout the course. This finding may be an important clue in studying the mechanism of DIC and non-septic endotoxemia both developing in liver cirrhosis.     

超声早期诊断卵巢过度刺激综合征的价值

目的探讨超声对卵巢过度刺激综合征(ovarian hyperstimulation syndrome,OHSS)的早期诊断价值.方法经腹超声,对使用促排卵药物后发生过度刺激反应的卵巢动态观察和监测.结果卵巢体积增大、成熟卵泡(直径>2.0 cm)数目增多并等大、陶氏腔积液、腹水、胸水等是超声诊断OHSS发生的早期声像表现.结论超声对OHSS具有较高的早期诊断价值.     

Internal jugular vein thrombosis with OHSS

Ovarian hyperstimulation syndrome (OHSS) includes ovarian enlargement and ascites. It is usually mild but can be, rarely, fatal. Deep vein thrombosis (DVT) is among the potentially fatal complications of OHSS. During pregnancy, DVT is more common in the lower extremities than in the upper part of the body, but OHSS‐related DVT occurs more frequently in the upper part. Internal jugular vein thrombosis is considered rare, and duplex ultrasound is the appropriate examination for its diagnosis. We present a rare case of internal jugular vein thrombosis following OHSS. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45 :450–452, 2017