S. Monica Soni, HMS III Gillian Lieberman,...
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Ovarian Hyperstimulation Ovarian Hyperstimulation Syndrome Syndrome S. Monica Soni, HMS III S. Monica Soni, HMS III Gillian Lieberman, MD Gillian Lieberman, MD November 2008
Transcript of S. Monica Soni, HMS III Gillian Lieberman,...
Ovarian Hyperstimulation Ovarian Hyperstimulation SyndromeSyndrome
S. Monica Soni, HMS IIIS. Monica Soni, HMS IIIGillian Lieberman, MDGillian Lieberman, MD
November 2008
Agenda
Ovarian hyperstimulation syndrome (OHSS)– Pathophysiology– Presentation– Risk factors– Severity grading
Menu of tests
Anatomy
Case examples
Treatment modalities
Our patient: Ms. IHOur patient: Ms. IH
CC: Intense RLQ pain and DOE x 2 daysCC: Intense RLQ pain and DOE x 2 days
HPI: 35 year old undergoing infertility RxHPI: 35 year old undergoing infertility Rx
hCG trigger, 43 oocytes retrieved week prior, hCG trigger, 43 oocytes retrieved week prior, no embryos implantedno embryos implanted
Labs:Labs:–– hCG negativehCG negative–– Estradiol 9000 pg/mL Estradiol 9000 pg/mL –– Hct 41 (hemoconcentrated)Hct 41 (hemoconcentrated)–– ALT 30, AST 44 (slight elevation)ALT 30, AST 44 (slight elevation)
RLQ pain: Differential DiagnosisRLQ pain: Differential Diagnosis
Gynecologic:Gynecologic:–– Ovarian torsionOvarian torsion–– Ruptured ovarian cystRuptured ovarian cyst–– TOATOA–– PIDPID–– Ectopic pregnancyEctopic pregnancy
NonNon--Gynecologic:Gynecologic:–– AppendicitisAppendicitis–– Renal calculusRenal calculus–– HerniaHernia–– IleitisIleitis
Ovarian Hyperstimulation Ovarian Hyperstimulation Syndrome (OHSS)Syndrome (OHSS)
Occurs after induction of ovulation with Occurs after induction of ovulation with exogenous gonadotropinsexogenous gonadotropins
Ovarian enlargement, multifollicular Ovarian enlargement, multifollicular developmentdevelopment
VEGFVEGF--induced perifollicular induced perifollicular neovascularization, increased neovascularization, increased capillary capillary permeability,permeability, massive fluid shiftsmassive fluid shifts
OHSS: Presentation
3rd spacing – Ascites– Hydrothorax – ARDS
Intravascular hypovolemia– End-organ failure 2/2 hypoperfusion
Hemoconcentration– Thromboembolic events – DIC
OHSS: Risk factorsOHSS: Risk factors
YOUNG AGE
HIGH ESTRADIOL
>8 FOLLICLES
Grades of
OHSS
Grade I: Mild
Grade II: Moderate
Grade III: Severe
OHSS: Severity grading
Grade I– Ovaries <5cm by US
Grade II– Ovaries 5-10cm by US– Abdominal discomfort, GI symptoms – Sudden increase in weight > 3 kg
Grade III– Ascites– Effusions– Hemoconcentration– Thromboembolic events
Menu of TestsMenu of Tests
UltrasoundUltrasound
MRIMRI
CT CT
Menu Menu ofof TestsTests
UltrasoundUltrasound–– No radiation, lowNo radiation, low--costcost–– Operator dependentOperator dependent
MRIMRI–– No radiationNo radiation–– Expensive, timeExpensive, time--consumingconsuming
CT CT –– Rapid Rapid –– Expensive, radiation exposureExpensive, radiation exposure
Menu of Tests : UltrasoundMenu of Tests : Ultrasound
UltrasoundUltrasound–– TransTrans--abdominalabdominal–– TransTrans--vaginalvaginal
MRIMRI
CT CT
Imaging Modality of ChoiceImaging Modality of Choice
TransTrans--vaginal USvaginal US
TransTrans--abdominal USabdominal US
Images from : http://www.sonoguide.com/obgyn.html
Imaging Modality of Choice: Imaging Modality of Choice: UltrasoundUltrasound
