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MRCOG PART 2 SBAs and EMQs

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Essay 291 - Sub-fertility

Posted by dr neelangini G.
a) I will like to take history of severity of pain, nature of pain weather intermittent or continuous . Site of pain & aggravating factors should be sought to rule out gastritis, UTI. History of fever & vaginal discharge to be noted to rule out PID. Her previous records of hormonal treatment & serum oestrogen levels on the day of HCG administration will be seen as there is possibility of OHSS. I will also ask her current history of progesterone & HCG treatment & number of embryos transferred . Previous history OHSS will be asked as more chance of recurrence. I will like to know her recent weight gain, breathlessness, lump or heaviness in abdomen as these are suggestive of OHSS. Subjective decrease in urine output should be sought . On examination her weight and height for BMI for weight gain, vitals like Pulse , B.P. R.R . to know the severity & s/o shock. Pallor to see anaemia secondary to intraperitoneal bleeding. . I will examine her respiratory system & cardiovascular system to find out hydrothorax or pericardial effusion. Per abdominal examination to see any distension, mass, and ascites. Per vaginal examination by speculum to see any vaginal discharge .

b) I will ask for investigations like FBC, Haematocrit, U&E, I would also do LFT to know hypoalbuminaemia . MSSU to rule out UTI. U/S to know ascites, ovarian mass & its size as this is one of the criteria to diagnose severity of OHSS. X- Ray chest & ECG – Echocardiography are necessary if she has chest symptoms . I will see her coagulation profile as risk of DIC is more with OHSS.

c) As management of OHSS depends on severity of OHSS , I will ascertain the degree of OHSS . In severe case with pain, ascites +/- pleural effusion, haematocrit more than 44%, I will admit her in ITU. Intravenous fluids in the form of crystalloid will be started to replace fluid loss . Antiemetics will be given to control vomiting. Analgesics like paracetamol or codein sulphate will be started .Multidisciplinary approach is important involving physician, haematologist, and a clinician expert in management of OHSS . Daily monitoring of weight gain, abdominal girth, Input/Output charting to know oliguria. Daily investigations like FBC, serum electrolytes, LFT, clotting to know the prognosis. If ascites is causing distress ,U/S guided paracentesis is an option . I will stop Inj. HCG as this aggravates the condition , but I will allow her to continue progesterone for luteal support of IVF cycle. I will start her on thromboprophylaxis by LMW heparin as risk of arterial thrombosis is more in this condition. In mild to moderate OHSS , I will manage on OPD basis .I will tell her to come for follow up, every 2-3 days for her weight gain , abdominal girth & investigations FBC, U&E, U/S . I will give her contact number if she develops any complication.I will assure her that most of the OHSS get subsided with conservative treatment & it does not have any adverse effect on pregnancy. I will provide her with information leaflets. I will fill up incident forms. If she does not respond to conservative management & her condition get deteriorated, I will give a choice of termination of pregnancy. Patients wishes are also to be considered.
Posted by G. K.
a
A history of PCOS and subfertility folllowed by IVF, and leading to the symptoms of abdominal pain and vomiting are highly suggestive of Ovarian hyperstimulation syndrome.However, a thourough history and examination should be undertaken to confirm the suspected diagnosis and rule out other causes of abdominal pain.
Inquiry should be made about the severity of symptoms. Any aggravating or relieving factors should be inquired about along with the type of pain and it\'s location and radiation.
Any associated symptoms such as urinary and bowel problems should be inquired about to rule out the possibility of UTI and gasteroenteritis.
Medical history relating to peptic ulcer disease, gall stones, cholycystitis, pancreatitis should be inquired about.
Inquire about any past history of surgery such as appendectomy, cholycystectomy.
Inquire about alcohol intake, since it can be associated with pancreatitis.
Examination include blood pressure, pulse and temperature measurement.
Abdominal examination should be carried out to assess the location severity of pain by checking for tenderness , guarding, rigidity and rebound tenderness.Rosving\'s sign can be elicited if appendicitis is suspected.Abdomen should be asesessed for by measuring the girth checking for ascites.
Chest should be auscultated if any respiratory symptoms and percussed to elicit presence or absence of hydrothorax.
Renal angles tenderness should be checked for if Pyelonephritis is suspected.
Pelvic examination should be done to palpate any adnexal masses.
b)
Investigations include, FBC, coagulation screen U&Es, LFTS and renal function tests.CRP and ESR to asess systemic inflammatory response.
Pelvic and abdominal ultrasound to assess ovarian size, presence of ascites.Chest x-ray should be done if there are any respiratory symptpoms, to rule out hydrothorax.
c
Depending on the severit of symptoms, the patient can be managed as an outaptient or as an inpatient.
In case of mild or moderate symptoms, oral paracetamol and antiemetics are all that is needed. Patient should be reviewed daily for asseessmment.
If the patient condition is worsening or the symptoms are severe enough to begin with, she should be hospitaliized for hydration, analgesia and aniemtics.Most patients settle with conservatve management.They are advised to increase their oral fluid intake.They can continue to take oral progesterone support but not HCG supportshould be stoped.
In case of severe or critical condition which is characterized by severe vomiting and pain,tense ascites, respiratory compromise, and oliguria,the patent should be transferred to Intensive care unit and her care should be in close collaboration with Intensive care consultants. Care should include judicious fluid replacement to correct haemoconcentration and dehydration,hourly urometry,paracentesis of ascites or drainage of hydrothorax if present.Thromboprophylaxix in the form of TEDS and LMWH should be instituted as soon as possible. Albumin infusion can be given if serum albumin is very low.
Regular monitoring of U&Es, creatinine, and hematocrit should be carried out.
Surgery isnot indicated unless there is torsion/rupture of enlarged ovaries.
The HFEA should be informed of the incident within 12 hours and an incident form should be filled.
In case of


Posted by S D.
a) The most likely gynaecological causes could be OHSS, PID and ovarian cyst accidents. However other causes such as UTI, appendicitis, cholecystitis should be considered. History of abdominal distension with pain and shortness of breath suggests OHSS (considering PCOS and IVF treatment), Offensive pv discharge with lower abdominal pain and pyrexia suggests PID. Unilateral lower abdominal pain which was initially intermittent and now continuous pain with vomitings suggests ovarian cyst torsion. H/O dysuria with loin pain, fever and vomiting suggests pyelonephritis; Right hypochondrial pain with vomitings may suggest cholecystitis. H/O right iliac fossa pain with vomiting,constipation and anorexia suggests appendicitis.
Examination includes checking PR, BP, Temp.
CVS examination for muffled heart sounds suggesting cardiac effusion, Respiratory examination for tracheal deviation and decreased air entry for pleural effusion.
Abdominal examination for distension, palpable masses, tenderness, guarding and rigidity should be checked.
P/S for any vaginal or cervical discharge
Bimanual exam for uterine tenderness and adnexal tenderness suggesting PID.
b) FBC to check for anaemia and leucocytosis points towards systemic inflammatory response along with raised CRP. Base line serum B-HCG along with U&E\'s, LFT\'s and clotting. USS abdomen and pelvis for ovarian cysts, ascites, gallstones. CXR if pleural effusion suspected; ECG and ECHO if cardiac effusion suspected.
c) Management depends on severity of OHSS. Unit protocol for management of OHSS should be followed. If mild or moderate OHSS, then patient can be managed as an outpatient. Treatment is supportive until resolution of symptoms. She should be given verbal and written information on the signs and symptoms of OHSS, symptoms needing urgent assessment, 24 hour contact number for advice and support. She should be advised to drink to thirst, adequate pain relief by paracetamol or codeine provided. She should be reviewed regularly every 48-72 hrs with checking of weight and abdominal girth and reviewing of symptoms. If symptoms become worse or pain remains uncontrolled, then will need admission.
If severe or critical OHSS characterised by severe haemoconcentration, abnormally deranged LFT\'s, U&E\'s and clotting with tense ascites and pleural and pericardial effusions, she will need admission. Management is multidisciplinary with involvement of consultant gynaecologist, anaesthetist, ITU physician. IV fluids , either cystalloids or colloids should be started with strict input and output chart. Pain relief by paracetamol or codeine given and NSAID\'s avoided as it may cause renal failure. Maternal monitoring by PR, BP, TEMP, RR, O2 Sats; Investigations such as FBC, U&E\'S, LFT\'s, clotting every 4-6 hrs; review of clinical condition daily with checking of weight, abdominal girth, clinical symptoms should be done. USS of abdomen and pelvis and CXR need to be repeated with progressive symptoms. TED stockings and apropriate thromboprophylaxis should be given as at high risk of VTE secondary to haemoconcentration. If oliguria persists despite adequate fluid replacement, then paracentesis under ultrasound guidance should be done as relieving intraabdominal pressure may improve renal perfusion. This may inturn relieve pleural effusion in some cases but if not, then pleural tap has to be performed. If oliguria persists inspite of these measures, then CVP monitoring with involvement of ITU physician should be done with a cautious trial of diuretics. TOP is the last option if condition deteriorates inspite of effective resuscitation.



