6. Incidence
ā¢Mild: common, up to 33% of IVF Mod to Severe: 3ā8% of IVF cycles
ā¢Varies:
1.Treatments: IVF, CC, Gnt 2. Patient 3. Classification schemes
Aboubakr Elnashar
8. Women at risk
1.Previous OHSS.
2.PCO
3.Young: <30 y
4.ART written information risks, symptoms, what action to take& a 24-h contact number with prompt access to a clinician 5. Ovarian stimulation written information. 6. Use of GnRHa 7. Exposure to LH/hCG 8. Development of multiple follicles during tt
Aboubakr Elnashar
18. II. Lab:
1.Hgb
2.Hct
3.Serum creatinine
4.Liver function tests.
5.Electrolytes
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19. III. Review
/2ā3 d
If pregnant: prolonged monitoring
If not pregnant: resolution by the time of the withdrawal bleeding.
Aboubakr Elnashar
20. Treatment
I.Reassurance
II.Analgesia: Paracetamol or codeine NSAID should not be used {precipitate R failure by inhibiting R PG which maintains RBF despite hypovolemia}. III. Continue progesterone luteal support but hCG luteal support is inappropriate.
Aboubakr Elnashar
21. IV. Instruct the patient to
1.Drink to thirst, rather than to excess. Drink at least 1,000 ml of fluid per day 3 litres per day, in the form of protein rich drinks, eg. milk, if possible 2. Avoid: a. Strenuous exercise b. Sexual intercourse {fear of injury or torsion of hyperstimulated ovaries}. Complete bed rest (Increase DVT) 3. Urgent clinical review:
A.increasing severity of pain
B.increasing ab distension
C.shortness of breath
D.reduced u output. <1.01 (given 3 litre intake)/24 h
Aboubakr Elnashar
23. Indications 1. Severe OHSS. keep under review until resolution. 2. Moderate OHSS
a.Unable to achieve control of pain
b.N with oral tt
c.Difficulties in monitoring
Aboubakr Elnashar
24. Who should provide care to women with OHSS?
ā¢Multidisciplinary care: Experienced in OHSS 1. Gynecologist 2. Intensivest
3.Anaesthesia
4.Medical
ā¢Critical OHSS: intensive care.
Aboubakr Elnashar
25. Assessment & monitoring
Investigations
His& Exam
ā¢/4-8 H
Hct while titrating vol status
ā¢Daily:
CBC (Hgb, hct, WCC)
Electrolytes
ā¢Baseline
Liver function tests
Urea
Clotting studies
US: ascites, ov size
Chest X-ray or US (if res sym)
ECG& echocardiogram (if suspect pericardial effusion)
ā¢/4H
V signs,
Intake& output
Pain
Breathlessness
ā¢Daily
Wt
Ab girth
Ascites
Aboubakr Elnashar
26. ā¢Worsening OHSS:
1.Increasing: ab pain Wt gain girth 2. Breathlessness 3. Oliguria U output<1000 ml/d Persistent Positive fluid balance.
Aboubakr Elnashar
27. ā¢Severe pain Torsion, rupture or hge in the enlarged ovaries. Ectopic pregnancy.
ā¢Haemoconcentration: measure of the severity of OHSS measured by raised hgb& hct.
ā¢WCC increase: An ongoing systemic stress response.
Aboubakr Elnashar
28. ā¢Hyponatraemia: 55% of severe OHSS Ā±dilutional {ADH hypersecretion}.
ā¢Oliguria 1/3 of severe OHSS {reduced R perfusion 2ndry to hypovolaemia or tense ascites} ARF is rare.
ā¢Abnormal liver function tests: 1/3 of severe OHSS usually normalise with resolution of the disease.
Aboubakr Elnashar
29. ā¢Chest X-ray: Indication
1.Resp symptoms
2.Signs suggestive of hydrothorax, pulm infection or pulm embolism. Findings: increased size in the cardiac shadow, with the heart appearing globular or pear shaped.
ā¢Chest US: diagnosis of hydrothorax.
Aboubakr Elnashar
30. ā¢ECG
ļ¼Indication pulm embolism or pericardial effusion is suspected.
ā¢Echocardiography confirms the diagnosis of pericardial effusion.
Aboubakr Elnashar
31. Treatment I. Treatment of symptoms II Fluid balance 1. Oral intake: 2. IV crystalloids: 3. 1 liter N saline over 1h: 4. Colloids: 5. Paracentesis: III. Treatment of ascites or effusions IV. Thrompoprophylaxis V. Surgical tt
Aboubakr Elnashar
32. I. Treatment of symptoms
1.Reassurance
2.Pain relief:
ā¢Paracetamol
ā¢Opiates: oral or parenteral. care should be taken to avoid constipation
ā¢NSAID: not recommended {compromise R function}. 3. Antiemetics:
ā¢Prochlorperazine
ā¢Metoclopramide
ā¢Cyclizine.