Ultrasound:Ultrasound:–– TransTrans--abdominalabdominal
Greater penetrationGreater penetration
Lower frequency, lower resolutionLower frequency, lower resolution
Larger field of viewLarger field of view
Requires full bladderRequires full bladder
–– TransTrans--vaginalvaginal
Lower penetrationLower penetration
Higher frequency, higher resolutionHigher frequency, higher resolution
Smaller field of viewSmaller field of view
PostPost--void bladdervoid bladder
AnatomyAnatomy
Image from: www.uptodate.com
Companion Patient #1: Normal right ovary on trans-vaginal US
Transverse view of
right ovaryImage from: PACS, BIDMC
1.54 cm
3.37 cm
Anechoic follicle
Companion Patient #1: Normal ovary on trans-vaginal US
Image from: PACS, BIDMC
Sagittal view of
right ovary
2.63 cm
2.05 cm
Ms. IH: Enlarged ovary on Ms. IH: Enlarged ovary on transtrans--abdominal USabdominal US
Transverse view of enlarged right ovary
8.97cm
6.51cm
Image from: PACS, BIDMC
Ms. IH: Enlarged right ovary Ms. IH: Enlarged right ovary on transon trans--abdominal USabdominal US
Image from: PACS, BIDMC
Sagittal view of enlarged right ovary
10.44 cm
8.55cm
Enlarged follicle
Ms. IH: Enlarged left ovary Ms. IH: Enlarged left ovary on transon trans--abdominal USabdominal US
Sagittal view of enlarged left ovary
8.74 cm
7.42 cm
Image from: PACS, BIDMC
Enlarged anechoic follicle
Ms. IH: Free fluid on Ms. IH: Free fluid on transtrans--abdominal USabdominal US
Image from: PACS, BIDMC
Transverse view of
anechoic free fluid
Ms. IH: Ms. IH: Normal color Doppler USNormal color Doppler US
Image from: PACS, BIDMC
Multiple foci with blood
flow
Normal pulsatile
arterial flow tracing
Ms. IH: Ultrasound findings
Bilateral enlarged ovaries
Multiple enlarged follicles
Free intra-abdominal fluid
No evidence of torsion– Scattered blood flow signals throughout ovary– Pulsatile flow tracing between Doppler gates
Consistent with grade III/severe OHSS
OHSS: ComplicationsOHSS: Complications
Ovarian torsionOvarian torsion
Ovarian necrosisOvarian necrosis
Thromboembolic Thromboembolic eventsevents
EndEnd--organ failureorgan failure
Image from: http://radiology.uchc.edu/eAtlas/GYN/383b.htm
Infarcted and hemorrhagic ovary
Companion Patient #2: Companion Patient #2: Known OHSS on transKnown OHSS on trans--vaginal USvaginal US
6.62cm
4.02 cm
Sagittal view of left ovary
Image from: PACS, BIDMC
Enlarged follicular cyst
Companion Patient #2: Companion Patient #2: Ovarian torsion on color Doppler USOvarian torsion on color Doppler US
Image from: PACS, BIDMC
Central areas
without flow Irregular venous flow
Companion Patient #2: Companion Patient #2: Ovarian torsion with normal comparisonOvarian torsion with normal comparison
Images from: PACS, BIDMC
Irregular venous flow
Doppler US of ovary: normal venous flow
OHSS: Treatment
Grade I– Supportive
Grade II– Bed rest, volume repletion
Grade III– Volume repletion– Heparin – Paracentesis
OHSS: Treatment
Grade I– Supportive
Grade II– Bed rest, volume repletion
Grade III– Volume repletion– Heparin – Paracentesis
ParacentesisParacentesis
Indications:– Diagnostic– Therapeutic
Large-Volume Paracentesis
Approaches:– Trans-abdominal– Trans-vaginal
Outpatient
Image from: http://clinicalcases.blogspot.com/
Trans-abdominal paracentesis
Paracentesis: Procedure
Sterile procedure
Ultrasound guided
Avoid overlapping cutaneous & peritoneal entry sites– Prevent ascitic leak
