OVARY amp

EMERGENCY

LAKSHMI SUJANICHAlluri Sitaramaraju Academy Of

Medical Sciences

OVARIAN HYPERSTIMULATION

SYNDROME

GRADING OHSSDEGREE GRADE CLINICAL FEATURES

MILD GRADE 1

GRADE 2

Abdominal distention pain

Vomiting diarrhea ovary enlargement less than 5 cms weight gain less than 3kg

MODERATE GRADE 3 Mild OHSS + Ultrasound evidence of asciteselectrolyte disturbances ovarian size upto10cmsweight gain of 10lbs

SEVERE GRADE 4

GRADE 5

GRADE 6

Moderate OHSS + ovary size gt 12cm weight gain gt5kgGrade 4 + tense ascites hydrothorax

Grade 5 + haemoconcenteration coagulation abnormalities renal dysfunction respiratory failure

PREVENTION OF OHSS

Adjunctive use of metformin in

PCOS patientsup1 (GRADE-A evidence)

Cabergoline 05 mg daily x 7

days following retrievalsup2 (GRADE A

evidence)

- dopamine antagoinst

- reduces VEGF production

- Long term use causes

valvular heart defectsup1Tso LO Costello MF Albuquerque LE et alMetformin treatment before and during IVF and ICSI in women with

PCOD Cochraine database Syst Rev 20092CD006105sup2 Garcia-Velasco JA How to avoid ovarian hyperstimulation syndrome a new indication for dopamine agonists

Reprod Biomed Online 200918(Suppl 2) 71-75

PREVENTION OHSS

Cryopreservation of all embryos without transfer will prevent late onset OHSSsup1(GRADE B evidence)

IN VITRO OOCYTE MATURATION completely obviates the need to stimulate ovaries by gonadotrophinssup2

sup1Aboulghar M Symposium update on prediction and management of OHSS Reprod Biomed Online 20091933-42

sup2Siristatidis CS Maheshwari A Bhattacharya S Invitro maturation in subfertile women PCOD undergoing assisted reproduction Cochrane Database Syst Rev 2009192005-2013

PREVENTION OHSS

COASTING is considered when estradiol levels are less than 4500pgml and 15 to 30 mature follicles are present sup1( level B evidence)

- Gonadotropin stimulation is withheld and estradiol levels are checked daily

-patient is triggered when estradiol levels fall below 3500pgmlAlteration of trigger in high risk patientssup1LOW dose FSH use starting from 150IU(grade A evidence)

Reintroduction of gonadodropinantagonists following retrievalsup1

sup1 Garcia-Velasco JA How to avoid ovarian hyperstimulation syndrome a new indication for dopamine agonists Reprod Biomed Online 200918(Suppl 2)

71-75

Reducing the risk of OHSS-what does not work

Intravenous albumin (level A evidence)Follicle aspiration

(level A evidence )

Using recombinant LH instead of HCG (level A evidence)

Using recombinant HCG instead of urinary HCG(level A evidence)

NOTE Usage of letrozoleis banned in india since 2011

PREDICTION OF OHSS

Estradiolconcenteration more than 3500pgml at time if trigger (15 severe OHSS

risk)

More than 20 preovulatory follicles (15 severe OHSS risk)

Doppler changes

RUPTURE OVARIAN PREGNANCY

3 of ectopics amp

most common non tubal ectopicsup1

Increased incidence in IUCD users 1 out of 9 ectopics in IUCD users is ovarian ectopicsup2

Not associated with PID or infertilitysup1

Classical triad of pain bleeding and amenorrhoea absent in ovarian ectopicsup2

sup1 Jonathan S Berek Berek amp Novakrsquos Gynaecology2012sup2John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY

Differential diagnosis hemoperitoniumwith ovarian mass

ruptured ovarian

ectopic

ruptured luteal

hematoma

ruptured ovarian

endometrioma

Rupture ovarian cyst

bull Traumatic rupture common in functional cysts amp dermoid cyst

bull Spontaneous rupture in rapidly growing ovarian neoplasm(muciousepithelial neoplasms)

bull Rupture corpus luteal cyst ddovarian ectopic

- Hcg levels fall in ectopic n not in lueteal cyst

- DampC reveals chorionic villi in corpus leuteal cystsup1

sup1John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY

Ruptured chocolate cyst

Diagnosed by a typical CT picture showingsup1

Bilateral mutilocularovarian cysts with thick wall

Loculated ascites confined to pelvic cavity

Pelvic fat infiltration

HAS EXTREMELY HIGH CA 125 LEVELS MIMICKING CARCINOMA

sup1Young Rae Lee MD CT Imaging Findings of Ruptured Ovarian EndometrioticCysts Emphasis on the Differential Diagnosis with Ruptured Ovarian

