Aboubakr Elnashar

Background

Aboubakr Elnashar

Define Systemic disease resulting from

vasoactive products released by

hyperstimulated ovaries.

Aboubakr Elnashar

Pathophysiology Inc cap permeability:

leakage of fluid from vas

compartment:

- 3rd space fluid accumulation

-IV dehydration.

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Morbidity

Thrombosis

Renal& liver dysfunction

ARDS

Mortality

•True incidence: unknown

•Causes

1. ARDS

2. Cerebral infarction

3. Hepatorenal failure

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Incidence •Mild:

common, up to 33% of IVF

Mod to Severe:

3–8% of IVF cycles

•Varies:

1. Treatments:

IVF, CC, Gnt

2. Patient

3. Classification schemes

Aboubakr Elnashar

Diagnosis

Aboubakr Elnashar

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

Fiedler

and

Ezcurra,

2012

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Based on cl criteria

Hx of ov stimulation followed by

Ab distension,

Ab pain,

N&V.

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DD

1. Complicated ov cyst (torsion, hge)

2. Pelvic infection,

3. Intra-abdominal hge,

4. Ectopic pregnancy

5. Appendicitis.

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Assessing severity •Severity could worsen over time

•TT is guided by the severity

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Critical Severe Moderate Mild

•Tense ascites

•Oligo/anuria •Thromboembolism

•ARDS

• Ascites

•Oliguria

•Mod ab pain

•N± V

•Ab bloating

•Mild ab

pain

Cl

•large hydrothorax •±hydrothorax

•Ov›12 cm*

•Ascites

•Ov: 8–12 cm*

Ov: ‹8 cm*

US

•Hct›55%

•WCC›25 000/ml

•Hct ›45%

•Hypoproteina

emia

Lab

•ICU •In pt • Out pt

• In pt:

1.unable to

control pain

2.N with oral tt,

3.Difficulties in

monitoring

Out pt TT

Mathur, 2oo5 Aboubakr Elnashar

Aboubakr Elnashar

Types

Late Early

After 9 d of HCG

Within 9 d of HCG

Endogenous HCG of early

pregnancy.

Exogenous HCG

More severe& last longer

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Outpatient management

Indications 1. Mild OHSS

2. Many of moderate OHSS.

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Assessment & monitoring

I. Cl:

Wt

Ab girth

US {ov size, ascites}.

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II. Lab:

1. Hgb

2. Hct

3. Serum creatinine

4. Liver function tests.

5. Electrolytes

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III. Review

/2–3 d

If pregnant: prolonged monitoring

If not pregnant: resolution by the time of

the withdrawal bleeding.

Aboubakr Elnashar

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

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

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Inpatient management

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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

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Who should provide care to women with

OHSS?

•Multidisciplinary care: Experienced in

OHSS

1. Gynecologist

2. Intensivest

3. Anaesthesia

4. Medical

•Critical OHSS: intensive care.

Aboubakr Elnashar

Assessment & monitoring Investigations His& Exam

•/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)

•/4H

V signs,

Intake& output

Pain

Breathlessness

•Daily

Wt

Ab girth

Ascites

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•Worsening OHSS:

1. Increasing:

ab pain

Wt gain

girth

2. Breathlessness

3. Oliguria

U output<1000 ml/d

Persistent Positive fluid balance.

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•Severe pain Torsion, rupture or hge in the enlarged ovaries.

Ectopic pregnancy.

•Haemoconcentration: measure of the severity of OHSS

measured by raised hgb& hct.

•WCC increase: An ongoing systemic stress response.

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•Hyponatraemia:

55% of severe OHSS

±dilutional {ADH hypersecretion}.

•Oliguria

1/3 of severe OHSS

{reduced R perfusion 2ndry to hypovolaemia

or tense ascites}

ARF is rare.

•Abnormal liver function tests:

1/3 of severe OHSS

usually normalise with resolution of the

disease.

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•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.

•Chest US:

diagnosis of hydrothorax.

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•ECG Indication

pulm embolism or pericardial effusion is

suspected.

•Echocardiography

confirms the diagnosis of pericardial effusion.

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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

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I. Treatment of symptoms 1.Reassurance

2.Pain relief: • Paracetamol

• Opiates: oral or parenteral. care should be

taken to avoid constipation

• NSAID: not recommended {compromise R

function}.

3. Antiemetics: •Prochlorperazine

•Metoclopramide

•Cyclizine.

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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}.

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2. IV crystalloids: •Where oral intake cannot be maintained

Crystalloid of choice

NS but D5NS can be given but not Ringer

Fluid intake: 2–3 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

3. 1 liter NS over 1h: • 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

4. Colloids:

•Indication

Persistent haemoconcentration

u output <0.5ml/kg/ h

•Human albumin,

Hydroxyethylstarch (HES)

Dextran

Mannitol

Haemaccel

Few comparative data to support the use of any

one of these over the other

Aboubakr Elnashar

Human albumin (25%)

•200 ml at 50 ml/h over 4 hs.

Hct /4 h

Repeat until Hct is 36%-38% (Hopkins protocol)

•50–100 g is infused over 4 h

Repeat at 4-12-h intervals as necessary to

reverse haemoconcentration

Aboubakr Elnashar

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

IV 500 ml 6% HES was given over 4 h then repeated/8 h

After 24 hour of HES the patient was evaluated

Vomiting & abdominal discomfort are improved

Bp: 120/75 puls: 76 Hct: 38%

Urine output within 24 h improved: 850ml =0.65 ml/kg/h

U/S ascites is regressing

HES is continued for other 2 days

Urine output 24h:1L

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•Hyperkalemia

(>5mEqu/L or tall peaked T waves in ECG):

Calcium gluconate.

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5. Paracentesis:

Haemoconcentration &/or oliguria

persist despite colloids

•Further fluid management guided

by CVP monitoring

Anesthetists should be involved.

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Diuretics

•Avoided {deplete IV volume},

oliguria {reduced bl vol &decreased R perfusion}

•Indication: rare

Oliguria persists despite adequate

rehydration& a normal intraabdominal

pressure.

•Requirements 1. invasive haemodynamic monitoring

2. senior multidisciplinary involvement

3. usually after paracentesis

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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}.

• Intraabdominal pressure:

measured via a u catheter

>20 mmHg suggestive of the need for decompression

Aboubakr Elnashar

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.

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Hydrothorax

Drainage of ascites alone may suffice to

resolve hydrothorax

Persistent symptomatic hydrothorax despite

abdominal paracentesis: Direct drainage

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IV. Thromboprophylaxis •Indications

all women admitted to hospital.

•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

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

Thrombosis with OHSS

•Incidence

0.7% and 10%

Sites:

preponderance of upper body sites

frequent involvement of the arterial system.

•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

Suspicion

Unusual neurological symptomatology following

ovarian stimulation

TT

1. If thromboembolism is suspected:

Therapeutic anticoagulation

Arterial blood gases

Ventilation/perfusion scan.

Aboubakr Elnashar

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

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

Thank you

Aboubakr Elnashar

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: /2–3 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

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

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: 2–3 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

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