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MRCOG PART 2 SBAs and EMQs

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ESSAY 184 - OHSS

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		Posted by Srivas P. Wed Feb 8, 2006 05:28 am
OHSS is a serious and potentially life threatening complication of ovulation induction. It is rare following induction with Clomiphene Citrate and GnRH but is an important complication following use of gonadotrophins for ovulation induction. Severe OHSS is found in 3-8 % of IVF cycles though mild cases can be seen in 30 % IVF cycles. Patient with severe OHSS may present with discomfort due to huge abdominal distension, significant clinical ascitis, pain abdomen, nausea vomiting, and dehydration; maybe associated with hydrothorax with discomfort and breathing difficulties and decreased urinary output. Likely major complications are renal failure, oliguria, ARDS, liver dysfunction, Thromboembolic complications, Ovarian Torsion and even death. The woman and her partner need to be counseled, reassured and told about the nature of the problem, possible complications and the treatment plan. Principles of management are essentially supportive while awaiting spontaneous resolution of symptoms. The intense and close monitoring needed for her will require admission to hospital and she should get multidisciplinary care which includes senior obstetrician, Intensive care specialist, senior physicians and anaesthetist if she needs ICU care. She should have close monitoring of pulse, B.P, clotting profile, RFT, LFT, urinary output and abdominal girth charts. Laboratory investigations which help in assessing the severity of OHSS are hemoglobin, haematocrit, White cell count, clotting profile, serum creatinine, electrolytes and liver function tests. She would need Pelvic ultrasound to assess amount of ascitis, and size of ovarian enlargement and chest X-ray for hydrothorax. In severe cases haematocrit may be as high as 45 % or even 55 % in critical cases while TLC may show high values between 15000-25000/ml and ovaries may be enlarged to more than 12cm in diameter. For pain relief analgesia using paracetamol or codeine is appropriate while NSAIDS are to be avoided as they may compromise renal function. Strenuous exercise and sexual intercourse should be avoided for fear of injury or torsion of hyperstimulated ovaries. Patients should be encouraged to drink to thirst, rather than to excess. If vomiting is severe anti emetics like metoclopramide may help control it. If the woman is dehydrated, oliguric and unable to retain oral fluids she may need to have intravenous hydration preferable with crystalloids like normal saline and later with colloids if she does not pass urine still but this has to be done under CVP monitoring to ensure she does not go hypervolemia. Paracentesis itself may improve urinary output when abdominal pressure gets relieved. If she shows suspicion of thromboembolism she would need ventilation perfusion scan and therapeutic anticoagulation while awaiting objective confirmation. In severe and critical OHSS there is a role for thromboprophylaxis up to end of first trimester with heparin if the woman has family history of thrombophilia, has other high risks for VTE like obesity, prolonged hospitalization, immobilization or dehydration. The condition is not entirely preventable but certain steps may be taken to reduce the incidence of OHSS. Woman who are high risk for OHSS?lean, underweight, PCO woman and those who showed mild OHSS in previous cycle are preferably started on lower dose of gonadotrophins. Low dose step up or step down regimes for Gonadotrophins are associated with lower incidence of OHSS. Use of GnRH antagonists like cetrorelix in these IVF cycles may reduce incidence of OHSS. During ovarian stimulation if serum estradiol levels are more than 12000pmol/litre and there are more than 20 follicles developing same time OHSS can be avoided by coasting?that is avoid giving further gonadotrophin and HCG till serum estradiol levels fall down again to less than 10000pmol/l . HCG too should be avoided for luteal phase support which is best given with progesterone. Other method of avoiding OHSS in hyperstimulated cycles is to cancel that cycle and freeze the embryos and use frozen embryos next cycle rather than fresh embryos in this cycle and also by restricting the number of embryos transferred to not more than two per cycle. Intravenous infusion of 6% hydroxyl ethyl starch or albumin at the time of embryo transfer may reduce OHSS in high risk cycles. In hyperstimulated cycles the severity of OHSS can be decreased by avoiding pregnancy by asking the woman to have abstinence around ovulation as late OHSS following conception is more prolonged and severe.