Functional Cysts Korean J Radiol 2011 Jan-Feb 12(1) 59ndash65

Published online Jan 3 2011 doi 103348kjr201112159

OVARIAN HYPERSTIMULATION

SYNDROME

GRADING OHSSDEGREE GRADE CLINICAL FEATURES

MILD GRADE 1

GRADE 2

Abdominal distention pain

Vomiting diarrhea ovary enlargement less than 5 cms weight gain less than 3kg

MODERATE GRADE 3 Mild OHSS + Ultrasound evidence of asciteselectrolyte disturbances ovarian size upto10cmsweight gain of 10lbs

SEVERE GRADE 4

GRADE 5

GRADE 6

Moderate OHSS + ovary size gt 12cm weight gain gt5kgGrade 4 + tense ascites hydrothorax

Grade 5 + haemoconcenteration coagulation abnormalities renal dysfunction respiratory failure

PREVENTION OF OHSS

Adjunctive use of metformin in

PCOS patientsup1 (GRADE-A evidence)

Cabergoline 05 mg daily x 7

days following retrievalsup2 (GRADE A

evidence)

- dopamine antagoinst

- reduces VEGF production

- Long term use causes

valvular heart defectsup1Tso LO Costello MF Albuquerque LE et alMetformin treatment before and during IVF and ICSI in women with

PCOD Cochraine database Syst Rev 20092CD006105sup2 Garcia-Velasco JA How to avoid ovarian hyperstimulation syndrome a new indication for dopamine agonists

Reprod Biomed Online 200918(Suppl 2) 71-75

PREVENTION OHSS

Cryopreservation of all embryos without transfer will prevent late onset OHSSsup1(GRADE B evidence)

IN VITRO OOCYTE MATURATION completely obviates the need to stimulate ovaries by gonadotrophinssup2

sup1Aboulghar M Symposium update on prediction and management of OHSS Reprod Biomed Online 20091933-42

sup2Siristatidis CS Maheshwari A Bhattacharya S Invitro maturation in subfertile women PCOD undergoing assisted reproduction Cochrane Database Syst Rev 2009192005-2013

PREVENTION OHSS

COASTING is considered when estradiol levels are less than 4500pgml and 15 to 30 mature follicles are present sup1( level B evidence)

- Gonadotropin stimulation is withheld and estradiol levels are checked daily

-patient is triggered when estradiol levels fall below 3500pgmlAlteration of trigger in high risk patientssup1LOW dose FSH use starting from 150IU(grade A evidence)

Reintroduction of gonadodropinantagonists following retrievalsup1

sup1 Garcia-Velasco JA How to avoid ovarian hyperstimulation syndrome a new indication for dopamine agonists Reprod Biomed Online 200918(Suppl 2)

71-75

Reducing the risk of OHSS-what does not work

Intravenous albumin (level A evidence)Follicle aspiration

(level A evidence )

Using recombinant LH instead of HCG (level A evidence)

Using recombinant HCG instead of urinary HCG(level A evidence)

NOTE Usage of letrozoleis banned in india since 2011

PREDICTION OF OHSS

Estradiolconcenteration more than 3500pgml at time if trigger (15 severe OHSS

risk)

More than 20 preovulatory follicles (15 severe OHSS risk)

Doppler changes

RUPTURE OVARIAN PREGNANCY

3 of ectopics amp

most common non tubal ectopicsup1

Increased incidence in IUCD users 1 out of 9 ectopics in IUCD users is ovarian ectopicsup2

Not associated with PID or infertilitysup1

Classical triad of pain bleeding and amenorrhoea absent in ovarian ectopicsup2

sup1 Jonathan S Berek Berek amp Novakrsquos Gynaecology2012sup2John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY

