RISK FACTORS: Young age, Low body weight, High doses of gonadotropins, Large number of intermediate sized follicles, Number of oocytes retrieved, Rapidly rising estradiol levels, High estradiol levels, Use of hCG for luteal support
RISK FACTORS
β’ Young age
β’ Low body weight
β’ High doses of gonadotropins
β’ Large number of intermediate sized follicles
β’ Number of oocytes retrieved
β’ Rapidly rising estradiol levels
β’ High estradiol levels
β’ Use of hCG (human chorionic gonadotropins) for luteal support
β’ Polycystic ovarian syndrome or polycystic ovaries on ultrasound
β’ Achievement of a pregnancy
β’ Multiple pregnancy
APPROPRIATE HEALTH CARE
. Mild OHSS
. Outpatient management with frequent followup
. Avoid physical exertion or possible abdominal trauma or impact
. Monitor for the development of further symptoms
. Self-limiting
. Moderate or severe OHSS including nausea or abdominal pain causing intolerance of food or liquids, or
abdominal pain suspicious of ovarian rupture or torsion.Other indications of moderate or severe OHSSinclude:
hypotension, abdominal ascites or plural effusions, hemoconcentration (Hct > 50%, WBC > 25,000), hyponatremia (Na < 135 mEq/L) or hyperkalemia (K >5.0 mEq/L) or ultrasound fi ndings of ascites with floating
bowel.
. Admit to hospital for further investigations
GENERAL MEASURES
. OHSS treatment consists of supportive and preventative measures to reverse the physiological changes
which occur and prevent complications
. During hospitalization
. Bedrest
. Daily body weight determination, strict monitoring of input and output, frequent monitoring of vital signs
including pulse oximetry, hemotocrit, hemoglobin and leukocyte count, creatinine, and electrolytes and liver
enzymes
. Hypovolemia requires fl uid resuscitation with crystalloid solutions
. Patients who cannot sustain adequate urine output with crystalloids may need 25% albumin
. Ascites should not be treated with diuretics because of the risk of intravascular fl uid depletion, but may
require paracentesis for symptomatic control and for pulmonary and/or renal compromise. A transvaginal
ultrasound guided approach is recommended to avoid the enlarged ovaries.
. Intensive monitoring may be required for pulmonary support in cases of ARDS or for renal failure
. Anticoagulation prophylaxis
SURGICAL MEASURES Surgery should be avoided whenever possible in these patients, and should not be used for ovarian aspiration. In situation of ovarian torsion, surgery may be performed to attempt to revascularize the ovary by unwinding the adnexa. When ovarian hemorrhage is suspected, surgery may be necessary. The goal should be hemostasis, and the ovaries should be conserved when possible.
ACTIVITY Patients being managed as outpatients or inpatients should be on bedrest or reduced activity. The enlarged ovaries are at risk of torsion and ovarian hemorrhage spontaneously, or from injury or trauma.
DIET
. Outpatient management
. Oral intake of 1.0-1.5 liters daily of balanced salt solution (sports drink) is recommended
. Record daily weight and urine output
. Inpatient management
. In the initial phase of hospitalization, patients may too nauseated to eat or drink. Once third-space edema
reenters the intravascular space, hemoconcentration reverses, and the patient begins to spontaneously
diurese. Fluid restriction at this point may prevent hemodilution.
PATIENT EDUCATION
. OHSS is a self-limiting disease. Patients who have conceived may have a longer course, however, the
disease will often resolve within two weeks. Supportive measures are the only treatment until the disease runs
its course.
. Patients who have had OHSS are more at risk for OHSS in the future, and this should be taken into
consideration in their next treatment cycles
DRUG(S) OF CHOICE
β’ Heparin 5000U SC every 8-12 hours. Hospitalized patients should be on anticoagulation prophylaxis to
prevent thrombotic events
PATIENT MONITORING
β’ Patients discharged from hospital should be followed with frequent health care provider contact until symptom resolution
β’ Patients who have conceived should have an early ultrasound to confirm pregnancy and rule-out multiple
gestations, and then routine antenatal care as indicated by their pregnancy
PREVENTION/AVOIDANCE Patients who have had OHSS are at high risk of a recurrence in their next COH cycles. The stimulation and monitoring protocol may be modifi ed to reflect this risk. If a patient is noted to be at high risk prior to induction of ovulation, consideration should be given to canceling the stimulation by withholding the preovulatory/pre-oocyte retrieval injection of hCG.
POSSIBLE COMPLICATIONS
β’ Ovarian hemorrhage
β’ Ovarian torsion
β’ Arterial and venous thrombosis
β’ Adult respiratory distress syndrome
β’ Liver failure
β’ Renal failure
EXPECTED COURSE/PROGNOSIS
OHSS is a self-limiting disease that will run its course over 10-14 days in the absence of an ensuing pregnancy, and may persist for weeks in the pregnant patient. Supportive treatment is initiated to prevent
further deterioration of the patientβs condition.