		Posted by Vaani M. Wed Feb 8, 2006 05:47 am
Severe OHSS is the complication of IVF treatment. It occurs as a result of hyperstimulated ovaries leading to increased vasoactive substances, increasing capillary permeability and causing fluid accumulation, thrombotic risks, renal and hepatic dysfunction and respiratory distress. Management of this woman would be by a multidisciplinary team of specialists including obstetrician, physician, surgeon, anaesthetist, and intensive care specialist. She has to be admitted to hospital initially for daily monitoring of her condition until resolution and for her treatment. She would present with of abdominal pain, distension, nausea, vomiting, diarrhoea, shortness of breath and decreased urine output. On examination she would be having ascites, distended abdomen, oliguria. Her investigations would show a raised haemoglobin, raised haemotocrit, abnormal liver and renal function tests, ascites and distended ovaries on ultrasound examination. Chest x-ray would should effusions. Echocardiography would be required with pericardial effusions. Thrombophilia screen would only be done if she has a personal of family history of thrombosis. Treatment would begin with analgesics as paracetamol, or codeine. Opiates also may be used. Non steroidal anti-inflammatory drugs are not to be used due to renal side effects. Fluid balance has to be closely monitored. She can drink water as per thirst. Crystalloids as normal saline and colloids as human albumin or 6% hydroxyethylstarch could be given. Invasive monitoring of fluid pressure may be required if severe oliguria and haemoconcentration is present. Paracentesis with continuous fluid drainage would help relieve the ascites as well as improve renal functions. Ultrasound guided paracentesis is to be done to avoid injury to the distended ovaries. Thromboprophylaxis in the form of venous stockings and heparin is required for the period of in patient stay and if required later as per her other risk factors. Surgery would only be indicated in case of torsion of an enlarged ovarian cyst and should be done only by an experienced operator. Prevention of this condition could be done by various methods. Ovulation induction therapy is known to cause OHSS and avoiding gonadotrophins and using anti oestrogens as clomiphene would benefit. Careful monitoring of all induced cycles with transvaginal ultrasound and serum oestradiol levels would help identify women at risk. Women with polycystic ovaries are particularly at risk of OHSS and alternative treatment as ovarian diathermy could be tried to improve fertility in these women. At risk cycles when identified after ovulation induction should be cancelled or delayed by late hCG injection for ovulation. Luteal phase support with progesterone rather than hCG could reduce risk of OHSS. Cryopreservation of embyos and use in free thawed cycles later could also be done. All women undergoing IVF should be informed of risk of OHSS, know the symptoms, and should have 24 hour access to specialist consultation and management if they develop symptoms of OHSS, and prompt treatment should be available.
		Posted by Farzana N. Wed Feb 8, 2006 05:53 am
Ovarian Hyperstimulation Syndrome is a potentially life threatening complication of ovarian stimulation by gonadotrphins used in assisted reproduction techniques, such as IVF. It is characterized by increase in vascular permeability, leading to fluid shift from intravascular to extra vascular space. This leads to reduced circulating volume, depletion of albumin and electrolytes and third space accumulation of fluid resulting in ascites and rarely hydrothorax. The management of OHSS should be under the supervision of a specialist in reproductive medicine. Severe OHSS as manifest by marked abdominal distention with ascites, Dyspneoa, blood showing Haematocrit >0.45,WBC>15,000 and deteriorating renal functions , should be promptly admitted. Initial management would be correction of hypovolemia by giving Hartman?s solution or Normal saline with added potassium. This would improve renal perfusion and reverse hemoconcentration. CVPline may be required.Use of albumin to correct hypovolemia and raise oncotic pressure is controversial. Giving prophylactic heparin can reduce risk of thromboembolic complication. Mannitol or dopamine may be required in severely oliguric patients. Prostaglandin synthetase inhibitors should be avoided for analgesia because of their adverse effect on renal blood flow. Monitoring - urinary output and fluid balance should be monitored closely, together with blood pressure, temperature and respiratory rate. Daily measurement of abdominal girth would indicate any deterioration of ascites, hematological and biochemical parameters should be checked by FBC (including Haematocrit),U&E ,LFTs and clotting tests to help manage fluid replacement. An indwelling catheter may be needed if urinary output is poor or vulval edema causing voiding difficulties. Pulse oximetry may be needed in cases with severe pleural effusion causing respiratory distress. Severe cases may need to be transferred to ITU. Drainage of abdominal fluid is a key step in management It will bring immediate relief not only to abdominal discomfort and respiratory difficulties but also to the urinary output. Ascitic fluid is rich in cytokines implicated in the alteration in vascular permeability and drainage may cause improvement in disease. Surgical interventions are best avoided, as the ovaries are large vascular and easily taumatised. Laparotomy may have to be done in suspected cases of torsion or significant intraperitoneal bleeding. Surgical procedure requires an experienced gynecologist or specialist in reproductive medicine Termination of pregnancy may be needed in exceptional cases. Measures to prevent OHSS include identification of risk factors such as patients with PCOS,previous H/o hyper stimulation and young age .In these cases ,administration of hCG can be withheld or cycle cancelled .Other measures would include reducing hCG stimulation ,using surrogate hCG i.e LHagonist.,Coasting-delaying administration of hCG.Elective cryopreservation of embryos avoids high levels of endogenous hCG arising from endogenous syncitiotrophobalast,but the pregnancy rates from replacement of frozen embryos are lower. Prophylactic albumin, Immunoglobulin therapy and luteal phase support by progesterone have also been suggested.
