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Treatment of OHSS
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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.
Aboubakr Elnashar
Morbidity
Thrombosis
Renal& liver dysfunction
ARDS
Mortality
•True incidence: unknown
•Causes
1. ARDS
2. Cerebral infarction
3. Hepatorenal failure
Aboubakr Elnashar
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
Aboubakr Elnashar
Based on cl criteria
Hx of ov stimulation followed by
Ab distension,
Ab pain,
N&V.
Aboubakr Elnashar
DD
1. Complicated ov cyst (torsion, hge)
2. Pelvic infection,
3. Intra-abdominal hge,
4. Ectopic pregnancy
5. Appendicitis.
Aboubakr Elnashar
Assessing severity •Severity could worsen over time
•TT is guided by the severity
Aboubakr Elnashar
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
Aboubakr Elnashar
Outpatient management
Indications 1. Mild OHSS
2. Many of moderate OHSS.
Aboubakr Elnashar
Assessment & monitoring
I. Cl:
Wt
Ab girth
US {ov size, ascites}.
Aboubakr Elnashar
II. Lab:
1. Hgb
2. Hct
3. Serum creatinine
4. Liver function tests.
5. Electrolytes
Aboubakr Elnashar
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
Aboubakr Elnashar
Inpatient management
Aboubakr Elnashar
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
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
Aboubakr Elnashar
•Worsening OHSS:
1. Increasing:
ab pain
Wt gain
girth
2. Breathlessness
3. Oliguria
U output<1000 ml/d
Persistent Positive fluid balance.
Aboubakr Elnashar
•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.
Aboubakr Elnashar
•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.
Aboubakr Elnashar
•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.
Aboubakr Elnashar
•ECG Indication
pulm embolism or pericardial effusion is
suspected.
•Echocardiography
confirms the diagnosis of pericardial effusion.
Aboubakr Elnashar
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
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.
Aboubakr Elnashar
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
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
Aboubakr Elnashar
•Hyperkalemia
(>5mEqu/L or tall peaked T waves in ECG):
Calcium gluconate.
Aboubakr Elnashar
5. Paracentesis:
Haemoconcentration &/or oliguria
persist despite colloids
•Further fluid management guided
by CVP monitoring
Anesthetists should be involved.
Aboubakr Elnashar
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
Aboubakr Elnashar
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.
Aboubakr Elnashar
Hydrothorax
Drainage of ascites alone may suffice to
resolve hydrothorax
Persistent symptomatic hydrothorax despite
abdominal paracentesis: Direct drainage
Aboubakr Elnashar
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