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

Acute Pelvic Pain

Differential diagnosis of acute pelvic pain

Gynecologic/Obstetric

• Normal variants may be noted on exam but generally do not cause pain or other symptoms
  • Nabothian cysts: Epithelial cells within mucous glans that appear as yellow inclusions on the cervix
  • Cervical Ectropion: Edothelial cells on the exterior of the cervix
  • Parous cervix: The is no longer round but may have multiple shapes after birth
• Pregnancy-related
  • Ectopic pregnancy
  • Spontaneous abortion, threatened or incomplete
  • Septic abortion
• Pelvic organ prolapse
• Acute Infections
  • Herpes
  • Cervicitis
  • Endometritis
  • Bartholin gland abscess
  • Pelvic inflammatory disease (PID)
  • Tubo-ovarian abscess
• Vulvovaginitis
  • Bacterial Vaginosis
  • Candida Vaginitis
  • Trichomonas
  • Contact Vulvovaginitis
  • Atrophic vaginitis
• Adnexal Disorders
  • Hemorrhage/rupture of ovarian cyst
  • Ovarian torsion
  • Twisted paraovarian cyst
• Other
  • Myoma (degenerating)
  • Genitourinary trauma
  • Ovarian hyperstimulation syndrome
  • Sexual assault
• Recurrent
  • Mittelschmerz
  • Primary/Secondary Dysmenorrhea
  • Pelvic Congestion Syndrome
  • Endometriosis

Genitourinary

• Cystitis
• Pyelonephritis
• Urethritis (e.g. N. gonorrhoeae/Chlamydia)
• Urolithiasis

Gastrointestinal

• Gastroenteritis
• Appendicitis
• Bowel obstruction
• Perirectal abscess
• Diverticulitis
• Inflammatory bowel disease
• Irritable bowel syndrome
• Mesenteric adenitis

Musculoskeletal

• Abdominal wall hematoma
• Psoas hematoma, psoas abscess
• Hernia

Vascular

• Pelvic thrombophlebitis
• Abdominal aortic aneurysm
• Ischemic bowel (Mesenteric Ischemia)

Diagnosis

Workup

• Urine pregnancy
• Pelvic ultrasound
• CBC
• Chem 10
• CXR
• Progesterone level
• Estradiol level
• PT/PTT
• Fibrinogen
• Beta-HCG may be positive if beta-HCG injection given as part of fertility treatment

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 Hct (>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 (Hct >55%) WBC >25,000/mL Serum creatinine >1.6 mg/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

• Fluid Resuscitation
• Therapeutic paracentesis if necessary
• Self limited, resolved in 10-14 days
• Urgent GYN consultation

Disposition

• May require ICU admission for third spacing
• Admit all but most mild cases to monitored setting

Complications

• Ovarian torsion
• Thromboembolism

See Also

• Ectopic Pregnancy
• Shock