Needle insertion sites
Angular insertionImages from: N Engl J Med (2006); 355:e21
Paracentesis: Benefits
Relieves symptoms– Even if < 1000cc removed
Shortens hospital stay
Hemodynamic improvement– Urinary output– Renal function– Cardiac output
Paracentesis: US guided Paracentesis: US guided
Aspiration needle
Image from: Archives of Gastroenterohepatology (2002); 21(1): 45-47
Anechoic free fluid
Paracentesis: Contraindications
Absolute:– DIC
Relative:– Pregnancy– Organomegaly– Small Bowel Obstruction
Paracentesis: ComplicationsParacentesis: Complications
Bleeding
Localized infection
Abdominal wall hematoma
Intra-abdominal organ injury
Post-paracentesis circulatory dysfunction
Ms. IH: Hospital Course
Grade III/severe treatment– Fluid repletion, heparin, pneumoboots
Therapeutic paracentesis recommended– Not enough ascitic fluid to tap
Discharged home on hospital day 2
Ms. IH: FollowMs. IH: Follow--upup
Returned to hospital in 1 week with acute RLQ pain
US evidence of right ovarian torsion
Emergent surgery– Right ovarian torsion, necrotic ovary
Discharged on post-operative day 3
Ms. IH: Ovarian torsion on color Ms. IH: Ovarian torsion on color Doppler USDoppler US
Image from: PACS, BIDMC
Ms. IH: Ovarian torsion with normal comparisonMs. IH: Ovarian torsion with normal comparison
Images from: PACS, BIDMC
Minimal venous flow, irregular arterial flow
OHSS: Summary
Increasing in frequency with popularity Increasing in frequency with popularity of IVFof IVF
Diagnosis made with US findings and Diagnosis made with US findings and clinical pictureclinical picture
HighHigh--risk group for ovarian torsionrisk group for ovarian torsion
Ultrasound guided paracentesis highly Ultrasound guided paracentesis highly effective treatmenteffective treatment
ReferencesReferences
Aboulghar M, Rizk B. Modern management of ovarian hyperstimulatiAboulghar M, Rizk B. Modern management of ovarian hyperstimulation syndrome. on syndrome. Human Reproduction Human Reproduction (1991); 6(8): 1082(1991); 6(8): 1082--1087.1087.
Albayram F, Hamper U. Ovarian and adnexal torsion. Albayram F, Hamper U. Ovarian and adnexal torsion. Journal of Ultrasound Journal of Ultrasound MedicineMedicine (2001); 20: 1083(2001); 20: 1083––1089.1089.
Al-Ramahi M et al. A novel approach to the treatment of ascites associatedwith ovarian hyperstimulation syndrome. Human Reproduction (1997); 12(12): 2614–2616.
Delvigne A, Rozenberg S. Review of clinical course and treatmentDelvigne A, Rozenberg S. Review of clinical course and treatment of ovarianof ovarianhyperstimulation syndrome (OHSS). hyperstimulation syndrome (OHSS). Human Reproduction UpdateHuman Reproduction Update (2003); 9(1): (2003); 9(1): 7777--96. 96.
Lincoln S et al. Aggressive outpatient treatment of ovarian hyperstimulation syndrome with ascites using transvaginal culdocentesis and intravenous albumin minimizes hospitalization. Journal of Assisted Reproduction and Genetics (2002); 19(4):159-163.
Thomsen T et al. Paracentesis. The New England Journal of Medicine (2006); 355:e21.
Whelan J, Vlahos N. The ovarian hyperstimulation syndrome. Whelan J, Vlahos N. The ovarian hyperstimulation syndrome. Fertility and Sterility (2000); 73(5): 883-896.
Acknowledgements: Acknowledgements:
Colin McArdle, MD
Sachin Pandey, MD
Dan Anghelescu, MD
Gillian Lieberman, MD
Maria Levantakis
