Ovarian Hyperstimulation Syndrome

Aka: Ovarian Hyperstimulation Syndrome, Ovarian Hyperstimulation

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II. Pathophysiology

  1. Hyperstimulation occurs with gonadotropin stimulation for Ovulation induction or Invitro Fertilization (IVF) Cycles
  2. Hyperstimulation increases ovarian capillary permeability and neoangiogenesis

III. Risk Factors

  1. Younger patients
  2. Lower body weight
  3. Polycystic ovarian syndrome
  4. High dose exogenous gonadotropins
  5. Increased Serum Estradiol (E2) levels (rapidly increasing or high absolute level)
  6. More than 24 oocytes retrieved
  7. Past history of Ovarian Hyperstimulation Syndrome (OHSS)

IV. Symptoms

  1. Gastrointestinal
    1. Abdominal discomfort
    2. Abdominal Distention (increased abdominal circumference)
    3. Nausea or Vomiting
    4. Diarrhea
  2. Systemic
    1. Rapid weight gain
    2. Tachypnea or respiratory distress
    3. Oliguria
    4. Anuria

V. Grading: Golan Classification for Ovarian Hyperstimulation Syndrome (OHSS)

  1. Mild Ovarian Hyperstimulation (20-33% of OHSS cases)
    1. Ovarian Size <6 cm
    2. Grade 1: Abdominal Distention
    3. Grade 2: Abdominal Distention, Nausea, Vomiting and Diarrhea
  2. Moderate Ovarian Hyperstimulation (3-6% of OHSS cases)
    1. Ovarian Size 6-12 cm
    2. Grade 3: Ascites on Ultrasound and weight gain, in addition to Grade 2 symptoms
  3. Severe Ovarian Hyperstimulation (0.1 to 2% of OHSS cases)
    1. Ovarian Size >12 cm
    2. Grade 4: Ascites and Hydrothorax, in addition to Grade 2 Symptoms
    3. Grade 5: Ascites and Hydrothorax with Hypovolemia, hemoconcentration, Coagulation Disorder, Oliguria, shock

VI. Labs

  1. Complete Blood Count
    1. Hemoconcentration (increased Hematocrit >45%)
    2. Leukocytosis (White Blood Cell Count >15,000)
  2. Comprehensive Metabolic Panel
    1. Hyponatremia (Serum Sodium <135)
    2. Hyperkalemia (Serum Potassium >5.0)
    3. Iincreased ALT and AST liver enzymes
    4. Increased Serum Creatinine (>1.2 mg/dl)

VII. Imaging

  1. Pelvic Ultrasound
    1. Measure ovarian size (<6 cm, 6-12 cm or >6 cm)
    2. Evaluate for Ascites (significant free abdominal fluid)
      1. Ascites and hemoperitoneum (e.g. ruptured Ovarian Cyst) may be indistinguishable on Ultrasound
      2. Consider CT Abdomen and Pelvis to characterize large intraabdominal fluid collection
  2. Lung Ultrasound or Chest XRay
    1. Indicated in Dyspnea, for evaluation of Pleural Effusions or hydrothorax
  3. CT Abdomen and Pelvis
    1. Consider in severe cases (Hounsfield Units may distinguish intraabdominal blood from Ascites)

VIII. Management

  1. Consult patient's reproductive specialist
  2. Hospital monitoring indications
    1. Severe Ovarian Hyperstimulation Syndrome (OHSS)
    2. Hemodynamic Instability
    3. Intractable Pain
    4. Intractable Nausea or Vomiting and unable to maintain hydration
    5. Respiratory distress
    6. Severe laboratory abnormalities
  3. Outpatient management is often indicated in Mild to moderate Ovarian Hyperstimulation Syndrome (OHSS)
    1. Requires close interval follow-up
    2. Serial labs (interval and lab type per reproductive specialist guidance)
    3. Monitor intake and output, daily weight and abdominal circumference

IX. Complications

  1. Acute Renal Failure
  2. Acute Respiratory Distress Syndrome (ARDS)
  3. Ruptured Ovarian Cyst with Hemorrhage
  4. Thromboembolism (OHSS is a Hypercoagulable state)

X. References

  1. Gallo, Suyama and Snook (2020) Crit Dec Emerg Med 34(10): 3-7
  2. Zivi (2010) Semin Reprod Med 28(6): 441-7 [PubMed]

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