Posted by Ahmad A.
Assessment of her general condition, vital signs. High temperature and tachycardia may prove infection and/ or deep venous thrombosis (DVT). High pulse rate and hypotension may prove internal haemorrhage and/or rupture ovarian cysts or twisted ovary. Severe abdominal pain, tachycardia, abdominal tenderness and rigidity may indicate torsion ovaries and/ or acute appendicitis. Signs of dehydration, tachycardia and decrease urinary out put and abdominal distension, big ovaries and ascites indicate ovarian hyperstimulation (OHSS). Gentle palpation of the abdomen, evaluation of the sizes of the ovaries and presence of ascetic fluid. Chest auscultation in case of difficulty of breathing especially in the back. Reduced air entry can be seen with pleural effusion. Assessment of the signs of DVT like tenderness, redness and leg oedema. Other possible risk factors can be assessed like body weight. Severity of the condition can be assessed and determine the case for admission.


Initial full blood count indicates presence of haemoconcentration, increase WBCs, RBCs and haematocrite concentration. Renal functions in form of BUN, creatinine and serum electrolytes, K, Na and Cl. Also liver enzymes (ALT, AST, biluribin) total protein and serum albumin. Urine test, dip stick and culture in case of possibility of infection (high nitrites and protein). CRP and ESR should be asked in suspicious of infection. Ultrasound abdomen and pelvis, to evaluate ovarian size and amount of ascetic fluid. Also Doppler can be asked to rule out torsion of the ovary. Chest X-ray may be asked in case of possibility of pleural effusion with shielded abdomen.


OHSS case should be assessed first regarding its severity. As, mild to moderate cases can be managed at home with paracetamol, antiemetic and luteal phase support in form of progesrone only and to avoid taking HCG. Patient can be asked to observe her symptoms and urine output and to reports to the hospital in case of increasing distension, difficulty in breathing, signs of DVT and reduction of urine output.
In case of moderate to severe cases admission should be offered under observation. The severity of the case can be determined first by severity of the patient\'s symptoms and the signs, size of the ovaries, amount of ascetic fluid, presence of pleural effusion, reduced urine out put and DVT symptoms and signs. Observation can be either in regular gynaecolgical ward or high dependent unit according to the severity of the case. Regular evaluation of the vital signs, daily body weight, abdominal girth and strict input-output chart. Increase fluid intake in case of reduced urine out put <30 ml/hour. Correction of the electrolyte imbalance using crystalloid and possible of plasma expander (Hestril). Oral fluid only on demand to avoid overload and accumulation of the ascetic fluid in case of normal output. Pain killer in form of paracetamol and thromboprophlaxis in form of low molecular weight heparin as daily injection and leg stockings. Diuretics should not be prescribed as it will aggravate the incidence of DVT. Abdominal tapping (parcentesis) can be offered in case of increase ascetic fluid, distension and pressure symptoms. Albumin infusion 100ml of 20% can be offered in case of tapping for each 1000 cc fluid. It is a self limiting disorder, however it may be persist and become more severe in case of pregnancy. So, termination of pregnancy can be discussed in such cases.
Posted by zakaria M.
drink to thirst, rather than to excess
Posted by zakaria M.
A)
Considering the history and presenting symptoms most likely cause can be ovarian hyperstimulation syndrome, alternative diagnoses need to be considered are complication of an ovarian cyst, pelvic infection, intra-abdominal hemorrhage and appendicitis. Thorough clinical assessment keeping in mind these possible causes will help in correct diagnosis and management accordingly. First of all I will assess general condition of patient, her B.P & pulse, respiratory rate, severity of her symptoms, to address the acute issues first. Followed by a detailed history of her presenting complaints, duration of onset of pain, severity and exact localization if possible. Any history of fainting attacks (any ovarian cyst accident), shortness of breath, chest pain, hemoptysis. I will inquire about any complaints of fever, foul smelling vaginal discharge (pelvic infection), bowel or urinary symptoms and calf pain. After taking history I will complete examination, look for signs of dehydration. Abdominal examination for any obvious distension, localized tenderness, shifting dullness, fluid thrill (ascites) , guarding or rigidity (signs of peritoneal irritation), any palpable mass and bowel sounds. I will measure abdominal girth and weight. I will examine chest for clinical signs of any pleural effusion and auscultate heart. Examine the limbs for any sign of DVT. I will note down few details about IVF to look for additional risk factors for ovarian hyperstimulation i.e. use of GnRH agonists, number of ovum retrieved, number of embryos transferred & any previous episode of OHSS.
b)
Investigation will include Blood group and save as even in stable patient condition could worsen overtime. CBC to look for any leukocytosis, hemoglobin level and hematocrit. Urea & electrolytes, LFTs, serum protein, coagulation profile will also be sent. Abdominal ultrasound scan to look for size of ovaries, ascites, gestational sacs. Chest X-ray in case of respiratory symptoms / signs. ECG and echocardiography will be done if suspected pericardial effusion.
(c)
Management of ovarian hyperstimulation is guided by the severity of the condition, but this may change over time. I will follow hospital protocol for management of OHSS.
Mild / moderate OHSS i.e. mild/moderate abdominal pain, ovarian size < 8cm (mild) or about 8-12 cm and ultrasound evidence of ascites in moderate cases can be managed on out patient basis. As underlying pathology is increased capillary permeability leading to leakage of fluid from vascular compartment to third space. Main principle of management is to restore intravascular fluid, provide analgesia & maintain close surveillance to identify and treat serious complications. Analgesics include paracetamol or codeine, non steroidal anti inflammatory drugs are avoided as they may compromise renal function.. She will be counseled to drink to thirst, rather than to excess , avoid strenuous exercise and sexual intercourse as there is risk of injury to enlarged ovaries.She is advised to review after 2 days, and to report immediately in case of increased pain, abdominal distension, reduced urine out put or shortness of breath.
In case of no relief / deterioration of symptoms or severe cases with clinical ascites + hydrothorax oliguria, hematocrit > 45%, ovaries > 12cm patient needs admission. Multidisciplinary care provided including intensive care specialist, anesthetist and medical specialist. Critical cases with hematocrit >55%, tense ascites, large hydrothorax, WBC > 25000/ml, thromboembolism, oliguria/anuria and acute respiratory distress need prompt intensive care. A doctor experienced in managing OHSS will be overall incharge. Woman and her partner will be reassured that OHSS has no adverse effect on pregnancy. Management is mainly supportive, with analgesics (paracetamol or opiates), anti emetics & I/V fluids +/- albumin to restore intravascular fluid.TED stocking and prophylactic heparin given considering high risk of thrombosis, continued until discharge or longer in case of other risk factors.Patient will be assessed daily or more frequently in critical cases, inquired about symptoms of pain, shortness of breath, nausea/vomiting, chest pain/hemoptysis and calf pain. B.P & pulse checked 4-6 hourly, weight and abdominal circumference checked daily, intake/output charts maintained. CBC, U&E, LFT, Coagulation profile tested daily. Rising WBC count, hematocrit, and abnormal electrolytes are markers of increasing severity. Invasive monitoring considered if oliguria persists despite colloids. Diuretics should be avoided. or considered only with invasive monitoring. Ultrasound guided paracentesis considered in cases of distress due to marked ascites or persistent oliguria. I/V colloids will be given in case of drainage of large volumes, as massive fluid shifts may cause cardiovascular collapse. Laparoscopy/laparotomy considered in case of ovarian torsion, by an experienced surgeon after careful assessment. Termination of pregnancy my be required in exceptional circumstances.