Differential diagnosis hemoperitoniumwith ovarian mass

ruptured ovarian

ectopic

ruptured luteal

hematoma

ruptured ovarian

endometrioma

Rupture ovarian cyst

bull Traumatic rupture common in functional cysts amp dermoid cyst

bull Spontaneous rupture in rapidly growing ovarian neoplasm(muciousepithelial neoplasms)

bull Rupture corpus luteal cyst ddovarian ectopic

- Hcg levels fall in ectopic n not in lueteal cyst

- DampC reveals chorionic villi in corpus leuteal cystsup1

sup1John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY

Ruptured chocolate cyst

Diagnosed by a typical CT picture showingsup1

Bilateral mutilocularovarian cysts with thick wall

Loculated ascites confined to pelvic cavity

Pelvic fat infiltration

HAS EXTREMELY HIGH CA 125 LEVELS MIMICKING CARCINOMA

sup1Young Rae Lee MD CT Imaging Findings of Ruptured Ovarian EndometrioticCysts Emphasis on the Differential Diagnosis with Ruptured Ovarian

Functional Cysts Korean J Radiol 2011 Jan-Feb 12(1) 59ndash65

Published online Jan 3 2011 doi 103348kjr201112159

GRADING OHSSDEGREE GRADE CLINICAL FEATURES

MILD GRADE 1

GRADE 2

Abdominal distention pain

Vomiting diarrhea ovary enlargement less than 5 cms weight gain less than 3kg

MODERATE GRADE 3 Mild OHSS + Ultrasound evidence of asciteselectrolyte disturbances ovarian size upto10cmsweight gain of 10lbs

SEVERE GRADE 4

GRADE 5

GRADE 6

Moderate OHSS + ovary size gt 12cm weight gain gt5kgGrade 4 + tense ascites hydrothorax

Grade 5 + haemoconcenteration coagulation abnormalities renal dysfunction respiratory failure

PREVENTION OF OHSS

Adjunctive use of metformin in

PCOS patientsup1 (GRADE-A evidence)

Cabergoline 05 mg daily x 7

days following retrievalsup2 (GRADE A

evidence)

- dopamine antagoinst

- reduces VEGF production

- Long term use causes

valvular heart defectsup1Tso LO Costello MF Albuquerque LE et alMetformin treatment before and during IVF and ICSI in women with

PCOD Cochraine database Syst Rev 20092CD006105sup2 Garcia-Velasco JA How to avoid ovarian hyperstimulation syndrome a new indication for dopamine agonists

Reprod Biomed Online 200918(Suppl 2) 71-75

PREVENTION OHSS

Cryopreservation of all embryos without transfer will prevent late onset OHSSsup1(GRADE B evidence)

IN VITRO OOCYTE MATURATION completely obviates the need to stimulate ovaries by gonadotrophinssup2

sup1Aboulghar M Symposium update on prediction and management of OHSS Reprod Biomed Online 20091933-42

sup2Siristatidis CS Maheshwari A Bhattacharya S Invitro maturation in subfertile women PCOD undergoing assisted reproduction Cochrane Database Syst Rev 2009192005-2013

PREVENTION OHSS

COASTING is considered when estradiol levels are less than 4500pgml and 15 to 30 mature follicles are present sup1( level B evidence)

- Gonadotropin stimulation is withheld and estradiol levels are checked daily

-patient is triggered when estradiol levels fall below 3500pgmlAlteration of trigger in high risk patientssup1LOW dose FSH use starting from 150IU(grade A evidence)

Reintroduction of gonadodropinantagonists following retrievalsup1

sup1 Garcia-Velasco JA How to avoid ovarian hyperstimulation syndrome a new indication for dopamine agonists Reprod Biomed Online 200918(Suppl 2)

71-75

Reducing the risk of OHSS-what does not work

Intravenous albumin (level A evidence)Follicle aspiration

(level A evidence )

Using recombinant LH instead of HCG (level A evidence)

Using recombinant HCG instead of urinary HCG(level A evidence)

NOTE Usage of letrozoleis banned in india since 2011

PREDICTION OF OHSS

Estradiolconcenteration more than 3500pgml at time if trigger (15 severe OHSS

risk)

More than 20 preovulatory follicles (15 severe OHSS risk)

Doppler changes

RUPTURE OVARIAN PREGNANCY

3 of ectopics amp

most common non tubal ectopicsup1

Increased incidence in IUCD users 1 out of 9 ectopics in IUCD users is ovarian ectopicsup2

Not associated with PID or infertilitysup1

Classical triad of pain bleeding and amenorrhoea absent in ovarian ectopicsup2

sup1 Jonathan S Berek Berek amp Novakrsquos Gynaecology2012sup2John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY

