Ovarian hyperstimulation syndrome: Difference between revisions

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*Threaputic [[paracentesis]] if ascites  
*Threaputic [[paracentesis]] if ascites  
**Aspirate 0.5-4 L
**Aspirate 0.5-4 L
*Prophylaxis for thromboembolic events (e.g. [[LMWH]])
*Thromboembolic prophylaxis (e.g. [[LMWH]])
**All hospitalized patients
**All hospitalized patients
**Outpatients with 2-3 risk factors:
**Outpatients with 2-3 risk factors:

Revision as of 12:28, 3 April 2016

Background

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

Clinical Features

Differential Diagnosis

Acute Pelvic Pain

Differential diagnosis of acute pelvic pain

Gynecologic/Obstetric

Genitourinary

Gastrointestinal

Musculoskeletal

Vascular

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[2].

Classification Clinical features Lab findings
Mild Normal
Moderate Above plus:
  • Ultrasonographic evidence of ascites
  • Elevated Hct (>41%)
  • Elevated WBC (>15,000/mL)
  • Hypoproteinemia
Severe Above plus:
  • 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: Worsening findings


Management

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

  • Urgent GYN consultation for all

Mild

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

  • Maintain intravascular blood volume (e.g normal saline)
  • Relieve ascites, hydrothorax, and/or pericardial effusion
  • Prevent thromboembolism (e.g. LMWH)

Critical

  • As for severe + resuscitation 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)
    • Encourage oral fluids (1-2 liters/day)
    • Ambulate, but avoid other physical activity. Avoid sexual intercourse
    • Daily weights, abdominal circumference measurements, and urinary output recordings
  • Severe: admit
  • Critical: ICU

Disposition

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

Complications

See Also

References

  1. Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
  2. Navot D, Bergh PA, Laufer N. Ovarian hyperstimulation syndrome in novel reproductive technologies: prevention and treatment. Fertil steril 1992; 58:249. From: Fiedler K, Ezcurra D. Predicting and preventing ovarian hyperstimulation syndrome (OHSS): the need for individualized not standardized treatment. Reprod Biol Endocrinol 2012; 10:32. Copyright © 2012 Fiedler and Ezcurra. Reproduced from BioMed Central Ltd