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.     

Intensive care for ovarian hyperstimulation syndrome

The paper reviews the current data available in the literature on the pathophysiology, clinical presentation, and treatment of the ovarian hyperstimulation syndrome (OHSS). Today due to the intensive development of high assisted reproductive techniques (ART) using the current superovulation stimulation, the risk of OHSS grows steadily. The clinical symptoms of OHSS appear in the luteal phase of a cycle and in early pregnancy when most females have just left the in vitro fertilization centers. In this connection, physicians of many specialties, including obstetricians, gynecologists, and intensivists should know the clinical manifestations of this syndrome and can correctly render a medical aid. Disputable issues of inpatient therapy for OHSS and the specific features of infusion management and intensive care are discussed.     

Use of Point-of-Care Ultrasound for the Diagnosis of Ovarian Hyperstimulation Syndrome

BackgroundOvarian hyperstimulation syndrome (OHSS) occurs when ovaries are overstimulated and enlarged due to fertility treatments resulting in a shift of serum from the intravascular space to the third space, mainly the abdominal cavity. It is the most serious complication of ovarian hyperstimulation for assisted reproduction.Case ReportWe present the case of a 40-year-old woman who presented with abdominal bloating and nausea 2 weeks after undergoing in vitro fertilization (IVF); she was diagnosed by an outside radiology ultrasound as having a ruptured ovarian cyst. A point-of-care emergency ultrasound performed by the emergency physician made the diagnosis of ovarian hyperstimulation syndrome. This led to more expedient management and obstetrical consultation.Why Should an Emergency Physician Be Aware of This?Abdominal bloating and nausea are common presenting complaints in pregnant women. OHSS is a rare but potentially fatal complication of IVF. Recognition and early diagnosis by the emergency physician can lead to appropriate intervention and consultation.     

An unusual cause of tachycardia, hypotension, and intraabdominal free fluid: ovarian hyperstimulation syndrome

We report a case of ovarian hyperstimulation syndrome (OHSS) in a 37-year-old female who had recently underwent assisted reproductive technology involving oocyte retrieval. Her emergency department (ED) presentation, clinical course, and a discussion of ovarian hyperstimulation syndrome are also presented. Ovarian hyperstimulation syndrome is a critical diagnosis in emergency medicine, and emergency physicians must consider it in the differential for any female nontrauma patient presenting with hypotension, tachycardia, and abdominal pain.     

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.     

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.     

Association of ovarian response with picoAMH in women undergoing controlled ovarian hyperstimulation

ObjectiveOur study aims to evaluate the diagnostic performance of a high-sensitivity picoAnti-Müllerian Hormone (picoAMH) for predicting ovarian response in women undergoing controlled ovarian hyperstimulation and occurrence of ovarian hyperstimulation syndrome.MethodsRetrospective cohort study at a single academic fertility center including all patients with picoAMH ELISA who underwent controlled ovarian hyperstimulation. The primary outcome was the number of oocytes retrieved, and secondary outcomes included cycle cancellation and ovarian hyperstimulation syndrome. Patients were grouped into poor, normal, and hyper-responders based on number of oocytes retrieved.ResultsThe mean AMH and antral follicle count (AFC) were significantly different between normal response vs. hyper response group (p < 0.0001). Only serum AMH and not AFC was significantly increased in patients diagnosed with ovarian hyperstimulation syndrome (OHSS). For prediction of OHSS, receiver operating characteristic (ROC) analysis revealed that AMH (area under the ROC curve [AUC] = 0.85) was significantly better than the AFC (AUC = 0.64). The serum AMH cut-off at sensitivity of 80% for predicting OHSS among hyper responders from ROC curve was 3.67 ng/ml. Serum AMH measured by picoAMH ELISA showed superior correlation to number of oocytes retrieved when compared to AFC in the age group over 40 years old (r² = 0.74 and r² = 0.4, respectively)ConclusionThis study shows great utility of picoAMH ELISA for predicting ovarian response to controlled ovarian hyperstimulation (COH). Diagnostic performance of picoAMH for prediction of OHSS is superior to the AFC in our cohort.     

中、重度卵巢过度刺激综合征31例临床分析

目的探讨卵巢过度刺激综合征(OHSS)的临床表现及相应的治疗对策。方法回顾分析本院发生的31例中、重度OHSS临床资料。结果OHSS绝大多数发生在促排卵治疗后,临床表现主要为腹胀、恶心、腹水、胸水、水肿、尿少、血液浓缩、低蛋白血症、氮质血症,经严密监护、输白蛋白或血浆扩容及放腹水等对症治疗后治愈。结论OHSS在严密监护下,经相应的对症治疗可治愈。     

卵巢过度刺激综合征的临床治疗与分析

目的 探讨卵巢过度刺激综合征(OHSS)的特征以及防治疗方法 .方法 对我院46例OHSS患者的临床资料采取回顾性分析的方法 .结果 经过治疗,所有患者症状均有所缓解,复查各项生化指标正常.结论 OHSS应高度重视和警惕,早期识别、相应的预防措施及对症支持治疗能减少OHSS发生,保护患者的生命安全.     

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     

Spontaneous ovarian hyperstimulation syndrome and hyperreactio luteinalis are entities in continuum.