Differential diagnosis hemoperitoniumwith ovarian mass

ruptured ovarian

ectopic

ruptured luteal

hematoma

ruptured ovarian

endometrioma

Rupture ovarian cyst

bull Traumatic rupture common in functional cysts amp dermoid cyst

bull Spontaneous rupture in rapidly growing ovarian neoplasm(muciousepithelial neoplasms)

bull Rupture corpus luteal cyst ddovarian ectopic

- Hcg levels fall in ectopic n not in lueteal cyst

- DampC reveals chorionic villi in corpus leuteal cystsup1

sup1John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY

Ruptured chocolate cyst

Diagnosed by a typical CT picture showingsup1

Bilateral mutilocularovarian cysts with thick wall

Loculated ascites confined to pelvic cavity

Pelvic fat infiltration

HAS EXTREMELY HIGH CA 125 LEVELS MIMICKING CARCINOMA

sup1Young Rae Lee MD CT Imaging Findings of Ruptured Ovarian EndometrioticCysts Emphasis on the Differential Diagnosis with Ruptured Ovarian

Functional Cysts Korean J Radiol 2011 Jan-Feb 12(1) 59ndash65

Published online Jan 3 2011 doi 103348kjr201112159

PREVENTION OF OHSS

Adjunctive use of metformin in

PCOS patientsup1 (GRADE-A evidence)

Cabergoline 05 mg daily x 7

days following retrievalsup2 (GRADE A

evidence)

- dopamine antagoinst

- reduces VEGF production

- Long term use causes

valvular heart defectsup1Tso LO Costello MF Albuquerque LE et alMetformin treatment before and during IVF and ICSI in women with

PCOD Cochraine database Syst Rev 20092CD006105sup2 Garcia-Velasco JA How to avoid ovarian hyperstimulation syndrome a new indication for dopamine agonists

Reprod Biomed Online 200918(Suppl 2) 71-75

PREVENTION OHSS

Cryopreservation of all embryos without transfer will prevent late onset OHSSsup1(GRADE B evidence)

IN VITRO OOCYTE MATURATION completely obviates the need to stimulate ovaries by gonadotrophinssup2

sup1Aboulghar M Symposium update on prediction and management of OHSS Reprod Biomed Online 20091933-42

sup2Siristatidis CS Maheshwari A Bhattacharya S Invitro maturation in subfertile women PCOD undergoing assisted reproduction Cochrane Database Syst Rev 2009192005-2013

PREVENTION OHSS

COASTING is considered when estradiol levels are less than 4500pgml and 15 to 30 mature follicles are present sup1( level B evidence)

- Gonadotropin stimulation is withheld and estradiol levels are checked daily

-patient is triggered when estradiol levels fall below 3500pgmlAlteration of trigger in high risk patientssup1LOW dose FSH use starting from 150IU(grade A evidence)

Reintroduction of gonadodropinantagonists following retrievalsup1

sup1 Garcia-Velasco JA How to avoid ovarian hyperstimulation syndrome a new indication for dopamine agonists Reprod Biomed Online 200918(Suppl 2)

71-75

Reducing the risk of OHSS-what does not work

Intravenous albumin (level A evidence)Follicle aspiration

(level A evidence )

Using recombinant LH instead of HCG (level A evidence)

Using recombinant HCG instead of urinary HCG(level A evidence)

NOTE Usage of letrozoleis banned in india since 2011

PREDICTION OF OHSS

Estradiolconcenteration more than 3500pgml at time if trigger (15 severe OHSS

risk)

More than 20 preovulatory follicles (15 severe OHSS risk)

Doppler changes

RUPTURE OVARIAN PREGNANCY

3 of ectopics amp

most common non tubal ectopicsup1

Increased incidence in IUCD users 1 out of 9 ectopics in IUCD users is ovarian ectopicsup2

Not associated with PID or infertilitysup1

Classical triad of pain bleeding and amenorrhoea absent in ovarian ectopicsup2

sup1 Jonathan S Berek Berek amp Novakrsquos Gynaecology2012sup2John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY

