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Ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome. DR E.NAGHSHINEH DR.E ARSHAD. Case presentation. 31 y G1D1 Secondry infertility PMH:IVF & OHSS,IUI DH:Gonal,HMG,HCG,Metformin PSH:Laparascopy After induction ovulation :abdominal pain. Lab data. CBC(WBC:18500/Hb:15.7/HCT:46.7/PLT:290) LFT:NL

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Ovarian hyperstimulation syndrome

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  1. Ovarian hyperstimulation syndrome DR E.NAGHSHINEH DR.E ARSHAD

  2. Case presentation • 31 y G1D1 • Secondry infertility • PMH:IVF & OHSS,IUI • DH:Gonal,HMG,HCG,Metformin • PSH:Laparascopy • After induction ovulation :abdominal pain

  3. Lab data • CBC(WBC:18500/Hb:15.7/HCT:46.7/PLT:290) • LFT:NL • Na:138/k:4.5 • Cr:0.9 • Alb:2.7

  4. Hospitalization • Tab Dostinex daily • Tab Cholorpheniramin • Amp Enoxaparin • Vial Alb20% TDS • Tap of ascitis:4 Lit

  5. INTRODUCTION • The most serious complication of controlled ovarian hyperstimulation.

  6. Signs and symptoms • Abdominal distention and discomfort • Enlarged ovaries • Ascites

  7. Pathophysiology • Increased capillary permeability • Loss of fluid into the third space • Overexpressionof VEGF leading to administration of hCG

  8. Two clinical forms of OHSS • The early-onset form (occurring on the first eight days after exogenous hCG administration) • The late-onset form (occurring nine or more days after hCG administration

  9. APPROACH TO MANAGEMENT

  10. Mild OHSS • Managed conservatively • With a goal of relieving symptoms • Analgesics • Avoidance of heavy physical activity

  11. Moderate OHSS • Oral fluid intake of 1 to 2 liters per day. Diuretics are contraindicated • Ambulate Avoid sexual intercourse • Daily weights • Abdominal circumference measurements • Urinary output • Transvaginalultrasound (TVUS) • Laboratory testing CBC, electrolytes, cr, serum albumin, and liver enzymes • Daily communication with patient • Ascites/culdocentesis

  12. Ascites/culdocentesis • In women with tense ascites • Orthopnea • Rapid increase of abdominal fluid

  13. The volume of fluid to be removed is not well established. • After aspiration of 500 mL: patients typically report resolution of abdominal discomfort. • Removal of more than 4 liters of fluid is not recommended.

  14. Dopamine agonists (DA) • In women at high risk for OHSS • Cabergolin (0.5 mg/day orally), beginning on the day of hCG administration or oocyteretrieval

  15. Prophylaxis for thromboembolic • All hospitalized patients with OHSS • Outpatients with two to three additional risk factors (in addition to OHSS): • Age >35 years • Obesity • Immobility • Personal or family history of thrombosis • Thrombophilias • Pregnancy

  16. Severe and critical OHSS Hospitalization • HCT >45 percent, • Leukocytes >25,000/L • Cr>1.6 mg/dL. • Severe abdominal pain • Intractable vomiting • Severe oliguria/anuria • Tense ascites • Dyspnea or tachypnea • Hypotension • Dizziness or syncope • Severe electrolyte imbalance • Abnormal LFT

  17. Isotonic crystalloid solutions ( normal saline, Ringer's lactat) • Some clinicians use intravenous albumin in critically ill, volume-depleted patients • Thromboprophylaxis • Critical OHSS cases should be managed in an ICU • Assessment of fluid balance (daily or more often) • Weights and measurement of abdominal circumference • CBC , Electrolytes ,BUN, creatinine • Serum hCG measurements (to determine if patient has conceived) • Invasive monitoring of central venous pressure • Pelvic ultrasound as needed to evaluate ovarian size and ascites • CXR and echocardiogram when pleural or pericardial effusion is suspected

  18. Resolution and prognosis Clinical evidence of resolution includes: • Normalization of hematocrit • Progressive reduction of ascites on ultrasound • Alleviation of clinical symptoms

  19. PREVENTION • Recognizing risk factors • Using individualized ovarian stimulation regimens • Modifying treatment when indicators for increasing OHSS risk develop

  20. Thanks for attention

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