		Posted by adnan S. Wed Feb 8, 2006 07:24 am
Ovarian hyper stimulation syndrome is associated anxietyn &emotional distress hence approach should be supportive for both woman and her partner providing reassurance and information to alley anxiety. Iwill explain the woman ovarian hyper stimulation syndrome is an iatragenic condition that can occur as a complication of infertility treatment involving ovarian stimulation.Supraphysiological stimulation is an important part of many form of assisted conceptions,as it increases the number of oocytes and embriyos available. The principal underlying the management of sever OHSS are multidisciplinary care including specialists with appropriate expertise in intensive care.Specific complications like ARDS renal failure & thromboembolism may require intensive care management. Aneasthetist and medical colleague should be involved at an early stage .The management is essentially supportive until the condition resolve spontaneously. Pain relief is best provided with opiates if paracetamol and codiens are ineffective.Anti prostaglandins should be avoided as they may precipitate renal failure by inhibiting renal production of vasodilator prostaglandins that help to maintain renal blood flow despite low blood volume.If pain is sever other pathology must be consider like cyst complications ,rupture,torsion or heamorrhage or ectopic pregnancy.Anti-emetics such as prochlorperazine ,metaclopramide &cylazine are used for nausea &vomiting. Fluid replacement should initially be with crystalloids such as normal saline,guided by clinical assessment of dehydration ,haematocrite &electrolyte levels.2 -3litres of normal saline will be needed as maintenance dose.Persistent heamoconcentration and urine output <0.5ml/kg/hr may benefit from colloids.Human albumin .6%hydroxyethylstarch(HES),dextran ,heamaccel and manitol can be used.If heamoconcentration or oliguria persist despite these measures ultrasound guided paracentesis should be considerd ,the pressure effect of massive ascites on both the renal veins altering renal fuctions,and inferior vena cava reducing venous return is relieved there by improving the cardiac output.Further fluid management may be guided by CVP monitoring and involving aneasthetic colleage .Diuretics sould not be used where oliguria is secondry to reduce blood volume &decrease renal perfusion as they worsens intra vascular dehydration .If oliguria persist despite adequate hydration there may be role of diuretics with senior multidisciplinary involvement & after consideration of paracentesis. Thromboprophylaxis should be provided with oppropriate TED stockings and LMW heparins.An intermittent pneumatic compression device may be helpful when symptoms prevent ambulation and confine the patient to bed. Paracentesis is considerd if significant discomfort or respiratory embarrassment due to severe abdominal distention or oliguria not responding despite adequate fluid replacement.It is done under ultrasound guidance to minimize risk of injury to enlarged vascular ovaries.Transabdominal aspiration is likely to be better than a vaginal approach.Repeated paracentesis may be avoided by use of pigtail catheter that can be left in situ.Drainage of ascites alone may suffice to resolve hydrothorax if present. Pelvic surgery should be restricted for adenexal torsion or coincidental rupture ectopic pregnancy.It should be only undertaken by an experienced operator following careful assessment. If pregnancy occur she may be reassured that pregnancy continue normally ,and no increased risk of congenital anomalies or miscarriage. Steps that can be taken to prevent OHSS are ,methods of ovulation induction that carry lower risk of development of OHSS should be given preference when ever possible ,Including weight reduction in obese woman with PCOS.Insulin sensitizer like metformin appears to be effective in inducing ovulation without significant risk of OHSS .In woman with PCOS resistence to clomiphene laprascopic ovarian drilling carries lower risk of OHSS.The use of purified FSH by low dose incremental regime is less likely to have OHSS than a regime using GnRHa/HMG.Monitoring the ovarian response to gonadotrophins by USS can help to identify cycles with excessive ovarian response and cancellation should be considerd with cryopreservation of all embryos reduces the risk of sever OHSS.Replacement of hCG by progesterone for luteal support in cycles in risk of developing OHSS.Albumin administerd intravenously at the time of oocyte retrieval has been observed to reduce the incidence of OHSS in RCTs in with excessive ovarian response.Immunomodulation may become an option in the future to prevent OHSS.
