Ovarian hyperstimulation syndrome

Background

• Fertility treatments causing development of multiple follicles at once
• Fluid shifts out of vasculature

Clinical Features

• Ovarian enlargement
• Movement of fluid out of vasculature
  • Ascites
  • Pleural effusions
  • Pericardial effusion
  • Hypotension
• Electrolyte Imbalances
• DIC
• Thromboembolism
  • Both venous and arterial
• Hypervolemic hyponatremia

Differential Diagnosis

• Ectopic Pregnancy
• Molar Pregnancy
• Sepsis
• PE

Pelvic Pain

Pelvic origin

• Urinary Tract Infection
• Ectopic
• Ovarian torsion
• Endometriosis
• PID
• Cervicitis
• Ectopic Pregnancy
• Ovarian Torsion
• Spontaneous abortion
• Septic abortion
• Myoma (degenerating)
• Ovarian cyst (rupture)
• Tubo-ovarian abscess
• Mittelschmerz
• Sexual assault/trauma
• Ovarian hyperstimulation syndrome

Abdominal origin

• Appendicitis
• Kidney stone
• Psoas abscess
• Mesenteric adenitis
• Incarcerated hernia
• Diverticulitis
• Pyelonephritis

Evaluation

Workup

• Urine pregnancy
  • Beta-HCG may be positive if beta-HCG injection given as part of fertility treatment
• CBC
• Chem 10
• PT/PTT
• Pelvic ultrasound
• Consider:
  • CXR (rule out pleural effusion)
  • Cardiac ultrasound (rule out pericardial effusion)
  • Progesterone level
  • Estradiol level
  • Fibrinogen (rule out DIC)

Evaluation.

Classification	Clinical features	Lab findings
Mild	Abdominal distention/discomfort Mild nausea/vomiting Diarrhea Enlarged ovaries	Normal
Moderate	Above plus: Ultrasonographic evidence of ascites	Elevated hematocrit (>41%) Elevated WBC (>15,000/mL) Hypoproteinemia
Severe	Above 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	Hemoconcentration (hematocrit >55%) WBC >25,000/mL Serum creatinine >1.6mg/dL Creatinine clearance <50 mL/min Hyponatremia (Na+ <135 mEq/L) Hyperkalemia (K+ >5 mEq/L) Elevated liver enzymes
Critical	Above plus: Anuria/acute renal failure Arrhythmia Pericardial effusion Massive hydrothorax Thromboembolism Arterial thrombosis ARDS Sepsis	Worsening findings

Management

Pregnant patients must be followed very closely, as they are likely to worsen

• Urgent GYN consultation for all

Mild

• Pain control
  • Acetaminophen, Norco, or morphine
• Encourage oral fluids (1-2 liters/day)
• Ambulate, but avoid other physical activity. Avoid sexual intercourse

Moderate

• IV fluids (e.g normal saline)
• Threaputic paracentesis if ascites (aspirate 0.5-4 L)
• Thromboembolic prophylaxis (e.g. LMWH)
  • All hospitalized patients
  • Outpatients with 2-3 risk factors:
    • Age >35 years
    • Obesity
    • Immobility
    • Personal or family history of thrombosis
    • Thrombophilias
    • Pregnancy

Severe

• As above + consider need to drain pleural or pericardial effusion

Critical

• As above + resuscitative care

Disposition

• Mild: outpatient
  • Avoid heavy physical activity
  • Return for
    • Worsening abdominal pain
    • Weight gain (>1 kg/day)
    • Increasing abdominal girth
• Moderate: outpatient if close follow-up (discuss with GYN)
• Severe: admit
• Critical: ICU

Complications

• Ovarian torsion
• Venous thromboembolism
• Hydrothorax
• Pericardial effusion
• Arterial thrombosis
• Pulmonary embolism
• Sepsis
• Acute renal failure
• Acute respiratory distress syndrome (ARDS)
• Disseminated intravascular coagulation (DIC)

See Also

• Ectopic Pregnancy
• Shock

References

Authors

Ross Donaldson, Alex Linker, Neil Young, Daniel Ostermayer