Aboubakr Elnashar
33. II Fluid balance
1.Oral intake: Allowing women to drink acc to their thirst: {the most physiological approach, avoid risk of hypervolaemia& worsening ascites that may occur with vigorous IV therapy} Antiemetics & analgesics {enable to tolerate oral fluid intake satisfactorily}.
Aboubakr Elnashar
34. 2. IV crystalloids:
ā¢Where oral intake cannot be maintained Crystalloid of choice NS but D5NS can be given but not Ringer Fluid intake: 2ā3 lit/24 h Guided by a strict fluid balance chart. Ringer=lactated Ringer {Nacl: 6.5 g, Kcl:0.42 g, Ca cl: 0.25 g, 1 mol of Na bicarbonate is dissolved in 1 liter of distilled water
Aboubakr Elnashar
35. 3. 1 liter NS over 1h:
ā¢ Haemoconcentration (hgb>14g/dl, hct>45%) Assess change in Hct & u output response after 1 h: u output response is adequate & Hct normalizes: switch to IV D5NS & run at maintenance rate of 125-150 ml/h while closely monitoring input & output/4 h. Only NS should be used as infusion fluid {Hyponatraemia & hyperkalemia are typical of the synd} (McManus & McClure,2002)
Aboubakr Elnashar
36. 4. Colloids:
ā¢Indication Persistent haemoconcentration u output <0.5ml/kg/ h
ā¢Human albumin, Hydroxyethylstarch (HES) Dextran Mannitol Haemaccel Few comparative data to support the use of any one of these over the other
Aboubakr Elnashar
37. Human albumin (25%)
ā¢200 ml at 50 ml/h over 4 hs. Hct /4 h Repeat until Hct is 36%-38% (Hopkins protocol)
ā¢50ā100 g is infused over 4 h Repeat at 4-12-h intervals as necessary to reverse haemoconcentration
Aboubakr Elnashar
38. HES (6%): non-biological origin HES Vs Albumin higher M wt higher mean daily u output, fewer paracenteses shorter hospital stay Dose: 500ml infused over 4 h Repeat at 4-12-h intervals as necessary to reverse haemoconcentration. NB :In Egypt HES is available as HAES Sterile= HES(6%) in isotonic saline or Voluven 500 ml (68 EP)
Aboubakr Elnashar
39. ļ§IV 500 ml 6% HES was given over 4 h then repeated/8 h
After 24 hour of HES the patient was evaluated
ļ§Vomiting & abdominal discomfort are improved
ļ§Bp: 120/75 puls: 76 Hct: 38%
ļ§Urine output within 24 h improved: 850ml =0.65 ml/kg/h
ļ§ U/S ascites is regressing
ļ§HES is continued for other 2 days
ļ§Urine output 24h:1L
Aboubakr Elnashar
41. 5. Paracentesis: Haemoconcentration &/or oliguria persist despite colloids
ā¢Further fluid management guided by CVP monitoring Anesthetists should be involved.
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42. Diuretics
ā¢Avoided {deplete IV volume}, oliguria {reduced bl vol &decreased R perfusion}
ā¢Indication: rare Oliguria persists despite adequate rehydration& a normal intraabdominal pressure.
ā¢Requirements
1.invasive haemodynamic monitoring
2.senior multidisciplinary involvement
3.usually after paracentesis
Aboubakr Elnashar
43. III. Treatment of ascites or effusions Paracentesis Indication
1.Distress (significant discomfort or res embarrassment) due to abd distension
2.Oliguria persists despite adequate vol replacement {relief of intraabdominal pressure may promote R perfusion& improve u output}.
ā¢Intraabdominal pressure: measured via a u catheter >20 mmHg suggestive of the need for decompression
Aboubakr Elnashar
44. How?
1.US guidance {avoid puncture of vascular ovaries distended by large luteal cysts}. Transabdominal aspiration is better tolerated than vaginal. 2. Rate of ascitic fluid drainage should be controlled {avoid cardiovascular collapse from massive fluid shifts}, 3. Blood pressure& pulse should be monitored. 4. IV colloid replacement should be considered for women who have large volumes of ascitic fluid drained. 5. Repeated paracenteses may be avoided by the use of pigtail (that is used for nephrostomy) or suprapubic catheter that can be left in place.