Differential diagnosis hemoperitoniumwith ovarian mass

ruptured ovarian

ectopic

ruptured luteal

hematoma

ruptured ovarian

endometrioma

Rupture ovarian cyst

bull Traumatic rupture common in functional cysts amp dermoid cyst

bull Spontaneous rupture in rapidly growing ovarian neoplasm(muciousepithelial neoplasms)

bull Rupture corpus luteal cyst ddovarian ectopic

- Hcg levels fall in ectopic n not in lueteal cyst

- DampC reveals chorionic villi in corpus leuteal cystsup1

sup1John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY

Ruptured chocolate cyst

Diagnosed by a typical CT picture showingsup1

Bilateral mutilocularovarian cysts with thick wall

Loculated ascites confined to pelvic cavity

Pelvic fat infiltration

HAS EXTREMELY HIGH CA 125 LEVELS MIMICKING CARCINOMA

sup1Young Rae Lee MD CT Imaging Findings of Ruptured Ovarian EndometrioticCysts Emphasis on the Differential Diagnosis with Ruptured Ovarian

Functional Cysts Korean J Radiol 2011 Jan-Feb 12(1) 59ndash65

Published online Jan 3 2011 doi 103348kjr201112159

PREVENTION OHSS

Cryopreservation of all embryos without transfer will prevent late onset OHSSsup1(GRADE B evidence)

IN VITRO OOCYTE MATURATION completely obviates the need to stimulate ovaries by gonadotrophinssup2

sup1Aboulghar M Symposium update on prediction and management of OHSS Reprod Biomed Online 20091933-42

sup2Siristatidis CS Maheshwari A Bhattacharya S Invitro maturation in subfertile women PCOD undergoing assisted reproduction Cochrane Database Syst Rev 2009192005-2013

PREVENTION OHSS

COASTING is considered when estradiol levels are less than 4500pgml and 15 to 30 mature follicles are present sup1( level B evidence)

- Gonadotropin stimulation is withheld and estradiol levels are checked daily

-patient is triggered when estradiol levels fall below 3500pgmlAlteration of trigger in high risk patientssup1LOW dose FSH use starting from 150IU(grade A evidence)

Reintroduction of gonadodropinantagonists following retrievalsup1

sup1 Garcia-Velasco JA How to avoid ovarian hyperstimulation syndrome a new indication for dopamine agonists Reprod Biomed Online 200918(Suppl 2)

71-75

Reducing the risk of OHSS-what does not work

Intravenous albumin (level A evidence)Follicle aspiration

(level A evidence )

Using recombinant LH instead of HCG (level A evidence)

Using recombinant HCG instead of urinary HCG(level A evidence)

NOTE Usage of letrozoleis banned in india since 2011

PREDICTION OF OHSS

Estradiolconcenteration more than 3500pgml at time if trigger (15 severe OHSS

risk)

More than 20 preovulatory follicles (15 severe OHSS risk)

Doppler changes

RUPTURE OVARIAN PREGNANCY

3 of ectopics amp

most common non tubal ectopicsup1

Increased incidence in IUCD users 1 out of 9 ectopics in IUCD users is ovarian ectopicsup2

Not associated with PID or infertilitysup1

Classical triad of pain bleeding and amenorrhoea absent in ovarian ectopicsup2

sup1 Jonathan S Berek Berek amp Novakrsquos Gynaecology2012sup2John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY

Differential diagnosis hemoperitoniumwith ovarian mass

ruptured ovarian

ectopic

ruptured luteal

hematoma

ruptured ovarian

endometrioma

Rupture ovarian cyst

bull Traumatic rupture common in functional cysts amp dermoid cyst

bull Spontaneous rupture in rapidly growing ovarian neoplasm(muciousepithelial neoplasms)

bull Rupture corpus luteal cyst ddovarian ectopic

- Hcg levels fall in ectopic n not in lueteal cyst

- DampC reveals chorionic villi in corpus leuteal cystsup1

sup1John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY

Ruptured chocolate cyst

Diagnosed by a typical CT picture showingsup1

Bilateral mutilocularovarian cysts with thick wall

Loculated ascites confined to pelvic cavity

Pelvic fat infiltration

HAS EXTREMELY HIGH CA 125 LEVELS MIMICKING CARCINOMA

sup1Young Rae Lee MD CT Imaging Findings of Ruptured Ovarian EndometrioticCysts Emphasis on the Differential Diagnosis with Ruptured Ovarian

