para>Pelvic and bimanual examinations are contraindicated to avoid ovarian hemorrhage or rupture.
DIFFERENTIAL DIAGNOSIS
- Hemorrhagic ovarian cyst
- Ovarian torsion
- Ectopic pregnancy
- Pelvic infection
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
- CBC
- Hemoconcentration (hematocrit >45% indicates severe disease, >55% indicates critical disease)
- WBC >15,000 indicates severe disease
- Electrolytes to look for hyponatremia and hyperkalemia
- Renal function tests
- Liver enzymes
- Coagulation profile
- ฒ-hCG
- Abdominal/pelvic US to assess ovarian size, ovarian torsion or rupture, and abdominal ascites
- CXR to evaluate pleural effusion in presence of shortness of breath
Follow-Up Tests & Special Considerations
- For patients with mild or moderate OHSS being monitored as an outpatient, CBC and electrolytes should be performed q1 " 2d, until improvement in symptoms.
- Repeat abdominal/pelvic US as needed to assess ascites and guide management for paracentesis.
Test Interpretation
- Ovarian enlargement
- Decreased renal perfusion
- Thromboembolism
- Abdominal ascites
- Pleural effusions
- Pericardial effusions
TREATMENT
GENERAL MEASURES
- Mild to moderate OHSS: generally managed as outpatient
- Oral fluid intake of at least 1 L daily of a balanced electrolyte solution (sports drinks)
- Monitor daily weight, abdominal circumference, and urine output.
- Avoid physical exertion or abdominal trauma.
- Monitor for development of further symptoms.
- Frequent follow-up is required.
- For moderate OHSS, frequent assessments q1 " 2d including a physical exam and blood work should occur.
- Consider hospitalization with worsening signs or symptoms
- Severe abdominal pain
- Severe oliguria or anuria
- Tense ascites
- Dyspnea or tachypnea
- Hypotension, dizziness, or syncope
- Severe electrolyte imbalance: hyponatremia <135 mEq/L, hyperkalemia >5 mEq/L, hematocrit >45%
- Severe OHSS: should be managed as an inpatient
- Daily weight and abdominal circumference
- Frequent monitoring of vital signs q2 " 8h
- Strict monitoring of input and output to maintain urine output of 20 to 30 mL/hr.
- Bed rest or reduced activity; the enlarged ovaries are at risk of torsion and ovarian hemorrhage either spontaneously or from injury or trauma.
- With severe illness, oral fluids should be limited and rehydration provided with IV fluids until evidence of symptom resolution such as spontaneous diuresis.
- IV fluids should be administered to maintain urine output to 20 to 30 mL/hr. Normal saline with 5% dextrose is preferred to Ringer lactate.
- Once third-space edema reenters the intravascular space, hemoconcentration reverses and the patient begins to diurese spontaneously.
- Monitor leukocyte count, hematocrit and hemoglobin, electrolytes, creatinine, and liver enzymes.
- Thrombosis prophylaxis
- Intensive monitoring may be required for pulmonary support in cases of ARDS, thromboembolic events, or for renal failure.
MEDICATION
- Prophylactic heparin 5,000 U SC q8 " 12h or low-molecular-weight heparin (LMWH); all hospitalized patients should be on anticoagulation prophylaxis and graduated compression stockings to prevent thrombotic events unless contraindications are present (2)[C]. Thromboprophylaxis should be considered in all patients with moderate to severe OHSS (2)[C].
- Full anticoagulation therapy should be started if there is evidence of a thromboembolic event.
ISSUES FOR REFERRAL
Consultation with a reproductive endocrinology specialist or a gynecologist with experience in the management of OHSS and its complications
SURGERY/OTHER PROCEDURES
- Paracentesis/thoracentesis may be required for symptomatic control and for pulmonary and/or renal compromise (2). A US-guided approach for paracentesis is recommended to avoid the enlarged ovaries.
- Indications for paracentesis include severe discomfort or pain, respiratory compromise, evidence of hydrothorax, or persistent oliguria/anuria despite adequate fluid replacement.
- Paracentesis may be performed as an outpatient procedure if there is regular monitoring and follow-up by a specialist with experience in the management of OHSS.
- Surgery should be avoided whenever possible in these patients.
- When ovarian hemorrhage is suspected, surgery may be necessary. The goal should be hemostasis, and the ovaries should be conserved when possible.