Posted by Neelam A.
NA
(a)As she is high risk for ovarian hyperstimulation following in-vitro-fertilization, a detailed history of abdominal pain and vomiting should be taken. Site, nature, intensity, episodic or continuous and aggrevating and relieving factors for pain should be asked. History of fever, thirst, dark coloured urine, reduced urinary out-put, bloated abdomen, tender swollen legs or neurological symptoms should also be obtained. Past history of ovarian hyperstimulation should also be taken into consideration. Personal or family history of venous thromboembolism should also be documented. Type of hormonal support should also be asked as HCG makes ovarian hyperstimulation worse
I should check BP, temperature oxygen saturation, respiratory rate, weight, abdominal girth, signs of dehydration in form reduced skin turgor and chest auscultation for abnormal sounds. Lower limbs should be examined in presence of red swollen legs. Abdominal examination should be done to localize the site of tenderness, presence of guarding and rebound tenderness, free fluid and abdomino-pelvic lumps.
(b)Urine pregnancy test should be done to diagnose pregnancy. Bloods should be obtained for FBC, urea and electrolytes, liver function test and clotting screen. Ultrasound scan should be done to see size of ovaries, tubo-ovarian mass, ectopic pregnancy, intrauterine pregnancy, inflamed appendix and presence of free fluid. Thrombophilia screening, compression Duplex ultrasound and Ventillation-Perfusion scan should be performed if there is suspicious of venous thromboembolism. X ray chest and ultrasound should be performed if there is clinical evidence of plural effusion. ECG and echocardiography are indicated in cases of pericardial effusion.
(c)Management depends on category of ovarian hyperstimulation. Mild cases can be managed as out- patients. Paracetamol or codeine can be given for pain. Non steroidal anti-inflammatory should be avoided as they adversely affect the kidneys. Oral intake of fluid should be restricted to fulfil the thirst. Strenuous excercises and intercourse should be avoided as there is risk of rupture of enlarged ovaries. Symptoms should be monitored. She should be encouraged to mobilize. Worsening of symptoms would require admission.
Moderate to severe forms of ovarian hyperstimulation would require in-patient care. Their care should be multidisciplinary and should be managed in intensive care. Injectable opiates can be given to control pain. Antiemetics in form of cyclizine or stemetil can be prescribed. Main aim is to correct dehydration as there is reduced intravascular volume. Intravenous crystalloid or colloid can be given. Diuretics should be avoided in cases of reduced urinary output unless there is evidence of ARDS (adult respiratory distress syndrome). Full length stocking should be worn and clexane prophylaxis should be given as she is increased risk of venous thromboembolism. Her progress should be monitored by abdominal girth measurement, clinical symptoms and bloods. Rarely abdominal paracentasis is needed in cases of persistent oliguria. It should be done under ultrasound as there is risk of ovarian damage. Plural or pericardial effusion might require aspiration. Surgery might be required in cases of twisted enlarged ovaries.
HCG hormonal support should be stopped, progesterone support should be continued. She should be reassured that there will be no adverse effects on pregnancy. Patient information leaflet should be provided. Incidence form should be filled and Human Fertilization and Embryology Authority should be informed.
Posted by Manoj Babu  R.
(a) Justify your clinical assessment. [6 marks]
Detailed history may help to identify complications IVF like OHSS, ovarian cyst accidents and pelvic infection as well as unrelated causes like, acute appendicitis. Presence nausea, vomiting, severe of abdominal pain, abdominal distention and breathlessness may suggest severe OHSS. History of fever, vaginal discharge may suggest infection. Check her notes for the number and size of ovarian follicles, type of luteal support given.

Examination should include weighing, vitals, edema and CVS and respiratory system examination for any evidence of pleural effusion and basal crepitations. Abdominal examination should include measurement of abdominal girth, free fluid, localized tenderness and presence of any mass. Per vaginal examination may confirm large ovarian masses, tenderness may suggest torsion or pelvic infection.

(b) How would you investigate her symptoms? [4 marks]

History and examination should be able to guide investigations. The diagnosis of complications like OHSS is usually straight foreword. Serial serum beta hCG may help to confirm pregnancy which is the most important risk factor for severe OHSS. Other lab investigations include FBC, urine dip stick test for pus cells and appropriate swabs should be taken from the cervix if pelvic infection is suspected. Total count may be raised if there is pelvic infection, appendicitis or severe OHSS.

Investigations should include a TVS to see for evidence of OHSS, and to access the severity based on the size of the cysts and presence of ascites. It may suggest causes like torsion of ovaries as evidenced by probe tenderness and Doppler studies. Abdominal USG may help to diagnose acute appendicitis.

(c) She has ovarian hyperstimulation syndrome. Justify your management. [10 marks]

Four cases of deaths due to OHSS have been reported in the last CEMACH. Three of them had confirmed pregnancy. Once the diagnosis made, the management depends on the severity. Mild to moderate OHSS can be managed on an outpatient basis. Severe OHSS needs admission.

Symptomatic management on out-patient basis includes analgesics like parcetamol and codeine. NSAIDS should be avoided as they can precipitate renal failure in OIHSS. They should be advised drink fluids according to their thirst and report if there is reduced urine output. They should be advised to avoid sexual intercourse and strenuous exercise to prevent possible rupture and torsion. Luteal support can be continued with progesterones but hCG should be avoided as it increases the severity.

Hospital review should be done every 2-3 days and should include inquiry about reduced urine output or shortness of birth. Examination should include charting of weight and abdominal girth. Investgations include haemoglobin, haematocrit, serum creatinine, U&E, LFT and TVS for ascites and size of the cysts. Chest X ray and ECG should be considered in women with cardiorespiratory symptoms.

Inpatient management includes supportive management and monitoring to detect complications. Multidisciplinary team comprising intensivists and physician should be involved in the management of critical OHSS. Supportive management should consider parenteral and analgesics, IV fluids and antiemetics if oral tolerance is not adequate. Thromoprophylaxis with TED stockings and LMWH should be given to all as thrombotic complications especially arterial thrombosis is a common cause of death in severe OHSS.

Daily monitoring should include weighing, abdominal girth, symptom charting, urine output and lab parameters like FBC, hemoglobin, haematocrit, serum creatinine, U&E and LFT. Increasing total count and haematocrit suggest worsening of the condition. Electrolyte abnormalities like hyponatrimia, wosening renal and liver functioin are common in severe OHSS.

