Epidemiology

Risk Factors

• Age <30 y/o
• Asthenic Build
• Early Pregnancy (see Pregnancy, [[Pregnancy]])
• Large Number of Small Follicles (8-12 mm) Observed on Ultrasound
• Polycystic Ovaries or High Basal Antral Follicle Count on Ultrasound
• Prior History of Ovarian Hyperstimulation Syndrome
• Rapidly Increasing Serum Estradiol
• Treatment with Follicle-Stimulating Hormone: lesser risk with clomiphene (see xxxx, [[xxxx]])
• Use of Human Chorionic Gonadotropin (hCG): as opposed to progesterone for luteal phase support after *in vitro” fertilization

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Etiology

• Iatrogenic Complication of Supraphysiologic Ovarian Stimulation in the Luteal Phase or Early Pregnancy During Infertility Treatment
  • Usually Follows Stimulation by Human Chorionic Gonadotropin (hCG)

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Physiology

• Capillary Leak Syndrome

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Diagnosis

Abdominal/Pelvic Ultrasound (see Abdominal-Pelvic Ultrasound, [[Abdominal-Pelvic Ultrasound]])

• Findings: large ovaries with a large number of follicles, referred to as “necklace sign”

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Clinical Manifestations

Mild Ovarian Hyperstimulation Syndrome

Gastrointestinal Manifestations

• Abdominal Bloating
• Mild Abdominal Pain (see Abdominal Pain, [[Abdominal Pain]])

Reproductive Manifestations

• Ovarian Size Usually <8 cm

Moderate Ovarian Hyperstimulation Syndrome

Gastrointestinal Manifestations

• Ascites (see Ascites, [[Ascites]]): by ultrasound
• Moderate Abdominal Pain (see Abdominal Pain, [[Abdominal Pain]])
• Nausea/Vomiting (see Nausea and Vomiting, [[Nausea and Vomiting]])

Reproductive Manifestations

• Ovarian Size 8-12 cm

Severe Ovarian Hyperstimulation Syndrome

Gastrointestinal Manifestations

• Ascites (see Ascites, [[Ascites]]): by clinical exam
• Hypoproteinemia

Hematologic Manifestations

• Hemoconcentration with Hct >45%

Pulmonary Manifestations

• Pleural Effusion (see xxxx, [[xxxx]]): occasional

Reproductive Manifestations

• Ovarian Size Usually >12 cm

Critical Ovarian Hyperstimulation Syndrome

Cardiovascular Manifestations

• Dehydration (see Hypovolemic Shock, [[Hypovolemic Shock]])

Gastrointestinal Manifestations

• Ascites (see Ascites, [[Ascites]]): tense

Hematologic Manifestations

• Hemoconcentration with Hct >55%
• Hypercoagulable State (see Hypercoagulable State, [[Hypercoagulable State]])
• Leukocytosis (see Leukocytosis, [[Leukocytosis]]): WBC >25k

Neurologic Manifestations

• Ischemic Cerebrovascular Accident (CVA) (see Ischemic Cerebrovascular Accident, [[Ischemic Cerebrovascular Accident]]): may occur

Pulmonary Manifestations

• Acute Respiratory Distress Syndrome (ARDS) (see Acute Respiratory Distress Syndrome, [[Acute Respiratory Distress Syndrome]])
• Pleural Effusion (see xxxx, [[xxxx]]): large
• Venous Thrombembolism
  • Deep Venous Thrombosis (DVT) (see Deep Venous Thrombosis, [[Deep Venous Thrombosis]])
  • Acute Pulmonary Embolism (PE) (see Acute Pulmonary Embolism, [[Acute Pulmonary Embolism]])

Renal Manifestations

• Acute Kidney Injury (AKI) with Oliguria/Anuria (see Acute Kidney Injury, [[Acute Kidney Injury]])

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Treatment

• Hospital Admission: recommended for severe-critical ovarian hyperstimulation syndrome
• Culdocentesis (Outpatient): should be considered for the prevention of disease progression in moderate or severe ovarian hyperstimulation syndrome
• Intravenous Fluid Resuscitation
  • Normal Saline (see Normal Saline, [[Normal Saline]])
  • Albumin (see Albumin, [[Albumin]]): can be considered if crystalloid is ineffective
• Paracentesis: as required to relieve tense ascites
  • Indwelling Peritoneal Pigtail Catheter: may be considered in cases where repeat paracenteses are required
• Analgesia: as required
  • Acetaminophen (Tylenol) (see Acetaminophen, [[Acetaminophen]])
  • Opiates (see Opiates, [[Opiates]])
  • Avoid NSAID with Anti-Platelet Properties
• Anti-Emetics: as required
  • xxx
• DVT Prophylaxis: routine

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References

• Epidemiology and prevention of ovarian hyperstimulation syndrome (OHSS): a review. Hum Reprod Update 2002; 8(6):559-577 [MEDLINE]
• Joint Society of Obstetricians and Gynaecologists of Canada-Canadian Fertility Andrology Society Clinical Practice Guidelines Committee; Reproductive Endocrinology and Infertility Committee of the SOGC; Executive and Council of the Society of Obstetricians; Gynaecologists of Canada; Board of the Canadian Fertility and Andrology Society; Shmorgun D, Claman P.  The diagnosis and management of ovarian hyperstimulation syndrome.  J Obstet Gynaecol Can 2011; 33(11):1156-1162 [MEDLINE]