Hyperreactio luteinalis (HL) and spontaneous ovarian hyperstimulation syndrome (OHSS) are both rare conditions during pregnancy. The clinical presentation of HL and OHSS are comparable and both should be differentiated from ovarian carcinoma. We present a case of a 32-year-old woman who was initially seen with markedly enlarged multicystic ovaries and ascites in the 13th week of a spontaneously conceived pregnancy. Ultrasonographic follow-up and magnetic resonance imaging of the ovaries were employed in order to avoid exploratory laparotomy and rule out ovarian carcinoma. The patient received supportive therapy and delivered a healthy child at term. The increasing use of ultrasonography may lead to more frequent findings of multicystic ovaries in spontaneously conceived pregnancies. Making the distinction between HL and spontaneous OHSS in these cases may be difficult though clinically irrelevant as the approach to treatment is similar in both.     

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。     

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.     

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     

Continuous ascitic recirculation in severe ovarian hyperstimulation syndrome

Massive ascites, hydrothorax, acute renal failure and thromboembolism are clinical manifestations of severe ovarian hyperstimulation syndrome (OHSS) which may complicate the induction of ovulation with exogenous gonadotrophins. We report a case of severe OHSS with ascites formation in excess of five litres per day. Massive ascites and bilateral pleural effusions resulted in respiratory failure. Continuous ascitic recirculation (AR) was commenced after repeated paracentesis and IV fluid therapy failed to improve the patient's condition. The procedure was undertaken for a total of 15 days and rapidly resulted in marked improvement of impaired respiratory function. Febrile episodes occurred on 3 occasions, but we did not observe coagulation disturbances or adverse haemodynamic effects. Continuous AR is a safe and effective treatment of complicated severe OHSS.     

经阴道超声介入预防PCOS不孕症OHSS发生的探讨

目的评价经阴道超声（TVS）引导下小卵泡穿刺术（ASF）对于预防药物治疗多囊卵巢综合征（PCOS）不孕症患者发生中、重度卵巢过度刺激综合征（OHSS）的有效性。方法在辅助生殖治疗中，于药物促卵泡治疗的早期对有OHSS早期超声指征的25例PCOS患者行ASF。根据阴道超声检测卵巢及卵泡情况，保留3个或以下优势卵泡，对直径小于或等于12mm小卵泡进行穿刺抽吸，随访观察这些患者OHSS症状及体征。结果25例接受治疗的患者均没有发生中、重度OHSS，其中7例患者（28％）成功受孕。结论注射尿促性腺激素后早期进行ASF治疗对防止PCOS患者中、重度OHSS的发生有较大作用，且获得较高的妊娠率。掌握好进行ASF的时机是预防OHSS的重要因素，而早期TVS监测是十分重要的措施。     

Age dependent assessment of TFPI levels in follicular fluid of women undergoing IVF

BACKGROUND: Tissue factor pathway inhibitor (TFPI) is a multivalent Kunitz-type serine proteinase inhibitor which plays a central role in the extrinsic pathway of blood coagulation. A significant role of TFPI for the follicular development has been discussed in recent studies, and thrombotic complications during IVF procedure are a common problem. To elucidate the pathophysiological mechanisms underlying these problems, we have measured TFPI levels in human follicular fluid (hFF) of women undergoing in vitro fertilisation (IVF). METHODS: Total TFPI concentrations were determined in hFF of 28 women undergoing IVF treatment, 6 of whom developed an ovarian hyperstimulation syndrome (OHSS). RESULTS AND CONCLUSIONS: This is the first study to demonstrate an age-dependance of TFPI concentrations in hFF. Additionally, TFPI levels in hFF of women developing OHSS were determined as 323+/-66.8 ng/mL (mean+/-SD) in comparison with 279+/-137 ng/mL for non-OHSS patients. Our findings demonstrate that, unlike the decreased TFPI levels found in OHSS patients' blood, there is no statistically significant difference in hFF TFPI levels between OHSS and non-OHSS patients. Furthermore, we could show that the outcome of the IVF procedure is not correlated with TFPI levels in hFF.     

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.     

不同促排卵方法治疗不孕症成功47例分析

目的　分析不同促排卵方法对不孕症治疗的效果及其并发症的防治。方法　采用不同促排卵方法治疗成功的 4 7例不孕症患者 ,分成 3组 :克罗米酚 (CC)组、CC 人绝经期促性腺激素 (HMG)组、HMG组 ,比较其妊娠率、多胎率、流产率及卵巢过度刺激综合征 (OHSS)发生率。结果　各组的妊娠率、多胎率及流产率均无显著差异 (P >0 .0 5 )。HMG组、CC HMG组、CC组的OHSS发生率分别为 4 2 .0 % ,7.7% ,0 % ,HMG组显著高于CC组和CC HMG组 (P <0 .0 5 )。结论　应用HMG治疗不孕症的OHSS发生率较高 ,故严密监测极为重要。     

Hemoperitoneum from ruptured cyst in a hyperstimulated ovary: a sonographic mimic of ovarian hyperstimulation syndrome

We report a case of a ruptured cyst in a hyperstimulated ovary that was initially misinterpreted as ovarian hyperstimulation syndrome (OHSS). A 22-year-old woman who was on oral clomiphene citrate for primary infertility presented with pain in the lower abdomen, hypotension, and tachycardia. Sonographic examination revealed multiple cysts in both ovaries and free fluid in the abdomen, and the initial diagnosis was OHSS. However, sonographically guided aspiration of free fluid revealed a hemoperitoneum, and the patient underwent emergent surgery. At laparotomy, an actively bleeding ruptured cyst in a hyperstimulated ovary was found to be the cause of the hemoperitoneum. Radiologists must be familiar with the imaging features of this condition to avoid misdiagnosing it as OHSS, because this could potentially delay urgently required surgery.