Drainage of ascites and pleural effusions is important to relive the distress of women and prevent excess intraabdominal pressure. Aspirations should be done under ultrasound guidance to avoid injury to vascular ovaries. Role of surgery is only for csyt complications like rupture and torsion.

Women and partner should be counseled adequately and they should be reassured that pregnancy may continue normally and there is no evidence of any long-term sequale to the fetus.
Posted by Joanna L.
A 35 year old woman with the polycystic ovary syndrome and sub-fertility has undergone in-vitro fertilisation and embryo replacement. Five days after embryo replacement, she attends the emergency gynaecology clinic complaining of abdominal pain and vomiting.

(a) Justify your clinical assessment. [6 marks]
The most important symptoms to assess are breathlessness and abdominal bloating and pain. I would ask her whether she is breathless at rest or how much exercise she can do.

I would examine her abdomen, including percussion for shifting dullness, and measure her abdominal girth as well as temp, pulse and BP as a baseline. I would ask her how many eggs were collected as the more eggs, the higher the chance of OHSS.

She is at high risk of ovarian hyperstimulation as she has PCOS and is undergoing IVF, this would be late onset OHSS as she has had the embryo\'s replaced.


(b) How would you investigate her symptoms? [4 marks]
She should have an ultrasound scan as soon as possible for assessment of ovarian size as well as degree of ascites. It may also be helpful to mark a possible site for an ascitic drain or placement with US guidance. If there is significant ascites, US of chest or CXR to look for pleural effusions.
I would take blood for FBC - to assess haemoconcentration, U&E for renal function and LFTs for albumin level as this may need to be replaced.
It is a little early for a pregnancy test, as this may be falsely positive from the hCG injection, but this will need to be considered as pregnancy worsens the condition.

(c) She has ovarian hyperstimulation syndrome. Justify your management. [10 marks]

This can be a very serious and potentially life threatening condition.
Treatment is supportive as there is no cure for OHSS and it will be more severe if she is pregnant.

If the symptoms are mild she can be managed as an outpatient, told to drink to thirst and not excessively, and to report to hospital if she becopmes more breathless, more bloated or generally unwell. She can have an USS as an outpatient and contact her IVF unit at the first opportunity. Quite often she will have been given a telephone number for an on-call IVF doctor for advise. She should take simple analgesia as required and avoid medication not appropriate for pregnancy.

If the condition is more severe she should be admitted to hospital. The on-call consultant should be informed of her admission and condition as soon as possible, as well as her blood results when they are available. Her IVF consultant should also be informed at the earliest opportunity.

She will need careful fluid replacement and fluid balance to avoid overloading. If she remains oliguric despite fluid replacement she may need a central line.

She should have heparin and TED stockings for thromboprophylaxis as OHSS causes hypercoagulability compounded by immobility.

She may need ascitic drainage which should be done in a controlled fashion to prevent abrupt decompression of the peritoneal cavity and further blood volume loss. She may need albumin replacement, particularly if the ascites is drained as this is an exudate.

She should be given analgesia and antiemetics as required.

Her abdominal girth should be measured daily and she should have blood taken daily for FBCi inc haematocrit, U&E, albumin. TPR should be checked 4hourly or more often if acutely unwell. She may need to be admitted to ICU, and so anaesthetists/ICU physicians should be involved. As previously mentioned she will need a pregnancy test in due course.

She should be reassured that there is no reason that the pregnancy should not continue normally.
Posted by clarice M.
a) This patient is at risk of ovarian hyperstimulation syndrome (OHSS). However, other causes of abdominal pain and vomiting should be sought. A history of increasing generalised abdominal pain and increasing abdominal distension would be suggestive of OHSS. Patients can also complain of tachypnoea or pleuritic chest pain due to increasing abdominal distension or a thromboembolic event as a result of the fluid shift. A history of urinary frequency, dysuria and loin pain would be suggestive of a urinary tract infection or pyelonephritis. A history of central abdominal pain which localises to Mc Burney\'s point is suggestive of appendicitis. A history of diarrhoea and vomiting is associated with gastroenteritis.

Basic observations of the patient\'s pulse, blood pressure, oxygen saturation, and temperature should be done.

An examination of the respiratory system is important to exclude a pleural effusion. An abdominal examination should include abdominal girth if there is abdominal distension due to ascites. Renal angle tenderness is associated with pyelonephritis. For completion, the patient\'s calves should be measured for graduated compression stockings. A height and weight measurement will provide a guide to prophylactic low molecular weight heparin required as well as a baseline to assess improvement if she has OHSS.

b) A urinalysis should be performed and if positive for nitrites, a mid-stream urine sample should be sent for microscopy, culture and sensitivity.

A blood sample should be sent for full blood count to look for leucocytosis and haemoconcentration. Urea and electrolytes should also be checked as renal function may be impaired by OHSS or pyelonephritis. Liver function tests including corrected albumin concentration should also be requested as a low albumin may necessitate an colloid transfusion. A quantitative hCG may indicate whether the embryo transfer was successful.

An ultrasound of the pelvis should be requested to assess the size of the ovaries and if there is ascites present. An erect chest x-ray with appropriate shielding to the pelvis should also be requested as this will demonstrate a pleural effusion. The presence of free air under the diaphragm is suggestive of a perforated viscous.

c) OHSS is a self limiting condition. It may increase patient anxiety, hence the condition should be explained and the aims of treatment emphasised. As this patient has vomiting AND abdominal pain, the classification of her OHSS is at least \"moderate\". The aims of treatment are to reduce the level of patient discomfort and prevent a venous thromboembolism (VTE).

Regular analgesia and anti-emetics should be prescribed. Non-steroidal analgesia should be avoided. As this condition is self limiting, outpatient management may be considered. The patient should be advised to drink whenever she feels thirsty. However, intravenous fluid replacement should be commenced if the patient is unable to tolerate oral fluids. Colloid replacement is not usually required but should be considered if the condition worsens or if there is reduced hourly urine output. Admission to hospital should also be considered if pain control is poor. Admission is mandatory if respiratory compromise is present.

Prophylactic LMWH should be administered to reduce the risk of a VTE. Graduated compression stocking should also be worn. Oxygen therapy may be necessary if oxygen saturations are less than 92% on air.

Drainage of a pleural effusion may be necessary if there is significant respiratory compromise or a lack of improvement with supportive therapy. Similarly, drainage of ascites should be considered if there is increasing abdominal distension or a lack of improvement with supportive therapy. Drainage of ascites should be done by an experienced individual and under ultrasound guidance to avoid ovarian cyst rupture. Drainage of ascites should be gradual to avoid an exacerbation of fluid shift into the 3rd space.

Hourly urine output should be documented to guide fluid replacement Blood tests should be performed daily to assess improvement.

Admission to a high dependency unit should be considered if the patient does not improve with supportive therapy or worsens as a result of the natural history of OHSS.