		Posted by Sarwat F. Wed Feb 8, 2006 08:32 am
Ovarian hyper stimulation syndrome is caused by various substances released by overly stimulated ovarian follicles by human chorionic gonadotrophins. These include vascular endothelial growth factors, various cytokines, prostaglandins and interleukin 1. These substances alter the vascular permeability resulting in fluid shift from intravascular to extra vascular compartment which causes increased haematocrit, ascites, pleural, pericardial effusion and renal failure. Principles underlying management include supportive management like tight fluid balance, analgesics, monitoring, thromboprophylaxis and preventing renal shut down. This condition is self limiting and therefore symptomatic treatment is done. Investigations are required like full blood count, renal function test, coagulation profile, LFTs and abdominal ultrasound to check the size of the ovaries and ascites. BP pulse will be monitored every 4 to 6 hrly, abdominal girth daily and full blood count and renal function are done daily or more frequently depending on severity. Patient will need normal saline infusion calculated in order to prevent renal shut down while preventing fluid overload at the same time. A CVP line will be needed for intensive monitoring. Patient may need positive pressure ventilation for breathing difficulties. She may need admission to high dependency unit but this is according to hospital protocol. Severe ascites may necessitate paracentesis. 2 to 3 litres can be removed at a time. Termination of pregnancy is done as a last resort. Multidisciplinary care in the form of involvement of anaesthetist and intensive care physician will be needed. Thromboprophylaxis in the form of TED stockings and prophylactic clexane is provided. Prevention includes use of other methods of ovulation induction and life style modification like weight reduction. In significantly obese women referral to a dietitian may be useful. Metformin is also effective as ovulation induction without the risk of OHSS. Similarly clomiphene citrate can be used with negligible risk of ovulation induction. Nonpharmacological methods like laparoscopic ovarian drilling are also effective. When gonadotrophins are used, various steps like avoiding HCG, delaying HCG dose, abandoning the cycle if there are more than 20 follicles or estradiol levels more than 15000 are effective for preventing OHSS. Prophylactic albumin can be given to minimize the risk of OHSS.
		Posted by Sreekala S. Wed Feb 8, 2006 10:13 am
OHSS is a systemic disease characterized by increased capillary permeability leading to leakage of fluid from the vascular compartment with third space accumulation and intravascular dehydration. The exact cause is not known. VEGF, TNF Alpha, IL-1 and 6 have been implicated in the pathogenesis.OHSS is more frequent with gonadotrophins than with the other ovulation inducing agents.Younger women and women with PCOS are at an increased risk of OHSS. Severe OHSS is a medical emergency and needs admission to a HDU and requires care by a multidisciplinary team involving the consultant obstetrician/gynaecologist, anaesthetist, physician and the HDU staff. OHSS may lead to comlplications like ARDS, Renal failure and thrombo embolism. The management is mainly supportive. IV access should be established and bloods sent off for FBC, Haemotocrit, LFTs, U&E , coagulation profile and crossmatch. IV fluids should be administered. Pain relief is best provided with paracetamol and if necessary with oral/parenteral opiates. NSAIDS should be avoided as they can compromise renal function. Antiemetics should be given as required. Thromboprophylaxis with heparin and TEDS is indicated. Input and output charts should be strictly maintained. Fluid and electrolyte balance maintained. Abdominal examination should be done to assess the degree of distension, to palpate ovaries, to look for paralytic ileus, abdominal girth measurement and body weight should be recorded. Paracentesis may be required in the event of a tense ascites and should be ideally performed under ultrasound guidance to avoid inadvertent injury to vascular ovaries distended by luteal cysts. Assessment of hydrothorax and cardio respiratory system is required. Chest X ray is indicated in the presence of respiratory symptoms and if hydrothorax /pulmonary infection or pulmonary embolism are suspected. Echocardiography is required if pericardial effusion is suspected. Diuretics should