A 30 year old patient underwent ovarian stimulation for assisted reproduction.

A 30 year old patient underwent ovarian stimulation for assisted reproduction.

This is the ultrasound scan picture on day 9.

What does this picture indicate? (10 marks)
- Multiple follicles seen suggestive of hyperstimulation

2. What are the risk factors for OHSS? (3X5=15 marks)

Young age (<30)
Low BMI
Polycystic ovarian syndrome or polycystic ovarian morphology
High anti-Mullerian hormone (AMH)
High antral follicle count (>24)
Previous OHSS
High or rapidly rising oestrogen levels
High number of follicles or collected eggs
Luteal support with hCG
Pregnancy

3. What steps can be taken to avoid worsening of her condition? (4X5=20 marks)

Cancelation the cycle
- Coasting
- Avoid embryo transfer and cryopreservation of embryos
- Elective single embryo transfer
- Reduced dose of HCG prior to aspiration
- Avoid HCG injection
- Use dopamine agonists (such as Cabergoline)
- Use of metformin in patients with polycystic ovarian syndrome
- “Step up” protocols rather than “step down”
- Using GnRH agonist to trigger ovulation

4. Describe the pathophysiology of ovarian hyperstimulation?

(10 marks)

Still remains controversial.
Believed to be cause by increased level of serum hCG concentration
The hCG can be endogenous or exogenous
Stimulate the ovarian stoma to produce inflammatory mediators
There is increase in Cytokines, interleukins and VEGF
These substance causing increased vascular permeability leading to leakage of fluid to extra vascular space.

The cycle was continued and follicle aspiration was done on day 14. This patient presents 3 days after follicle aspiration for the appointment for embryo replacement. She has abdominal pain and distension.

5. How would you assess this patient’s condition?

What are the features of severe ovarian hyperstimulation? (40 marks)

Symptoms
- Abdominal pain, distension
- Nausea and vomiting
- Fever
- Urine out put
- Neurological symptoms
- SOB / palpitation
- Calf pain or tenderness

Examination
Generalized oedema
Dyspnea
Respiratory rate
Pleural and pericardial effusions.
Blood pressure
Ovarian enlargement, with multiple cyst formation.
Presence of ascites,
Calf swelling or tenderness
Renal dysfunction – urine output

Investigations

Full blood count – PCV, WBC and Platelet count
- Renal function tests – S.Cr / S.E
- Liver function tests – ALT, AST, S. Protein
- Coagulation screening – PT/INR
- USS abdomen and pelvis – Ascites, ovarian size, Doppler
- CXR – Pleural effusion

These are the clinical findings and investigation reports of this patient on day 3. (summary and scan picture will be given)

Mrs B

C/o Abdominal pain and vomiting

On examination

Respiratory rate 40/min

Blood pressure – 130/80

Abdomen – Distended

Pelvic masses up to umbilicus

Shifting dullness present

Urine output – 60ml/hr

Investigations

PCV – 48%

Hb – 16g/dl

WBC – 16000/mm³

Platelet count – 160000mm³

6. How would you manage this patient? (70 marks)

Postpone embryo replacement – Freeze and keep
- Treatment is supportive and symptomatic while awaiting spontaneous resolution.Hospital admission is required in severe cases and should be to a unit experienced in dealing with OHSS.Multidisciplinary involvement, including admission to the intensive care unit, should be considered if the woman has features of critical OHSS.Pain relief:
  - Consists of paracetamol and opioids.Non-steroidal anti-inflammatory drugs need to be avoided to prevent compromising renal function further
  Antiemetics help the patient to tolerate oral intake.
  
  Fluid Management
  - Drinking to thirst replaces intravascular volume and avoids the risks of hypervolaemia from vigorous intravenous therapy.If oral intake is not possible or insufficient, crystalloids (physiological saline) should be used.Persistent haemo-concentration or oliguria (urine output less than 0.5 ml/kg/hour) may benefit from colloids (h. albumin, 6% hydroxyethyl starch, dextran, mannitol, gelofusine).Total fluid intake should be 2-3 litres/day.Intravenous albumin can be considered if hypoalbuminaemia is significant.Invasive monitoring should be considered where there is no improvement.
  Diuretics – contraindicated if haemoconcentration is present.
  
  Thromboprophylaxis is required,
  - Prophylactic heparinFull-length venous support stockings.
  Paracentesis
  - Under ultrasound guidance should be considered to relieve severe ascites or in those women with severe oliguria despite adequate volume replacement.
  Pelvic surgery should be avoided, unless ovarian torsion or intra-peritoneal bleeding is suspected.Surgery should only be performed by an experienced surgeon
- Monitoring
  - Vital signs, urine output, fluid balance, weight and abdominal girth need to be monitored.
  - Investigations
    - Maintain PCV
    - Maintain renal functions