Posted by Mark D.
=============================================
a)
The history is suggestive o f ovarian hyperstimulation syndrome but other causes like ,pyelonephritis, appendicitis,gastroenteritis ,and acute cholecystitis should be ruled out by well directed history. History of pain – its onset, character, constant or intermittent any aggervating or reveiving factors should be asked. Associated symptoms like fever, diarrhea or dysuria and chest discomfort or abdominal distension should be asked .past history of similar pain should be asked. Past history of ovarian hyperstimulation in previous cycles, appendicitis, renal or gall stones should be enquired. dysuria with loin pain and back pain and fever is suggestive of pylonephritis.right illac fossa pain with fever and rebound tenderness suggests appendicitis. History of renal /ureteric calculi point to renal colic.
Examination including weight, BMI, pulse BP, temperature should be taken.abdominal examination to locate tenderness and rule out signs of acute abdomen like rebound tenderness should be done. Bimanual examination should be done gently to detect any ovarian mass or cervical tenderness.
b)
I will take blood for FBC, Hematocrit, renal and liver function tests. I will ask for an abdominal and pelvic ultrasound to check for ovarian volume, presence of ascitis and rule out ureteric calculi.
If the patient has repiratory difficulty I will ask for xray chest to rule out pleural effusion and and ECG to check for signs of pericardial effusion.
c)
I will check from usg and hematocrit whether it is mild to moderate or severe OHSS. If ovarian volume less than 12 cms,hematoicrit less than 45 and symptoms not severe then it is moderate and can be given symptomatic treatment with analgesics and antiemetics on opd basis and followed up every 2-3 days. However the late onset OHSS tends to be severe .If hematocrit more than 45 and gross acsitis, severe voimtings and pain, and ovarian volume more than 12 cms is severe OHSS and needs admission.i will give symptomatic treatment with analgesics and antiemetics .NSAIDS should be avoided as may cause renal toxicity.
I will moniter the patient for pain, abdominal girth, p, BP, respiratory rate, and input output at 6 -8 hourly intervals and repeat investigations FBC, RFT,LFT, and serum albumin daily to check the severity.
She should be asked to drink to thirst.If cannot tolerate orally iv crystalloids or colloids (HES startch) will be given to maintain hydration. If despite colloids there is persistant oligouria or if there is severe respiratory difficulty then ascitic tapping should be done. Paracentesis should be done under continous ultrasound guidance to avoid trauma to the enlarged vascular ovaries. Drained volume should be adequately replaced.
Pleural effusion generally subsides after ascetic tapping but if causing severe respiratory discomfort then may need drainage. Most cases respond to supportive management.
Leuteal phase support should be given by vaginal progesterone and inj HCG avoided.
If PCV is more than 55% , wbc more than 25000/ml and massive ascitis with deranged renal function then this is critical OHSS.she should be transferred to ICU for more frequent monitering and managed by multidisciplinary team including intensivist, senior infertility specialist,anesthetist and renal physician with invasive monitoring like CVP line. Thromboprophylaxis should be given with low molecular weight heparin and TED stockings till well hydrated and fully mobile and symptoms resolve.Some may need it till end of first trimester.In refractory cases may need termination of pregnancy as Maternal mortality may rarely occur due to ARDS and venous thromboemboilsm.
Case should be informed to HEFA and CRM form filled .Couple should be updated about the proceedings at regular intervals. In next cycle there is risk of recurrence so she should be given a lower dose of gonadotropins and monitored closely .
Posted by Ron C.
RnRn
A.
Her complaints may be caused by the IVF-treatment. I’ll enquire on presence of risk factors that would increase likelihood of ovarian hyperstimulation syndrome (OHHS). I’ll ask whether she had previous attempts and whether OHHS occurred, what hormone regime was used in this IVF-cycle, the number of follicles harvested, and whether HCG rather than progesterone was used for luteal support. Having a history of PCO is a risk factor too. To determine possible other causes I enquire regarding stools (diarrhea, gastro-enteritis ?), previous history of gastric problems, gall stones, surgery (appendicitis) and also whether she has urinary symptoms or a history of renal stones. On examination I note temperature, pulse and blood pressure, to assess possibility of (procedure-related) infection or compromised haemodynamic status, caused by bleeding or deranged electrolytes & intravascular volume in OHSS. I’ll assess the abdomen, look if it is distended and if there are signs of ascites as in OHHS. I’ll take note of guarding or rebound suggesting peritonitis/infection. I’ll look at legs (oedema due to hypo-albuminaemia ?). I’ll assess her breathing, note any tachypnoe and auscultate lungs for pleural effusion due to severe OHSS.

B.
Bloods include FBC & CRP, mainly for infections and to identify haemoconcentration, Renal function, electrolytes & albumin, as these are deranged in OHHS, coagulation, TSH & fT4, liver function tests. Ultrasound to assess ovaries (enlarged, torsion ?), ascites. If significant respiratory symptoms I’d arrange a chest X-ray as wel.

C.
Management depends on severity and is mainly supportive. It is determined by combination of symptoms and findings on investigation. If she would have minimal abdominal pain with no or minimal vomiting, no clinical ascites and ovaries less than 12 cm, she could be managed as an outpatient with painkillers (paracetamol +- codein), re-assessment with scan & bloods in 2 days and instructions to come back earlier if symptoms aggravate. If she is very symptomatic, with clinically severe ascites and ovaries >12 cm, I will admit her. I will give paracetamol and anti-emetics (for example cyclizine 50 mg tds). I’ll start her on a fluid-chart and correct electrolytes and intravascular volume with colloid fluids if needed. Transfusion of albumin can be considered in severe hypo-albuminaemic cases with severe pleural effusion/ascites. As she is at risk for DVT due to haemodynamic changes I start her on Fragmin 5000 iu sc od (assuming she is between 50-90 kg). Daily monitoring of abdominal girth & weight as well as FBC, renal function, electrolytes and liverfunctions and every 2-3 days ultrasound to re-assess the ovaries to follow-up on improvement. If she is very symptomatic, ascites tapping under ultrasound guidance can be done, but this will often draw even more protein from the circulation when it re-accumulates. The need to terminate the pregnancy is very rare, and as the matter of fact, the pregnancy itself won’t be harmed and will often proceed successfully in OHSS.
Posted by J P.
a.The possible causes like ovarian hyper stimulation syndrome,pelvic infection,ovarian cyst torsion,ectopic pregnancy and gastro intestinal causes like appendicitis,cholecystitis ,pyelonephritis are to be ruled out.History of duration,severity,site of pain,aggravating and relieving factors will be enquired.Symptoms along with breathlessness and abdominal pain may point to OHSS inview of PCOS and IVF treatment.Number of embryos transferred also to be enquired.History of lower abdominal pain and bleeding per vaginum indicate ectopic pregnancy or miscarriage. History of vaginal discharge along with abdominal pain may suggest to pelvic infection.History of unilateral abdominal pain and vomiting suggest ovarian cyst accidents.History of loin pain,vomiting,fever and hematuria is suggestive of pyelonephritis.
Clinical assessment includes pulse and blood pressure measurement for assessment of haemo dynamic status.Cardio vascular system evaluation for heart sounds which may be muffled due to pericardial effusion in OHSS.Respiratory system assessment of breath sounds and tracheal shift if any indicate pleural effusion as a result of OHSS.Abdominal examination is done to detect any distension due to ascites ,tenderness,ovarian mass and rigidity. Speculumexamination for any vaginal discharge or bleeding which may point to PID and ectopic pregnancy.Bimanual pelvic examination for uterine, adnexal tendernes and mass suggestive of ovarian cyst will be done.Gentle bimanual examination has to be done for fear of rupture of cyst.
b.Investigations include FBC[haemoconcentration in OHSS],clotting profile ,urea and electrolytes,liver function test, for base line assessment.ECG,x-ray chest,ECHO to rule out pericardial effusion if symptoms of suggestive of OHSS will be done.USS abdomen and pelvis for the presence of ascites, ovarian cyst ,ectopic pregnancy will be done.Seum beta hcg will be needed then.
c.The management depends on severity of OHSS.Mild and moderate cases can be managed as out patient cases ,along with supportive treatment and review 48-72 hrs for the symptoms to resolve.Opioids for pain and drink to thirst is advised.In severe or critical characterised by ascites,haemoconcentration more than 45%,SOB,oliguria or anuria,clooting defects need in patient management in ITU.Care will be multi disciplinary involving ITU physician,renal physician.Opioids for pain relief and fluid replacement by previous hour output is done.Monitoring of pulse and BP every 4-6 hours ,intake output chart ,abdominal girth ,USS for ascites and ovarian cyst.Generally bimanual examination is avoided for fear of rupture.Frequent blood investigations like FBC,clotting profile,LFT ,urea and eletrolytes will be done for monitoring.Occasional CVP monitoring is needed in case of oliguria despite replacement of fluids. Thrombo prophylaxis in form of TED stockings and low molecular weight heparin is advocated in critical OHSS.Abdominal thoracentesis is needed if oliguria is not responding to fluid replacement.Usually surgical treament is not needed except in cases of ovarian torsion or rupture.Termination of pregnancy is needed in extreme cases if not responding to treatment.Case of OHSS has to be reported to HFEA.If pregnancy occurs prolonged monitoring needed and thromboprophylaxis continued
Posted by Priti T.
prt