be avoided as they deplete the intravascular volume further. Oral fluids should be encouraged if she can tolerate. The woman should be monitored daily at least once or more frequently as required. Increasing abdominal pain, oliguria, weight gain and breathlessness point towards worsening of OHSS and needs care by anaesthetist team possibly with invasive CVP monitoring. The woman and her partner should be counselled and reassured to allay anxiety. The following can be considered to prevent OHSS. Weight reduction should be considered as an essential initial treatment modality in women who are obese or who do not respond to clomiphene citrate before resorting to gonadotrophins as they may improve the ovulatory status on its own and improve the effectiveness of other methods. Insulin sensitizers like metformin appear to be effective in inducing ovulation without a significant risk of OHSS and should be considered a suitable treatment option particularly for obese women. Laparoscopic ovarian drilling should be considered which has comparable pregnancy rates as gonadotrophin treatment and has a reduced risk of OHSS. If gonadotrophins are used, then a low dose, step up regime should be used. The dose of FSH should not be increased if there is a good ovarian response as judged by the Serum estradiol levels. GnRH antagonists are preferable to GnRH agonists to reduce the risk of OHSS. The starting dose of FSH should be lower especially in young women and PCOS who are at an increased risk of OHSS. Cycles where the ovarian response has been judged to be excessive should be managed by ?Coasting? in which further gonadotrophins are withheld until estradiol concentration declines to acceptable levels. Cancellation of the cycle should be considered in the event of an exaggerated ovarian response by discontinuing FSH and withholding hCG. Embryo cropreservation should be considered. IV human albumin and 6% hydroxy ethyl starch administered around the time of embryo transfer have been shown to reduce the risk of OHSS. Progestogen support is preferable to gonadotrophins for the luteal phase support where possible will help reduce the incidence of OHSS. Avoiding multiple pregnancies will reduce the risk of OHSS.
		Posted by RAMKRISHNA J. Wed Feb 8, 2006 04:29 pm
OHSS is a condition caused by use of fertility drugs where there is an increase in capillary leakyness. This leads to an accumulation of fluid in 3rd spaces (ie) pleural effusions; ascities, ovarian swelling, haemoconcentration and increased coagulability. Management is history: assessing features associated with severity ? ie breathlessness due to pleural effusion/diaphragm splinting. Abdominal discomfort due to distension; or ovarian swelling/torsion. Colour ? ie jaundice due to liver involvement Chest pain/ calf pain due to PE/DVT Examination for severity; evidence for pericardial/pleural effusion through CVS examination. Distended abdomen, or particularly guarding & rigidity suggesting torsion. Tender calves suggesting DVT Observations: BP/pulse 4hourly, urine output, o2 sats, weight, abdominal girth ? to look for evidence of volume depletion; worsening condition and pre renal failure Investigations: U+E (to look for renal failure); LFT (liver failure), Coag (hypercoagulability), FBC (haemoconcentration, thrombocytosis) BHCG, ABG?s Treatment: Prevent DVT; by wearing TEDS, daily s/c lmwh. Prevent dehydration and also prevent volume overload ? strict fluid balance, oliguria may require volume expansion through use of colloid infusion. Associated with hyperkalaemic metabolic acidosis ? treat with appropriate IV fluids. Extreme dyspnoea/ abdominal distension may warrant paracentesis/ pleural effusion drainage; but beware of fluid reaccumulating in 3rd space, worsening volume depletion. Severe cases may be associated with multiorgan failure ? including renal failure, RDS, liver failure, heart failure & may warrant ICU involvement and /or TOP. OHSS can be avoided through achieving fertility through weight loss (in the obese) rather than injectable ovulation agents/ or preventing PCOS through ovarian drilling rather than injection. OHSS is more common in the younger age range and those with PCOS. It is associated with GnRH analogues as part of the down regulation phase ? avoid GnRH analogues. Is is associated with an excess number of follicles/high oestrodiol levels; so avoid embryo transfer in these situations and moniniter follicles by way of US and serum ostrodiol.