Functional Cysts Korean J Radiol 2011 Jan-Feb 12(1) 59ndash65

Published online Jan 3 2011 doi 103348kjr201112159

PREVENTION OHSS

COASTING is considered when estradiol levels are less than 4500pgml and 15 to 30 mature follicles are present sup1( level B evidence)

- Gonadotropin stimulation is withheld and estradiol levels are checked daily

-patient is triggered when estradiol levels fall below 3500pgmlAlteration of trigger in high risk patientssup1LOW dose FSH use starting from 150IU(grade A evidence)

Reintroduction of gonadodropinantagonists following retrievalsup1

sup1 Garcia-Velasco JA How to avoid ovarian hyperstimulation syndrome a new indication for dopamine agonists Reprod Biomed Online 200918(Suppl 2)

71-75

Reducing the risk of OHSS-what does not work

Intravenous albumin (level A evidence)Follicle aspiration

(level A evidence )

Using recombinant LH instead of HCG (level A evidence)

Using recombinant HCG instead of urinary HCG(level A evidence)

NOTE Usage of letrozoleis banned in india since 2011

PREDICTION OF OHSS

Estradiolconcenteration more than 3500pgml at time if trigger (15 severe OHSS

risk)

More than 20 preovulatory follicles (15 severe OHSS risk)

Doppler changes

RUPTURE OVARIAN PREGNANCY

3 of ectopics amp

most common non tubal ectopicsup1

Increased incidence in IUCD users 1 out of 9 ectopics in IUCD users is ovarian ectopicsup2

Not associated with PID or infertilitysup1

Classical triad of pain bleeding and amenorrhoea absent in ovarian ectopicsup2

sup1 Jonathan S Berek Berek amp Novakrsquos Gynaecology2012sup2John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY

Differential diagnosis hemoperitoniumwith ovarian mass

ruptured ovarian

ectopic

ruptured luteal

hematoma

ruptured ovarian

endometrioma

Rupture ovarian cyst

bull Traumatic rupture common in functional cysts amp dermoid cyst

bull Spontaneous rupture in rapidly growing ovarian neoplasm(muciousepithelial neoplasms)

bull Rupture corpus luteal cyst ddovarian ectopic

- Hcg levels fall in ectopic n not in lueteal cyst

- DampC reveals chorionic villi in corpus leuteal cystsup1

sup1John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY

Ruptured chocolate cyst

Diagnosed by a typical CT picture showingsup1

Bilateral mutilocularovarian cysts with thick wall

Loculated ascites confined to pelvic cavity

Pelvic fat infiltration

HAS EXTREMELY HIGH CA 125 LEVELS MIMICKING CARCINOMA

sup1Young Rae Lee MD CT Imaging Findings of Ruptured Ovarian EndometrioticCysts Emphasis on the Differential Diagnosis with Ruptured Ovarian

Functional Cysts Korean J Radiol 2011 Jan-Feb 12(1) 59ndash65

Published online Jan 3 2011 doi 103348kjr201112159

Reducing the risk of OHSS-what does not work

Intravenous albumin (level A evidence)Follicle aspiration

(level A evidence )

Using recombinant LH instead of HCG (level A evidence)

Using recombinant HCG instead of urinary HCG(level A evidence)

NOTE Usage of letrozoleis banned in india since 2011

PREDICTION OF OHSS

Estradiolconcenteration more than 3500pgml at time if trigger (15 severe OHSS

risk)

More than 20 preovulatory follicles (15 severe OHSS risk)

Doppler changes

RUPTURE OVARIAN PREGNANCY

3 of ectopics amp

most common non tubal ectopicsup1

Increased incidence in IUCD users 1 out of 9 ectopics in IUCD users is ovarian ectopicsup2

Not associated with PID or infertilitysup1

Classical triad of pain bleeding and amenorrhoea absent in ovarian ectopicsup2

sup1 Jonathan S Berek Berek amp Novakrsquos Gynaecology2012sup2John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY

Differential diagnosis hemoperitoniumwith ovarian mass

ruptured ovarian

ectopic

ruptured luteal

hematoma

ruptured ovarian

endometrioma

Rupture ovarian cyst

bull Traumatic rupture common in functional cysts amp dermoid cyst

bull Spontaneous rupture in rapidly growing ovarian neoplasm(muciousepithelial neoplasms)

bull Rupture corpus luteal cyst ddovarian ectopic

- Hcg levels fall in ectopic n not in lueteal cyst

- DampC reveals chorionic villi in corpus leuteal cystsup1

sup1John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY

Ruptured chocolate cyst

Diagnosed by a typical CT picture showingsup1

Bilateral mutilocularovarian cysts with thick wall

Loculated ascites confined to pelvic cavity

Pelvic fat infiltration

HAS EXTREMELY HIGH CA 125 LEVELS MIMICKING CARCINOMA

sup1Young Rae Lee MD CT Imaging Findings of Ruptured Ovarian EndometrioticCysts Emphasis on the Differential Diagnosis with Ruptured Ovarian

