Ovarian Hyperstimulation Syndrome Treatment & Management

Mild hyperstimulation

Treatment for ovarian hyperstimulation syndrome (OHSS) is supportive, as needed. Mild ovarian hyperstimulation can develop into moderate or severe disease, especially if conception ensues. Therefore, women with mild disease should be observed for enlarging abdominal girth, acute weight gain, and abdominal discomfort on an ambulatory basis for at least 2 weeks or until menstrual bleeding occurs.

Moderate hyperstimulation

Treatment of moderate OHSS consists of observation, bed rest, provision of adequate fluids, and sonographic monitoring of the size of cysts. Serum electrolyte concentrations, hematocrits, and creatinine levels should also be evaluated.

Some physicians have their outpatients keep track of their fluid intake and output. Intake or output less than 1000 mL/d or a discrepancy in fluid balance greater than 1000 mL/d is a cause for concern.^[18]

The beginning of the resolution of OHSS is apparent when the cysts shrink, as seen on 2 consecutive ultrasonographic examinations, and when clinical symptoms recede. In contrast, early detection of progression to the severe form of the syndrome is marked by continuous weight gain (≥ 2 lb/d), increased severity of existing symptoms, or appearance of new symptoms (eg, vomiting, diarrhea, or dyspnea).^[16]

Severe hyperstimulation

Experience with severe OHSS is mandatory for appropriate treatment. One should transfer the patient to a different center if no one who is experienced in managing severe OHSS is available at the present location.

Severe OHSS is not common, but it is dangerous. Severe and critical forms of OHSS are potentially lethal disorders, and history taking and physical examination are paramount at the time of admission. In most clinical situations, patients require bed rest. Daily physical examination should consist of measuring the patient's weight and abdominal girth. Fluid balance must be assessed every 4 hours.

Medical treatment of severe hyperstimulation is directed at maintaining intravascular blood volume. Simultaneous goals are correcting the disturbed fluid and electrolyte balance, relieving secondary complications of ascites and hydrothorax, and preventing thromboembolic phenomena.

The main interventions are fluid management and correction of hypovolemia. These measures consists of initial fast intravenous administration of normal saline. Dextrose 5% in normal saline or normal saline is infused at a rate of 125-150 mL/h with 4-hour tabulations of urine production. If urine production is restored or improved, a maintenance protocol is started. The patient should be closely monitored for clinical signs of overhydration. If urine output is unsatisfactory, hyperosmolar intravenous therapy is indicated with an infusion of 200 mL of 25% human albumin. The use of diuretics in patients with low urine production and hypovolemia is counterproductive and dangerous.^[16]

Close surveillance of fluid management is necessary. Intravenous fluid administration is stopped when urine production, appetite, or interest in drinking increases and when an overall clinical improvement is observed. In the resolution phase of severe OHSS, the patient's fluid intake should be restricted to avoid renewed hemodilution.

To prevent thrombosis, subcutaneous heparin 5000-7500 U/d is begun on the first day of admission. It is stopped after adequate mobilization is achieved.

To manage ascites, ultrasonographic-guided abdominal or vaginal paracentesis is indicated if the patient has severe discomfort or pain or if she has pulmonary or renal compromise.^[21] The vaginal procedure entails the same setup as that used for transvaginal follicular puncture. Whelan and Vlahos advise that an anesthesiologist be present. Paracentesis may be repeated if required.^[18]

Critical hyperstimulation

Critical OHSS may include renal failure, hepatic damage, thromboembolic phenomena, ARDS, and multiorgan failure.^[22] Its management and treatment requires intensive care in a critical care unit.

Intensive care should include invasive monitoring of circulatory indicators, including venous pressure and wedge pressure. The patient may need extra oxygenation (assisted ventilation).

If renal failure is present, an intravenous dopamine regimen should be started. To treat thromboembolism, therapeutic doses of anticoagulants should be administered. Thoracocentesis should be performed in the case of severe hydrothorax. Finally, if a pregnancy is maintaining a life-threatening OHSS, therapeutic abortion must be considered.

What not to do

• Aggressive palpation of the abdomen: This can precipitate follicular rupture.
• Early surgical intervention: Early surgery may cause extensive bleeding from ovarian cysts. However, surgery is mandated if torsion or rupture has occurred.
• Neglect of deterioration in organs and systems: Remember that OHSS is a syndrome of multiorgan dysfunction.

What to do

• Maintain a high degree of clinical suspicion and a low threshold for admission.
• Implement early surgical intervention in cases of ovarian torsion or hemorrhage.
• Perform paracentesis to address ascites. This decreases pressure on inferior vena cava and diaphragm.
• Place a transthoracic tube to manage pleural effusions.

After several days, third-space fluid begins to re-enter the intravascular space, hemoconcentration reverses, and natural diuresis ensues. Intravenous fluids may be tapered as the patient's oral intake increases. Complete resolution typically takes 10-14 days from the onset of initial symptoms.

Careful maintenance of blood volume, correction of electrolyte imbalances, and relief of secondary complications of ascites and hydrothorax are generally sufficient to support the patient during the severe phase of ovarian hyperstimulation. Anticoagulant therapy is usually unnecessary if these therapies are promptly administered. Blood coagulation may be monitored because of the danger of disseminated intravascular clotting.

Ovarian hyperstimulation syndrome is a self-limiting disease. Therefore, treatment should be conservative and directed at symptoms. Medical therapy suffices for most patients. Women with severe symptoms often require intensive medical care. Surgery is necessary only in extreme cases, such as in the case of a ruptured cyst, ovarian torsion, or internal hemorrhage.

Surgical management further aggravates electrolyte imbalances and increases morbidity. Ascites can be tapped by means of paracentesis. Harvesting of eggs in women with OHSS can lead to hemorrhage and peritonitis. However, tapping follicles when they are of moderate size may prevent OHSS. Laparotomy during torsion and intraperitoneal hemorrhage is life saving and recommended.

In severe cases of OHSS, consultation with a physician specializing in fluid and electrolyte imbalances is warranted. For some cases, aggressive treatment in the surgical intensive care unit may be required.

Ensure that patient receives plenty of hydration.

Activity should be minimal. Physical examination should be performed gently because of the tendency of follicles to rupture.