		Posted by Aroosha B. Wed Feb 8, 2006 10:23 pm
Ovarian hyperstimulation syndrome is an iatrogenic complication of ovulation induction with gonadotrophins or rarely antiestrogen. It is characterized by ovarian enlargement, a fluid shift from intravascular compartment to third space and sequel of the process. The underlying cause of pathophysciological change remains unknown. The object of monitoring to detect any changes in severity and to detect any complication. Treatment is symptomatic. A history should be taken and physical examination performed to determine the severity of disease. USG is done to determine the size of ovaries and amount of ascites and pleural effusion. Other investigation are full blood count, heamatocrit, serum urea, electrolytes liver function and coagulation profile. A chest X-ray is carried out in presence of dyspnoea and blood gases measured. Four hourly check on vital signs is essential, fluid balance should be carefully monitored daily measuring of abdominal girth may help to detect severity. Admission tests need to be repeated daily. In patients with severe nausea and vomiting parentral antiemetics are useful in providing symptomatic relief. I/V hydration should be commenced. Normal saline 2-3 l/24 hr is the fluid replacement of choice. Urine output and heamatocrit should be measured to assess severity, if improvement fails to occur than albumin 200 ml of 20% solution over 4 hr should be considered. Rapid rehydration with crystolloids should be avoided. Paracetamole alone or in combination with Codene may suffice. NSAID should be avoided as they increase the risk of failure in patient with renal impairment. In case of severe pain surgical causes such as ovarian torsion or ectopic pregnancy should be considered. Surgical intervention should be kept to minimum and performed by senior obstetrician. Patients with OHSS are at increased risk of thromboembolism and provided with TED stocking or low molecular weight heparin. Oliguria which fails to respond to intravenous fluid may be secondary to renal hypoperfusion and patient may respond to paracentesis which also relieve pain and respiratory embrassment from tense ascites. Renal failure ARDS and thromboembolism are life threatening. Management of these should be multidisciplinary and may require an intensive care setting. Patient should be provided with psychological support. The steps which can be taken to reduce the incidence of OHSS is a proper history as patient with previous history of OHSS are at increased risk and those with PCO\'s and young age. In patients with PCO\'s Laproscopic ovarian drilling is an effective alternative therapy with comparable success rate. If genadotrophin are chosen, low dose set up regemic give best clinical result. Monitoring the ovarian cycle during treatment by estradiol level and USG tracking can help to identify features associated with subsequent higher risk cycles which show excessive response and can be managed by coasting. In some cycle the only safe option to this excessive response is cycle cancellation. Embryo freezing can also be considered to prevent OHSS but the risk of OHSS is not completely eradicated. Aspiraiton of ovarian follicles might protect against OHSS by causing follicular heamorrage. Intravenous human albumen administered at the time of oocyte retrievel is also a method of preventing OHSS. Avoiding leuteal HCG exposure and giving progestrone is associated with decreased risk.
		Posted by BAHAA-Uddin BOR B. Thu Feb 9, 2006 12:21 pm
Ovarian hyperstimulation may be life threatening.It results from superovulation .,especially if induced by high doses of gonadotrophins,predisposed by large number of follicles and high peak of oestradiol levels on the day of beta-human chorionic gonadotrophins administration.,associated with increased capillary permeability. In the management of this patient ,fundamental principles that have to be followed include thorough history ,physical examination,appropriate investigations, supportive ,medical and surgical treatment .Ahistory of symptoms of abdominal pain,distension, nausea and vomiting.,shortness of breath, chest pain ,calf pain and haemoptysis. Examinations of chest including respiratory rate,abdomen for clinical ascites and lower limbs .Investigations : FBC and haematocrit.,Liver functions tests,Urea ,electrolytes,creatinine.and coagulation profile..Ultrasound scan of abdomen,pelvis ( for ascites and ovarian size ).,Chest X-ray or scan to rule out pleural effusion. Supportive treatment: Monitoring of vital signs and urine output.,Admission to Intensive Care Unit,Thromboembolic deterrent stockings.Corrections of fluid balance: Intravenous fluid ( albumin if necessary ).And Psychological support. Medical treatment : Heparin for thromboprophylaxis.Adequate analgesia:parcetamol, Codeine and opiates. Surgical treatment : Drainage of effusions for symptomatic relief. Abdominal paracentesis is indicated for symptomatic relief of large volumes of ascites.,also in addition results in improved renal function ,blood osmolarity,reduced haemoconcentration and reduced pulmonary compromise. In exceptional circumstances,Termination of pregnancy may be indicated as a life-saving procedure. Monitoring : daily weight and abdominal girth, fluid balance chart, Pulse,BP 4-6 hourly, daily FBC,Urea,electrolytes,LFT and coagulation profile. The prevention of OHSS starts with referral to an expert expert in assisted conception in a dedicated IVF unit would be the first step.Non-pharmacological preventive measures including diet programme for obese patients with PCOS. And Laparoscopic ovarian drill for women with PCOS. Serial follicular tracking and cancellation should be considered for cycles with excessive ovarian response.Measurment of serum oesradiol levels is also important in high-risk women as well as cryopreservation of all embryos. Also,the cautious use of gonadotrophins and manipulation of treatment may help to reduce severe OHSS. Purified FSH given by low-dose incremental regime can replace the GnRH analogue/HMG regime. In cycles with excessive ovarian response the ovulatory HCG can be with-held. Recombinant LH instead of HCG should be used for final follicular maturation. Albumin can be given Intravenously at time of oocyte retrieval to enhance oncotic pressure and reduce risk of OHSS. Studies in immunomodulation to be used in the future to prevent sevre OHSS in high-risk patients.