- In a situation of ovarian torsion, surgery may be performed to attempt to revascularize the ovary by unwinding the adnexa.
INPATIENT CONSIDERATIONS
Inpatients should have a CBC and electrolytes daily. Renal function, liver enzymes, and coagulation profile should be repeated as needed.
Admission Criteria/Initial Stabilization
- Abdominal pain suspicious of torsion or hemorrhage
- Intolerance of food or liquids
- Hypotension
- Significant ascites or pleural effusions or hemoconcentration: Hct >50%; WBC count >25,000
- Hyponatremia (Na <135 mEq/L) or hyperkalemia (K >5 mEq/L)
- Vital signs and O2 saturation
IV Fluids
- With severe illness, IV fluid rehydration should be used. After an initial bolus of 500 to 1,000 mL, fluid administration should continue to maintain a urine output of at least 20 to 30 mL/hr. 5% dextrose in normal saline is preferred over Ringer lactate because of the risk of hyponatremia.
- Colloids such as albumin 25% (50 to 100 g) or hydroxyethyl starch may be used when IV fluids are inadequate to maintain hemodynamic stability or urine output (3,4)[A].
- Diuretics should be used cautiously and only after intravascular volume has been restored. Diuretics may aggravate hypovolemia and hemoconcentration.
Discharge Criteria
- Tolerating oral liquids and diet, with adequate urine output
- Resolution of hemoconcentration and electrolyte imbalances
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patients discharged from the hospital should be followed by a gynecologist or physician familiar with OHSS until symptom resolution.
Patient Monitoring
Patients who have conceived should have an early US to confirm pregnancy and rule out multiple gestations and then routine antenatal care as indicated by their pregnancy.
DIET
Consume 1 to 1.5 L daily of a balanced salt solution, such as a sports drink, until resolution of symptoms.
PATIENT EDUCATION
- Monitor oral intake and urinary output; reduce activity to avoid abdominal trauma or impact.
- American College of Obstetricians and Gynecologists (ACOG) at http://www.acog.org.
PROGNOSIS
OHSS is a self-limited disease that will run its course over 10 to 14 days in the absence of an ensuing pregnancy and may persist for weeks in a pregnant patient. Supportive treatment is initiated to prevent further deterioration of the patient 's condition.
COMPLICATIONS
- Ovarian hemorrhage or torsion
- Arterial and venous thrombosis
- ARDS
- Liver or renal failure
Pregnancy Considerations
Patients who conceive a multiple gestation are at higher risk of OHSS.
Studies have shown an increased risk of prematurity, low birth weight, pregnancy-induced hypertension, and gestational diabetes in women who had severe OHSS.
REFERENCES
11 Lin H, Li Y, Li L, et al. Is a GnRH antagonist protocol better in PCOS patients? A meta-analysis of RCTs. PLoS One. 2014;9(3):e91796.22 Chen CD, Chen SU, Yang YS. Prevention and management of ovarian hyperstimulation syndrome. Best Pract Res Clin Obstet Gynaecol. 2012;26(6):817 " 827.33 Leitao VM, Moroni RM, Seko LM, et al. Cabergoline for the prevention of ovarian hyperstimulation syndrome: systematic review and meta-analysis of randomized controlled trials. Fertil Steril. 2014;101(3):664 " 675.44 Youssef MA, Al-Inany HG, Evers JL, et al. Intra-venous fluids for the prevention of severe ovarian hyperstimulation syndrome. Cochrane Database Syst Rev. 2011;(2):CD001302.
ADDITIONAL READING
- G ณmez R, Soares SR, Busso C, et al. Physiology and pathology of ovarian hyperstimulation syndrome. Semin Reprod Med. 2010;28(6):448 " 457.
- Practice Committee of American Society for Reproductive Medicine. Ovarian hyperstimulation syndrome. Fertil Steril. 2008;90(5 Suppl):S188 " S193.
- Raziel A, Schachter M, Friedler S, et al. Outcome of IVF pregnancies following severe OHSS. Reprod Biomed Online. 2009;19(1):61 " 65.
CODES
ICD10
N98.1 Hyperstimulation of ovaries
ICD9
256.1 Other ovarian hyperfunction
SNOMED
Ovarian hyperstimulation syndrome (disorder)
CLINICAL PEARLS
- Patients who have had OHSS are more at risk for OHSS in the future.
- OHSS is a self-limited disease. Management is mainly supportive.