a] Patient complaining of pain and vomitting 5 days after the in vitro fertilisation and embryo replacement should be assessed for early onset ovarian hyperstimulation.She should be asked the history of associated respiratory difficulty,chest pain,haemoptysis,abdominal pain and distention.Any calf pain and diarrhoea noted.Her details in the notes for the in vitro fertilisation are noted.Dosage of the gonadotrophins received and the number of oocytes received should be checked.Information should be obtained regarding oestradiol levels on the day of HCG administration.All these factors make her prone to Ovarian hyperstimulation syndrome[OHSS].
Previous and past medical history of ectopic pregnancy or acute abdomen or pelvic infection is taken to rule out other causes of acute abdomen.
Paient should be examined for BMI as low body mass index makes her prone for OHSS.Her pulse,respiratory rate,B.P are checked.Hydration level is assessed for the haemoconcentration.Chest and CVS is examined to detect pleural and pericardial effusion.Abdomen is examined to detect ascites,pelvic abdominal mass and acute abdomen.Lower limbs are examined for calf tenderness and oedema.

b] Patient should be investigated with FBC including haematocrit,WBC ,both of which are raised in ovarian hyperstimulation.U&E,LFT and clotting screen is done.Abdomen ultrasound is done to detect ascites and ovarian size.Ovary size less than 8 cms is mild OHSS,8-12 is moderate and more than 12 cms is severe OHSS.
X ray chest is done in patient with respiratory symptomsand signs.ECG and Echo is done for the suspected pericardial effusion.

c] Each unit should have a protocol for the referral and the initial management of OHSS.
Mild to moderate ovarian hyperstimulation may be managed on an outpatient basis.Antiemetics are given.Analgesia is given for pain like paracetamol and codeine.NSAIDs are avoided.Paient is advised to drink according to thirst and avoid strenuous exercise/sexual intercourse,as there is risk of injury to the enlarged ovaries.Progesterone support to the luteal phase is advised and further HCG is avoided as it increases ovarian hyperstimulation.Bed rest is avoided and the patient is reviewed every 2-3 days.Her weight ,abdominal girth and pelvic abdominal scan is done for the ovarian size and ascites.Urgent assessment is required if there is increasing pain,abdominal distention,subjective impression of reduced urine output.She should be given emergency contact numbers and the written information for the same.
Severe Ovarian hyperstimulation require in patient admission until the condition resolves.Moderate OHSS also requires admission if the pain and nausea is not controlled by the oral therapy or if the close out patient monitoring is not possible.
Treatment is supportive with intravenous fluids with or without albumin.CVP line may be inserted.Patient is monitored for daily weight,abdominal girth;Strict fluid input/output chart,pulse,B.P -4-6hourly and daily FBC,U&E,LFT and clotting screen.
Thromboprophylaxis is essential until discharge as thrombosis in upper extremities and arterial thrombosis are common.
ITU admission is required in critical cases.Diuretics are best avoided.Paracentesis should be performed under ultrasound guidence in severe abdominal distention or those who are oligouric despite volume replacement.Multidisciplinary care involving ITU physician& renal physician is done in critical cases.A clinician expert in the management of OHSS should be in charge.
Incident report form should be filled as OHSS is notifiable to HFEA with in 12 hours.


Posted by Manoj M.
A 35 year old woman with the polycystic ovary syndrome and sub-fertility has undergone in-vitro fertilisation and embryo replacement. Five days after embryo replacement, she attends the emergency gynaecology clinic complaining of abdominal pain and vomiting. (a) Justify your clinical assessment. [6 marks] (b) How would you investigate her symptoms? [4 marks] (c) She has ovarian hyperstimulation syndrome. Justify your management. [10 marks]

A) my clinical assessment is aimed at excluding differential diagnosis which may increase her risk for morbidity and mortality.
A history of in-vitro fertilisation and embryo transfer(IVF-ET) with polycystic ovary syndrome may likely suggest ovarian hyperstimulation syndrome(OHSS).
Nature of abdominal pain including site, type, severity, radiation and associated symptoms may suggest cause of pain.
Associated with vomiting may suggest underlying acute abdominal causes like ovarian cyst accident, peritonitis (iatrogenic risk with IVF-ET) or surgical causes like appendicitis.
Urinary symptoms like dysuria may suggest urinary tract infection.
Bowel symptoms like diarrhoea may suggest gastroenteritis.
Associated shortness of breath or breathing difficulty/ reduced urine output may suggest more likey with OHSS.
Examination of pulse, blood pressure, saturation with pulse oximeter will suggest any need for immediate resuscitation.
Raised temperature may suggest underlying infection.
Gentle abdominal examination to exclude other causes like appendicitis and avoid bimanual examination (likely OHSS as underlying fragile ovaries).
Body mass index obtained as a low BMI is more likely associated with OHSS with PCOS.

B) Investigation include a full blood count may suggest leucoytosis and severity of OHSS, anaemia may suggest underlying intraabdominal bleeding.
A raised CRP may suggest underlying infectious cause but has to be clinically correlated.
Liver function and renal function may suggest underlying derangement and provides as a baseline investigation.
Haematocrit is important as raised in severe and critical OHSS.
Mid specimen of urine for microbiology culture and sensitivity to exclude urinary tract infection.
Ultrasound of pelvic will help in assessing size of ovary to know the severity and diagnosis of condition and in detecting ascitis with OHSS.

C) OHSS is a iatrogenic condition with IVF-ET and most of these are self limiting with supportive measures.
Patient should be reassured that it is unlikely to complicate her pregnancy.
Most of mild to moderate OHSS can be managed on out patient basis with simple analgesics, antiemetics, drink to thirst and precautions to avoid strenous activities as fragile ovaries with OHSS.
Mild to moderate should be planned for regular followup 2-3 times weekly to exclude any worseing of symptoms.
Severe / critical OHSS need hospitilisation and care under multidisciplinary team including intensivist, radiologist and her care under lead O&G clinician.
Critical OHSS should be managed in intensive care unit as high risk of mortality.
She should be managed according to the unit protocol to optimise her outcome.
Pain relief with simple analgesics or opiates as necessary and avoid nonsteroidal antiinflammatory as risk of renal impairment.
Antiemetics for nausea and vomiting and maintain strict intake output balance with intrvenous fluids as risk of fluid overload with OHSS. Consider central venous acess if suggestive of fluid overload.
Daily monitor urine output, vital signs, abdominal girth and haematological indices to assess progress of OHSS.
Ascitis may need therapeutic tapping under ultrasound guidance as risk of underlying large vascular ovaries.
Consider chest X-ray with chest symptoms and may need therapeutic pleural aspiration.
Thromboprophylaxis and thromboembolic detterant stockings as high risk for thrombosis.
In exceptional cases may need to consider termination of pregnancy.