		Posted by SWATI M. Thu Feb 9, 2006 03:05 pm
Ovarian hyperstimulation syndrome ( OHSS) develops due to release of the vasoactive substances from the hyperstimulated ovaries which increases capillary pearmeability and causes fluid leakage in serous cavities with haemoconcentration. For the management of the severe OHSS ,inpatient care should be recommended.The unit should have protocol for the management. Management should be multidisciplinary, involving physician,anaesthetist and ICU physician should the condition deteriorate with the ICU care. Fluid balance is important, to maintain adequate perfusion of tissue and minimizing risk of fluid overload.Initial intensive rehydration with 1L of normal saline over 1 hour should be given.Colloids should be given if persistent heamoconcentration or oliguria.Woman should be encouraged to drink to the thirst which is a physiological approach.If oral fluids are not tolerated due to associated nausea ,vomiting ,intravenous crystalloids are given ,2-3 L in 24 hours with monitoring of urine output.Invasive monitoring is done for the fluid management if condition deteriorate to critical condition or oliguria. Adequate analgesia is provided with paracetamol or opiates given orally or injectable if oral is not tolerated.Avoid use of NSAIDS as renal perfusion may be affected. Monitor urine output and ensure adequate hydration if output is less.Avoid use of diuretics.Paracentesis may be needed to relieve the pressure and improve the renal perfusion ,if output does not improve after rehydration. Antiemetics such as metoclopramide is used for nausea/vomiting. Relief of respiratory discomfort due to tense ascitis may be achieved by paracentasis performed under ultrasound guidance to minimize injury to the hyperstimulated enlarged ovaries. Appropriate thromboprophylaxis with adequate hydration ,early ambulation ,use of full length TED stockings with heparin should be recommended.It is given till discharge / end of first trimester if pregnant. Monitor vitals with urine output regularly with symptomatology and daily weight ,abdominal girth measurement.Assess response to the treatment by clinical follow up with investigations such as FBC, U &E, LFTs, clotting studies, ultrasound scan. Surgery should be reserved for ovarian accidents such as torsion or rupture and to be undertaken by experienced surgeon . Counselling woman and the partner is important with reassurance that no harm to the fetus if pregnant. For prevention of OHSS,recommend other methods of ovulation induction such as weight reduction, laparoscopic ovarian drilling in the women with PCOS. Follicular monitoring should be done by ultrasound and omitting further dosage of gonadotrophins for its development or HCG for final maturation if ovaries are hyperstimulated.Avoid use of GnRHa especially in PCOS. Recommend use of progesterone rather than HCG for the luteal phase support. Freezing of embryos and transfer in the sunsequent cycle if evidence of hyperstimulation.
