etiology,pathophysiology,clinical presentation

1. Ovarian Hyperstimulation Syndrome
(OHSS)
Prepared By:
Hemin Jamal

2. Definition
 Ovarian hyperstimulation syndrome (OHSS) is an
exaggerated response to ovulation induction therapy

3. Causes
 Fertility drugs
 Injections
 Gonadotropins( anovulation and ovarian stimulation)
 Human chorionic gonadotropin(maturation of egg)
 Gonadotropin-releasing hormone(to suppress the LH surge)
 Oral
 Clomiphene citrate (anovulation and ovarian stimulation)

4.  Spontaneous OHSS (without medication)
 Hydatiform mole
 multiple pregnancy
 Hypothyroidism

5. F
F
F
F
F F
F
F
F
F F
Stimulation Multiple follicles
VEGF
VEGF
VEGF
VEGF
VEGF
Bloodvessel
Ovary
enlargement
t
Production of
VEGF
Increase
permeability
Shift of fluid to
3rd space
edema
ascites
Effects
Risk
factors
Pathophysiology Endo hCG
Upregulate
F F
F F
F
F
F
Mature
Mature
Mature
Mature
Mature
VEGF
Mature

6. Risk factors
Primary risk factors (patient-related):
1. Young age
2. Previous OHSS
3.polycystic ovary syndrome (PCOS)
4.Low body weight
Secondary risk factors ( ovarian response related); On day of
hCG trigger:
1. High number of medium/large follicles
2. High or rapidly rising E2 levels
Pregnancy (increase in endogenous hCG)

7. Clinical presentation
 It occurs after 10 days oocyte retrieva
 correlated to endogenous hCG produ
by implanting embryo.
Onset
Late OHSSEarly OHSS
 It occurs within 9 days after
oocyte retrieval .
 correlated to ovarian response to
exogenous hCG stimulation.

8. Clinical presentation
Severity
CriticalMild to moderate Severe

9. Mild to moderate OHSS
 Mild to moderate abdominal pain
 Abdominal bloating
 Nausea
 Vomiting
 Diarrhea
 Tenderness in the area of ovaries

10. Severe OHSS
 Rapid weight gain — 2.3 kilograms in one day
 Severe, persistent nausea and vomiting
 Sever abdominal pain
 Shortness of breath
 Dark urine
 Dizziness/syncope
 Hemodynamic instability
 Edema
 Ascites

11. Critical
 Acute renal failure
 Arrhythmia(Electrolyte disturbances )
 Thromboembolism(hemoconcentration)
 Pericardial effusion
 Massive hydrothorax
 Adult RDS
 Ovarian torsion
 Rupture of a cyst in an ovary

12. Diagnosis
Laboratory investigations:
 Complete blood count (CBC) with differential:
 Hematocrit- >55%(hemoconcentration )
 Leukocyte count - >22,000 cells/µL is related to the seriousness
of OHSS
 Beta-hCG concentration
 A positive result indicates pregnancy.

13.  Estradiol levels
 Estradiol levels are increased
 estradiol >2000 pg/mL
 Complete metabolic panel
 Liver function test: AST, ALT , and ALP
 Renal function test: blood urea and creatinine
 Albumin and protein levels are decreased.
 Electrolyte imbalances: hyperkalemia and acidosis may be
present.

14. Imaging
 Ultrasonography
 to assess the follicles
 To measure the size of the ovaries
 to evaluate ascites
 Chest radiography
 may be indicated if dyspnea is present.

15. Treatment
Outpatient management
(follow up twice-weekly):
 mild & moderate OHSS.
 Severe OHSS
Inpatient management :

16. Conservative
 Education
 Fluid: the patient should receive plenty of of fluid (not less
than 1 liter).
 Activity: the patient should avoid vigorous activities
 Weight: should be recorded daily,
 urine output: the frequency and/or volume

17.  Pain relief:
- Symptomatic relief of abdominal pain can be achieved with
acetaminophen and if necessary oral or parenteral opiates.
 Nausea and/or vomiting
Antiemetic agents considered to be safe in early pregnancy
should be used to alleviate nausea and/or vomiting.

18. - Hospitalized patients should be considered at risk of thrombosis
secondary to hemo-concentration and immobilization.
- Full-length venous support stockings are recommended Daily
prophylactic doses of low-molecular weight heparin
(e.g., dalteparin sodium 5000 IU/day).
Thromboprophylaxis:

19. 1.Fluids and electrolytes:
 Hypovolemia correction
 Rapid initial hydration may be accomplished with a bolus
of IV fluid (500–1,000 mL). normal saline is preferable to
lactated Ringer’s solution.
 Albumin (25%) in doses of 50–100 g, infused over 4 hours
and, is an effective plasma expander when infusion of
normal saline fails

20.  Volume overload
Treatment with diuretics (e.g., furosemide, 20 mg IV) may be
considered after an adequate intravascular volume has been
restored (hematocrit <38%).
 Hyperkalemia
 calcium gluconate
 insulin
 sodium bicarbonate
 Kayexelate

21. 2.Paracentesis
 Indication
 Ascites with pain
 Ascites compromised pulmonary function
 oliguria/ anuria that does not improve
with appropriate fluid management
 Procedure
 A transvaginal or transabdominal approach may be used,
under gentle ultrasound guidance
 Replace plasma protein

22. 3- Pleuracentesis:
 Bilateral or severe pleural effusion
that persists after paracentesis
INTENSIVE CARE TREATMENT
renal failure
thromboembolism
adult respiratory distress syndrome

23. surgery
 Indications
 ovarian torsion
 a ruptured cyst in the ovary
 an internal hemorrhage
 Approach
 Laparoscopy(detorsion of ovaries )
 Laparotomy
 Preserve ovaries

24. prevention
 Recognition of risk factors for OHSS
 Ovulation induction regimens should be highly
individualized
 Use the minimum dose and duration of gonadotropin
therapy necessary to achieve the therapeutic goal.
 Monitoring(E2 and ultrasoography) and prophylactic
treatment with volume expanders