Functional Cysts Korean J Radiol 2011 Jan-Feb 12(1) 59ndash65

Published online Jan 3 2011 doi 103348kjr201112159

PREDICTION OF OHSS

Estradiolconcenteration more than 3500pgml at time if trigger (15 severe OHSS

risk)

More than 20 preovulatory follicles (15 severe OHSS risk)

Doppler changes

RUPTURE OVARIAN PREGNANCY

3 of ectopics amp

most common non tubal ectopicsup1

Increased incidence in IUCD users 1 out of 9 ectopics in IUCD users is ovarian ectopicsup2

Not associated with PID or infertilitysup1

Classical triad of pain bleeding and amenorrhoea absent in ovarian ectopicsup2

sup1 Jonathan S Berek Berek amp Novakrsquos Gynaecology2012sup2John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY

Differential diagnosis hemoperitoniumwith ovarian mass

ruptured ovarian

ectopic

ruptured luteal

hematoma

ruptured ovarian

endometrioma

Rupture ovarian cyst

bull Traumatic rupture common in functional cysts amp dermoid cyst

bull Spontaneous rupture in rapidly growing ovarian neoplasm(muciousepithelial neoplasms)

bull Rupture corpus luteal cyst ddovarian ectopic

- Hcg levels fall in ectopic n not in lueteal cyst

- DampC reveals chorionic villi in corpus leuteal cystsup1

sup1John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY

Ruptured chocolate cyst

Diagnosed by a typical CT picture showingsup1

Bilateral mutilocularovarian cysts with thick wall

Loculated ascites confined to pelvic cavity

Pelvic fat infiltration

HAS EXTREMELY HIGH CA 125 LEVELS MIMICKING CARCINOMA

sup1Young Rae Lee MD CT Imaging Findings of Ruptured Ovarian EndometrioticCysts Emphasis on the Differential Diagnosis with Ruptured Ovarian

Functional Cysts Korean J Radiol 2011 Jan-Feb 12(1) 59ndash65

Published online Jan 3 2011 doi 103348kjr201112159

RUPTURE OVARIAN PREGNANCY

3 of ectopics amp

most common non tubal ectopicsup1

Increased incidence in IUCD users 1 out of 9 ectopics in IUCD users is ovarian ectopicsup2

Not associated with PID or infertilitysup1

Classical triad of pain bleeding and amenorrhoea absent in ovarian ectopicsup2

sup1 Jonathan S Berek Berek amp Novakrsquos Gynaecology2012sup2John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY

Differential diagnosis hemoperitoniumwith ovarian mass

ruptured ovarian

ectopic

ruptured luteal

hematoma

ruptured ovarian

endometrioma

Rupture ovarian cyst

bull Traumatic rupture common in functional cysts amp dermoid cyst

bull Spontaneous rupture in rapidly growing ovarian neoplasm(muciousepithelial neoplasms)

bull Rupture corpus luteal cyst ddovarian ectopic

- Hcg levels fall in ectopic n not in lueteal cyst

- DampC reveals chorionic villi in corpus leuteal cystsup1

sup1John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY

Ruptured chocolate cyst

Diagnosed by a typical CT picture showingsup1

Bilateral mutilocularovarian cysts with thick wall

Loculated ascites confined to pelvic cavity

Pelvic fat infiltration

HAS EXTREMELY HIGH CA 125 LEVELS MIMICKING CARCINOMA

sup1Young Rae Lee MD CT Imaging Findings of Ruptured Ovarian EndometrioticCysts Emphasis on the Differential Diagnosis with Ruptured Ovarian