		Posted by M H. Fri Feb 10, 2006 10:10 pm
Severe OHSS is an iatrogenic condition secondary to ovarian stimulation that occurs in 0.3-0.5% of stimulated assisted reproductive cycles. The pathogenesis is unknown but there is increased capillary permeability causing extravasation of fluid leading to haemoconcentration, ascites, pleural/pericardial effusion and increased thorombosis. A history of abdominal pain, nausea and vomiting, shortness of breath, chest pain and haemoptysis 3-7 days (early onset) or 12-17 days (late) post Human Chorionic Gonadotrophin (HCG) administration is suggestive. A distented abdomen with a mass (enlarged ovaries / ascites), crepitations on chest examination (pleural effusion) and lower limb pain (suggestive of a deep venous thrombosis) are all suggestive of complications of OHSS. Daily haematocrit, renal function tests to monitor renal function, clotting profile and liver function tests are necessary. An ultrasound examination may reveal ovarian cysts are more than 12cm in size. There may also be evidence of multiple pregnancies in late onset OHSS. A strict intake/output chart or a central venous line may be necessary to monitor fluid balance. The mainstay of treatment is supportive and this lady may require intensive care, respiratory support. Her pain should be managed with appropriate analgesics. Blood pressure and pulse rate every 4-6 hours with daily weight and abdominal circumference monitoring will alert to deterioration or improvement of her condition. The ascites, ovarian cyst fluid, pleural effusion may be drained. Correction of fluid and electrolyte balance is vital; albumin may be added. Thromboprophylaxis with a low molecular weight and TED stockings prevents a thrombotic event in this lady. In extreme cases, a termination of pregnancy may be a life saving procedure. Counselling is a vital part of management of this lady and her partner as this is a stressful time. It should be done in a private setting by the most experienced obstetrician. They are likely to require a lot of support and should be given opportunity to ask questions, seek a second opinion and referred onto a support group if necessary. OHSS can be prevented. Patients at high risk of OHSS (thin, young with polycystic ovarian syndrome) should be offered HCG stimulated cycles as a last resort, a trial with ovarian drilling or progesterone supported cycles should be offered. If HCG is used, there should be close monitoring using ultrasound and serial oestradiole and HCG levels. Cycles where there is a high number of follicles and high serum oestradiole prior to HCG administration are at an increased risk of OHSS; coasting (HCG witheld until oestradiole levels are acceptable) or abandoning the cycle should be considered.
		Posted by hala M. Sun Feb 12, 2006 12:31 pm
Severe OHSS is an iatrogenic condition during the course of ovulation induction with gonadotrophin injection leading to an ovarian enlargement which is thought to produce a vasoactive substance. This leads to the increase in the capillary permeability causing the albumin rich fluid shift from the intravascular fluid. This results in the development of ascites, hydrothorax and pericardial effusion. Severe OHSS is a life threatening condition (clinical ascites, hydrothorax, haemoconcentration, hypovolaemia, hyponatraemia, hypoalbunimia, oliguria and ovarian size of more than 12 cm) as it might be complicated with the A RDS, renal dusfunction, liver dysfunction, cerebral accident and VTE, therefore it should be managed in a unit familiar with its management provided with a clear protocol and with good communication with the IVF unit. In severe critical cases this should be done in the ITU. Basic tests should be done initially and this should include HB, HCT, U&E, LFT, creatinin, coagulation and albumin. This needs to be repeated twice weekly during the course of OHSS treatment. Multidisciplinary care with input from anaesthetist and medical colleague is important in critical cases. Symptomatic and supportive treatment is by the use of simple analgesia (paracetamol and dehydrocodien with avoiding constipation) and ant emetics. Non steroid anti inflammatory drugs should be avoided as it affects renal function. Fluid replacement should be guided by the blood results (HB, HCT, U& E, creatinin, albumin) and clinical parameters (Symotoms relief, weight, abdominal girth and urine volume). If oral fluids are intolerable then an IV infusion of 2-3 l/day of crystalloid should be given with the addition of colloid in case of albumin less than 30mmol/l. Diuretics for oliguria should not be used as it causes more volume depletion. CVP line should be considered when fluid management is problematic. The risk of VTE is increased especially with immobility, therefore full length TED stockings should be used to prevent it. Hiparin prophylaxis should be considered in high risk cases. The paracenthesis and hydrothorax drainage is considered for severe symptoms relief. Most cases resolve spontaneously but in protracted cases TOP is considered. Surgery for the ovarian cysts should only be considered in case of an accident with them (haemorrhage and torsion). The steps that can be taken to prevent the condition include the identification of patient with risk factors for the development of the condition (young, lean and PCO). This knowledge would increase the awareness of the potential development of the condition but nothing can be done to prevent its occurrence. G nRH use in PCO stimulate OHSS occurance, therefore it should not be used. The use of the lowest effective dose of gonadotrophin and the monitoring with USS and Oestradiol serum levels prevent its development. In case of high serum oesradiol, multiple egg retrieval and multiple secondary follicle development then the cycle needs to be cancelled and the eggs are used for embryo cryopreservation for future use. Progesterone should be used instead of HCG for pregnancy support reduces the risk of OHSS development. Educating the patient about the condition helps in early detection but does not prevent its occurrence.