Aboubakr Elnashar
45. Hydrothorax Drainage of ascites alone may suffice to resolve hydrothorax Persistent symptomatic hydrothorax despite abdominal paracentesis: Direct drainage
Aboubakr Elnashar
46. IV. Thromboprophylaxis
ā¢Indications all women admitted to hospital.
ā¢Duration At least until discharge from hospital& possibly longer, depending on other risk factors. -Not pregnant: discontinued with resolution of OHSS. -Pregnant: {The risk of thrombosis appears to persist into the first trimester of pregnancy} until the end of 1st trim, or even longer, depending on the presence of risk factors& course of the OHSS.
Aboubakr Elnashar
47. How?
1.Full-length venous support stockings
2.Prophylactic heparin therapy. Heparin: 5000 u twice daily SC 3. Intermittent pneumatic compression device is helpful when symptoms prevent ambulation& confine the patient to bed.
Aboubakr Elnashar
48. Thrombosis with OHSS
ā¢Incidence 0.7% and 10% Sites: preponderance of upper body sites frequent involvement of the arterial system.
ā¢Mechanisms
1.Haemoconcentration
2.Altered coagulation system
3.Reduced venous return {enlarged ovaries, ascites and immobility}
4.Personal or family history of thromboembolic events, thrombophilia or vascular anomalies.
Aboubakr Elnashar
50. V. Surgical management Indications:
1.Adnexal torsion
2.Co-incident problems requiring surgery Torsion: Risk factor: Pregnancy Suspicion: Further ovarian enlargement Worsening particularly unilateral pain, N, leucocytosis& anemia. Diagnosis: Color Doppler assessment of ovarian blood flow TT: Laparoscopy or laparotomy: Untwisting of the twisted adnexa followed by observation of improved color: favorable prognosis for ovarian function.
Aboubakr Elnashar
51. Risks associated with pregnancy& OHSS Data are inconclusive 1. Pregnancy may continue normally despite OHSS 2. No evidence of an increased risk of cong abnormalities. 3. High rates of miscarriage, PIH& PTL: not confirmed by controlled studies.
Aboubakr Elnashar
53. Out patient management Indications: Mild OHSS Assessment & monitoring Cl: Wt, Ab girth, US {ov size, ascites}. Lab: Hgb, Hct, Serum creatinine, Liver function tests, Electrolytes Review: /2ā3 d Treatment I. Reassurance II. Analgesia: Paracetamol or codeine III. Continue progesterone luteal support IV. Instruct the patient to 1. Drink to thirst, rather than to excess. Drink at least 1,000 ml of fluid/d 2. Avoid: Strenuous exercise, Sexual intercourse, complete bed rest 3. Urgent cl review: increasing severity of pain, abdominal distension, shortness of breath, reduced u output.
Aboubakr Elnashar
54. Inpatient management Indications: 1. Severe OHSS. 2. Moderate OHSS Assessment & monitoring Cl: /4H: V signs, Intake& output, Pain, Breathlessness Daily: Wt, Ab girth, Ascites Investigations /4-8 H: Hct while titrating vol status Daily: CBC (Hgb, hct, WCC), Electrolytes Baseline: Liver function tests, Urea, clotting studies, US: ascites, ov size, Chest X-ray or US (if res sym), ECG& echocardiogram (if suspect pericardial effusion) I. TT of symptoms Reassurance Pain relief: Paracetamol, Opiates: oral or parenteral. Antiemetics: Prochlorperazine, Metoclopramide, Cyclizine.
Aboubakr Elnashar
55. II Fluid balance 1. Oral intake: drink according to her thirst 2. IV crystalloids: Where oral intake cannot be maintained. Crystalloid of choice: NS but 5%dextrose saline can be given but not Ringer. Fluid intake: 2ā3 L/24 h. Guided by a strict fluid balance chart. 3. 1L NS over 1h: indication: Haemoconcentration (hgb>14g/dl, hct>45%). Assess change in Hct & urine output response after 1 h 4. Colloids: Indication: Persistent haemoconcentration or u output <0.5ml/kg/ h. Human albumin (25%) 200 ml at 50 ml/h over 4 hs. Hct /4 h, Repeat until Hct is 36%-38%. 5. Paracentesis: indication Haemoconcentration &/or oliguria persist despite colloids
Aboubakr Elnashar
56. III. TT of ascites or effusions: Paracentesis Indication: 1. Distress (significant discomfort or res embarrassment) due to abdominal distension. 2. Oliguria persists despite adequate vol replacement Direct drainage: Persistent symptomatic hydrothorax despite abdominal paracentesis IV. Thromboprophylaxis: Indication: all women admitted to hospital with OHSS. V. Surgical management Indications: Adnexal torsion, Co-incident problems requiring surgery
Aboubakr Elnashar