Posted by Arun J.
a -I would ask the following Hx to ascertain the cause of her complaints.The site ,character and radiation of pain is asked.Intermittent abdominal pain in the lower abdomen either to the left or to the right suggest ovarian cyst torsion.Pain in right illiac fossa moving on to the umbilicus and associated with fever suggests appendicitis. Associated urinary frequency urgency,dysuria suggests UTI and altered bowel habbits suggest gastrointestinal problem.I would enquire whether she had previous history of Ovarian hyperstimulation syndrome(OHSS) as they recur.I would quickly record her pulse ,B.P,temperature,and asses her hydration status so as to asses need for imediate resuscitation.I would examine her cardiovascular and respiratory system as part of general systemic examination.I would examine her abdomen to look for tenderness ,rebound tenderness(present in ovarian cyst rupture -peritonism) and distension(because of ascitis)

b--I would do the following for arriving at a diagnosis.FBC, and haematocrit,liver and renal function test for OHSS, CRP and ESR for IBD, urine routine and MSU culture and sensitivity for UTI,and USS to find anyadnexal cyst,OHSS and ascitis.

c--I would explain to her that she has mounted an increased sensitivity response to her fertility treatment and that she has to be cared by multidisciplinary team consisting of senior obstetrician trained in OHSS management,ITU physician and midwife.I would reassure and give her support as it is likely to cause anxiety.I would follow the units protocol.I would investigate her to find out the severity.So ,i would do FBC,haematocrit, renal and liver function test,clotting profile, chest x ray ,ECG,ECHO for pericardial effusion,and USS to ascertain the size of the ovaryand to look for ascitis.If mild/moderate OHSS is present ,i would tell her to drink as much fluids to maintain hydration, and give her paracetamol or codiene for analgesia.I would tell her to be vigilant and to report imediately to hospital if she becoms unwell as the clinical condition changes with time.Advice given to her to refrain from strenuous activities and coitus as they may cause rupture of the ovarian cyst.If severe OHSS is present i would admit her to optimise management.Daily abdominal girth and weight checks done to monitor treatment. Input and output chart maintained to asses renal function.Intravenous crystalloids given to improve urine output.If unsuccessful colloids are given.URIne output maintained to atleast 0.5ml/kg/hr.If the out doesnot improve, abdominal paracentesis is done to releive the pressure and improve the output.In resistent cases thoracentesis would be needed.I would monitor the resolution of ascitis and the ovarian size by regular USS.I would asses need for thromboprophylaxis and administer it in conjunction with the haematologist. .I would document the whole treatment as part of risk management strategy.Incident reporting form would be filled.I would debrief her about her condition.If pregnancy ensues i would reassure her that a normal course would be expected and she stands at no increased risk of congenital anomalies of the fetus.I would tell her to come for regular follow up antenal visits.
Posted by Maayka ..
nellie

a) Clinical assessment would involve taking a history and examination to consider differentials for this presentation, namely OHSS, ectopic pregnancy, ovarian cyst accident (hemorrhage/torsion), other causes of acute abdomen and pyelonephritis. Her history of IVF and PCOS and onset of her symptoms within 5 days makes OHSS a likely diagnosis. I would also ask about changes in any abdominal distension, shortness of breath and subjective reduced urine output because it is likely to suggest more severe form of OHSS. If there is also calf pains and neurological deficits, noticed by her partner, as this suggests thromboembolic events. The onset of the pain and any associated shoulder tip pains or syncope may suggest and ectopic pregnancy. The presence of fever would suggest an infective cause.
Examination of pulse, BP, RR will give information on her haemodynamic stability and checking mucous membranes and skin turgor will assess her hydration state. A SpO2 will be useful if there is any possibility of pulmonary oedema. The abdominal examination may reveal large masses if the ovaries are enlarged or rebound tenderness if ectopic. Presence of ascites directs the diagnosis to the severity of OHSS.

b) Blood investigations – U&Es, FBC, LFTs, amylase will be useful as a baseline for monitoring OHSS and to rule out other diagnoses. The FBC will give evidence of Hb level and Hct, the latter being important specifically because if > 45% suggests severe OHSS. Abdominal / TVS will rule out an ovarian cyst accident or ectopic pregnancy and will identify the presence of ascites. Abdominal girth measurements would be useful for further monitoring.

c) She likely has moderate OHSS and if so can be monitored as an outpatient. She would be given analgesics like acetaminophen and advised to avoid NSAIDS because it reduces urine output. She is to rehydrate by drinking to relieve her thirst and to avoid sexual intercourse or stress activity, because it may worsen the pain by the already enlarged ovaries. She should be reviewed every 2-3 days, because the condition can worsen, by an obstetrician / physician with special interest in IVF complications/OHSS. Should be given information leaflets and phone contact for the hospital to call in or return if there are worsening symptoms of increased shortness of breath, abdominal pain worsening or not being alleviated with analgesics.