Functional Cysts Korean J Radiol 2011 Jan-Feb 12(1) 59ndash65

Published online Jan 3 2011 doi 103348kjr201112159

Differential diagnosis hemoperitoniumwith ovarian mass

ruptured ovarian

ectopic

ruptured luteal

hematoma

ruptured ovarian

endometrioma

Rupture ovarian cyst

bull Traumatic rupture common in functional cysts amp dermoid cyst

bull Spontaneous rupture in rapidly growing ovarian neoplasm(muciousepithelial neoplasms)

bull Rupture corpus luteal cyst ddovarian ectopic

- Hcg levels fall in ectopic n not in lueteal cyst

- DampC reveals chorionic villi in corpus leuteal cystsup1

sup1John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY

Ruptured chocolate cyst

Diagnosed by a typical CT picture showingsup1

Bilateral mutilocularovarian cysts with thick wall

Loculated ascites confined to pelvic cavity

Pelvic fat infiltration

HAS EXTREMELY HIGH CA 125 LEVELS MIMICKING CARCINOMA

sup1Young Rae Lee MD CT Imaging Findings of Ruptured Ovarian EndometrioticCysts Emphasis on the Differential Diagnosis with Ruptured Ovarian

Functional Cysts Korean J Radiol 2011 Jan-Feb 12(1) 59ndash65

Published online Jan 3 2011 doi 103348kjr201112159

Rupture ovarian cyst

bull Traumatic rupture common in functional cysts amp dermoid cyst

bull Spontaneous rupture in rapidly growing ovarian neoplasm(muciousepithelial neoplasms)

bull Rupture corpus luteal cyst ddovarian ectopic

- Hcg levels fall in ectopic n not in lueteal cyst

- DampC reveals chorionic villi in corpus leuteal cystsup1

sup1John ARock Howard w Jones TeLindersquos OPERATIVE GYNECOLOGY

Ruptured chocolate cyst

Diagnosed by a typical CT picture showingsup1

Bilateral mutilocularovarian cysts with thick wall

Loculated ascites confined to pelvic cavity

Pelvic fat infiltration

HAS EXTREMELY HIGH CA 125 LEVELS MIMICKING CARCINOMA

sup1Young Rae Lee MD CT Imaging Findings of Ruptured Ovarian EndometrioticCysts Emphasis on the Differential Diagnosis with Ruptured Ovarian

Functional Cysts Korean J Radiol 2011 Jan-Feb 12(1) 59ndash65

Published online Jan 3 2011 doi 103348kjr201112159

Ruptured chocolate cyst

Diagnosed by a typical CT picture showingsup1

Bilateral mutilocularovarian cysts with thick wall

Loculated ascites confined to pelvic cavity

Pelvic fat infiltration

HAS EXTREMELY HIGH CA 125 LEVELS MIMICKING CARCINOMA

sup1Young Rae Lee MD CT Imaging Findings of Ruptured Ovarian EndometrioticCysts Emphasis on the Differential Diagnosis with Ruptured Ovarian

Functional Cysts Korean J Radiol 2011 Jan-Feb 12(1) 59ndash65

Published online Jan 3 2011 doi 103348kjr201112159

Rupture ovarian abscess

Primary ovarian abscess is rare however it can be life threatening(Wetcher and Dunn 1985)

Early surgical intervention recommended to salvage the ovary (Stubblefield1991)

Even after proper periopcare mortality is as high as 71 sup1Prescence of subphrenic pus and

bowel injury are poor prognostic factorssup1

sup1ROBERT G FORMAN

Torsion ovarian cyst

rarr 3 gynaecologicalemergenciessup1

rarr NORMAL VASCULARITY DOESNOT EXCULDE TORSION AS OVARY HAS DUAL SUPPLY FROM UTERINE AND OVARIAN ARTERIESsup1

rarr Inflammatory cysts and malignant cysts rarely undergo torsion due to adhesionssup2

sup1 httpenwikipediaorgwikiOvarian_torsionsup2sup2Jonathan S Berek Berek amp Novakrsquos

Gynaecology2012

Thankyou

Torsion ovarian cyst

rarr 3 gynaecologicalemergenciessup1

rarr NORMAL VASCULARITY DOESNOT EXCULDE TORSION AS OVARY HAS DUAL SUPPLY FROM UTERINE AND OVARIAN ARTERIESsup1

rarr Inflammatory cysts and malignant cysts rarely undergo torsion due to adhesionssup2

sup1 httpenwikipediaorgwikiOvarian_torsionsup2sup2Jonathan S Berek Berek amp Novakrsquos

Gynaecology2012

Thankyou

Thankyou