If she develops sever OHSS or not responding to treatment for moderate OHSS, then inpatient monitoring is advised and she should be in close observation setting like a high dependency unit. Her vital signs – pulse, BP, SpO2 and urine out put should be monitored closely. If there is insufficient urine output despite intravascular volume being corrected, as identified by a CVP line, then paracentesis may be considered. This is also an option if tense ascites develops with respiratory compromise. Thromboprophylaxis with use of LMWH, TED stockings is to be used because or the risk of embolic events, especially to cerebral region. Strict input / output monitoring is necessary until condition resolves
Posted by A S.
Aa
a) The woman has just had IVF for PCO so she is in increased risk of developing OHSS . Clinical assessment is important to assess the severity of the condition as this will determine the lines of management . Clinical assessment will aim to differentiate gynecological from non gynecological causes .Differential diagnosis includes acute appendecitis , PID ,complicated ovarian cyst , severe urinary infection , acute cholecystitis and gastroenteritis . I will ask her about fever , abdominal distention , dysuria , shortness of breath , diarrhea and vaginal discharge .I will ask her about Luteal phase support drugs like progesterone or h CG injections . Details about the pain when did it started , upper or lower abdominal or loin pain, site of radiation , and its severity will be asked for . General examination will be done , pulse, blood pressure , temperature , weight . Her abdomen will be examined for areas of tenderness , ascites and abdominal girth will be measured . Vaginal examination will be done carefully to test for adnexal tenderness and vaginal discharge.
b)Investigations will include full blood count ,( heamoglobin , haematocrit , WBCs ) ,BhCG, liver function tests , creatinine , electrolytes and urine analysis . U/S abdominal and pelvis will be requested to see measure the size of the ovaries ,and examine for ascites . X-ray chest and ECG will be done if the patient is markedly distressed .
c) I will explain to the woman that the OHSS is generally self limited and that there is no danger on the fetus if she is pregnant . She will be managed according to the severity of the condition The factors judging the severity are degree of ascites , WBCs count (>15000, >25000) , heamatocrit (>45, >55 ) , normal or abnormal creatinine , the presence of throboembolic manifestations or acute respiratory distress syndrome. .Mild cases will not have ascites , ovarian size less than 8 cm ,will be generally well with normal lab results . Mild cases will be managed on outpatient basis and will be followed every 2-3 days . The patient will be instructed to drink to thirst , avoid intercourse and strenuous exercise . She will be given paracetamol or codeine for pain and cyclizine as antiemetic . if she is having moderate or more severe stage , she will be managed as inpatient till natural resolution . Intensive care unit admission is justified for severe or critically ill stages . She will be managed by a multi disciplinary team including a doctor with experience in managing OHSS ,gynecologist , ICU specialist and anaesthisist . Analgesics will be given with avoidance of nonsteroidal antiinflamatory drugs as they may affect renal function . Fluid balance will be charted and the patient may need invasive measures like CVP if renal fuction is affected or with severe oliguria .Intravenous fluids will include colloids as human albumin or 6%HES solution . Daily assessment will be done with clinical examination for vital signs , wt , abdominal girth and repeated lab tests to judge improvement . Special care will be given regarding thromboprophylaxis as the patient is immobile with heamoconcentration . Graduated elastic stocking and low molecular weight heparin will be offered . If ascites is tense , paracentesis will be done cautiously and gradually as this may hurt severely enlarged and vascular ovaries . Replacement of the withdrawn fluid is by colloids . If hydrothorax is resistant it may be drained directly .The case will be reported to HFEA with incident report .
Posted by Shoba V.
History of the woman having PCOS & subfertility & having undergone IVF & embryo replacement,stongly suggests Ovarian Hyperstimulation Syndrome,nevertheless,the symptoms could also occur in othernon gynecological condions like gastritis & gastroenteritis,appendicitis,pancreatitis,pyelonephritis,intestinal obstruction & gynaecological conditions like tortion of ovarian cyst,PID,,ectopic pregnancy
A detailed history of the type & duration of pain should be taken,whether it was intermittent initially & now continuous suggesting it to be a tortion of ovary.A history of flank pain with dysurea & fever to rule out pyelonephritis ,tenderness over the Mc Burneys point ,suggests appendicitis.History of epigastric pain or burning sensation sugggests gastritis,history of shortness of breathe,ECG changes & BP recording to rule out cardiac lesion.
The site of pain should be examined,if its in the lower abdomen& associated with heavy discharge & pyrexia,suggestive of PID,a Per speculum examination should be also done.The abdomen should be examined for any distention or signs of ascitis,any mass .Examination of her limbs for swelling or tenderness for signs of DVT.In case of OHSS VTE of the upper limb is common.
History of previous ovarian hyperstimulation syndrome will be asked for as there are chances of recurrence.Patient should be asked whether she recieved ing HCG or progesterone for luteal support.t
b) will include,FBC for haematocrit & WBC count.platelet count & coagulation study ,Urea & electrolytes where there may be hypnatremia & hyper kalemia,LFT to look for hypoalbuminemia,MSUS to rule out Urinary tract infection,Ultrasound studies of pelvis & abdomen to look for ascitis & measure ovaian size,number of gestational sac,B hcg to rule out for ectopic pregnancy,X ray chest & ECG to rule out hydrothorax respiratory distress syndrome.Urinary input out put chart to maintain fluid balance as oligure or anurea can occur.
c)Management of OHSS depends on the severity.
If mild-moderate OHSS,patient can be managed on out patient basis,withadequate analgesics like codein & paracetamol,NSAIDS are avoided as it may precipitate renal dysfunction,patient should be advised to drink to thirst.She should be told to avoid strenous evercise & intercourse & be mobile.Her vitals like BP,Respiratory rate,pulse rate ,body weight & abdominal girth should be monitored daily.Progesterone support should be continued.In case her symtoms like breathlessness or swelling inthe lower limbs increase or decreased urinary output,she should report to hospital immediately.
In case of severe to critical OHSS which is diagnosed depending on her hematocrit value,>45% or WBC count >25,000 & anurea with tensed ascitis & resp distress with signs of DVT,she should be managed in ITU through multidisciplinary approach of renal physician & a well trained clinician in OHSS.A CVP monitoring,urine in put outflow chart,BP , Resp Rate & pulse rate should be recorded at 4 hourly interval.IV Fluids with colloids for hypo albuminemia,LMW heparin to prevent thromboembolism.Paracentesis in case of severe respiratory distress,but should be replaced by IV colloids.Analgesics can be given with the exeption of NSAIDS.Pregnancy will not need to be teminated ,ante emetics can be given & diuretics is generally avoide unless sever pleural effusion.HEFA should be notified within 12 hrs & an incidental form should be submitted within 24 working hours.
Posted by A H.
AH
a) This is most likely ovarian hyperstimulation syndrome (OHSS), but history and examination will be necessary to help determine its severity and exclude other important diagnoses like ectopic pregnancy, haemorrhage torsion of the ovary or acute appendicitis.
Features of the pain will be asked including severity and if relieved by simple analgesia. Associated diarrhoea and fever may be present if it is acute appendicitis. A drug history of analgesia and anti-emetics used will be taken.
Sudden onset of pain associated with dizziness or loss of consciousness mayl be present if there is haemorrhage into the ovaries or abdomen.
Chest pain, haemoptysis or shortness of breath will be present in severe OHSS if there is associated pulmonary embolism.
Tachycardia and hypotension will be present if there is hypovolaemia, so pulse and blood pressure will be measured as a baseline and for ongoing monitoring. Teperature will be measured as pyrexia will point to an infection. The hydation status will also be noted.
The chest will be examined for signs of effusion.
Abdominal examination will include careful palpation to avoid injury to the ovaries, measurement of abdominal girth because the abdomen may be or become distended due to ascites or intraperitoneal haemorrhage. Bowel sounds will be auscultated.
A pelvic examination will not be done as it is unlikely to be beneficial.

b)A full blood count will be done to determine haemoglobin concentration, haematocrit and white cell count. Liver function and renal function (serum urea,electrolytes and creatinine) tests as well as clotting screen will be done.
A pelvic ultrasound will be done to determine ovarian volume and the presence and degree of ascites.
A chest X-ray and ECG will be done if there are chest signs suggestive of pleural effusion or pulmonary embolism.

c) OHSS will be managed according to the department\'s protocol by a gynaecologist with expertise in caring for these patients.She will be counselled about the severity of her condition and if mild she will be told that it can worsen with time.Because she became symptomatic within nine days of embryo transfer it is expected to resolve. Progesterone will be used for luteal support. Beta hCG will be avoided as it will worsen her condition.
For mild OHSS, care will be mainly supportive as an outpatient. She will be prescribed anti-emetics and simple analgesia such as paracetamol or codeine and paracetamol preparations. She would be advised to drink according to her thirst for maintenance of her hydration. She would be given written and verbal information about what to expect if the condition is worsening, for example worsening pain, vomiting or reduced urine output. She would be advised and to contact the hospital via the 24 hour contact number she is given.
For moderate OHSS not responding to the above treatment or for severe OHSS she will be admitted. Opioids may be necessary for pain relief but NSAIDS would not be uced because it can cause deterioration of renal function.
Bloods will be drawn for full blood count (haemoglobin, haematocrit and white cell count), renal function and liver function tests as well as clotting studies. These will be repeated daily to monitor progress. Pulse and blood pressure will be monitored four to six hourly.Intravenous fluids will be given to maintain intravascular volume and the urinary bladder will be catheterise for monitoring fluid balance. Abdominal girth will be monitored daily. Low molecular weight heparin and thromboembolic deterrent stockings will be given for thromboprophylaxis.
If her condition is worsening as evidenced by inceasing haematocrit greter than 45-55%, haemoglobin greater than 15g/dl, oliguria/anuria, or respiratory distress due to tense ascites or pleural effusion, she will be admitted to ITU for joint management with intensivists and renal physician. Cosideration will be given to ultrasound guided paracentesis, pleurocentesis and CVP monitoring.
If the condition resolves she will be reassured that the drugs used were not teratogenic and that OHSS does not worsen pregnancy outcome.
If she is unresponsive to intensive treatment, the pregnancy will
be terminated as a last resort.

If her condition i