OHSS

Case
Presentation
&
Discussion
Dr. Tanya Chawla
Dr. U. N. Jindal
1
• Mrs M, 30 yrs, married life – 5years, P1011
• FIRST VISIT : 17/08/21 for evaluation for OD.
• LMP: 16/08/21; Prev cycles: 3-4/28, Reg
• Obstetric history: P1011 P1 : FTNVD/ MCh /3yrs/A & H
A1 :Spontaneous abortion at ~ 6-7 weeks/medically
managed
• Past / Family history : Not significant

TVS Injection Ovurelix 0.25mg S/C

Uterus AV, Normal size on 17/08 and 18/08.
RO : Normal; AFC : 5-6 Routine Investigations : Normal
AMH : 3.47ng / mL
LO : Normal; AFC : 6-7
DECLARED FIT FOR PROCEDURE .
2
 Stimulation From 19/08/21
• ANTAGONIST PROTOCOL
- Inj RECAGON 200IU + Inj MENODAC 75 IU (5 days)

- Inj RECAGON 200IU + Inj MENODAC 150 IU + Inj

OVURELIX (next 5 days)

- Trigger : Inj hCG 5000IU + Inj Ovitrelle 250ug (29/08/21)

- OPU done on 31/08/21: 4RO + 5LO = 9 oocytes retrieved

- Pt discharged on the same day

3
• FOLLOW UP: DAY 8
GENERAL EXAMINATION
• Weight : 59.2kg
Pt came on D8 of OPU with • Vitals stable
complaints of : • SPO2 – 99% (room air)
• RS - B/L Chest clear
- Abdominal distension since 5- • P/A : Soft, NAD; AG : 36.5 in
6 days USG : Hyperstimulated ovaries with
- Vomiting since 2 days fluid in POD

- No breathing difficulties
- No c/o decreased urine Provisional Diagnosis:
output Mild Late Onset OHSS

ADMITTED:
TREATMENT STARTED : GnRH Antagonists (Inj Ovurelix 0.25mg) x 6 days
-Dopamine agonists (T. Cabergoline 0.5 mg) x 6 days
-Thromboprophylaxis (Inj Evaparin 40mg )
-I/V antibiotics (Inj Ceftriaxone 1gm)
-Antiemetics & PPIs 4
PARAMETER DAY 9 OPU (09 /09/21) DAY 10 (10/09/21) DAY 11 (11/09/21)
Symptoms / Orthopnoea; Orthopnoea Orthopnoea
Signs ↓ air entry in basal Abdominal pain Abdominal pain
areas

Pulse 100 /min 110 / min 100 /min

BP 110 / 70 110 / 70 110 / 70
SPO2 99 % ( room air) 96 % 95-96%
P/A AG- 39 in AG- 37.5 in AG- 39 in

Urine Output @ 80ml / hr @ 70 ml / hr @ 40ml / hr

Body Wt 59.3 kg 60.2 kg 60.7 kg
Invstg CXR: Obliterated Rt CP - Routine blood investig
angle B-hCG : 22.6
BhCG : 17.1
Intervention - Ascitic tapping 900cc 2 units of FFP - Ascitic tapping
-T. Mifepristone 200mg transfused 1100cc:
single dose - 2 units of FFP + 1
-IV fluids @ 50 ml/hr HES transfused
5
 RCOG :
Paracentesis (Indications)
• Severe abdominal distension & pain
(Ascitis)
• SOB and respiratory compromise (Ascitis
& ↑ IAP)
• Oliguria despite adequate volume
replacement (↑ IAP  reduced renal
perfusion)

POST PROCEDURE

Intravenous colloid therapy to be

considered for large volumes of fluid
removed .
6
 Large volume paracentesis with colloid replacement is
Commonest site : ~ 15 cm rapid, safe, and effective
lateral to umbilicus 4–6 l/day
Albumin infusion (8 g/litre of ascites removed)
For diagnostic purposes, 10–20 
ml. Total paracentesis is generally safer than repeated
Sent for Cytology, culture, paracentesis
biochemistry Failure to give volume expansion  circulatory dysfunction 
impairment of renal function & electrolyte disturbances
Informed consent

Albumin or Artificial plasma expanders. .????

Albumin is more effective in preventing hyponatraemia
Amount..?? VS other plasma expanders.
Time…??
Route..?? Till further studies:
 albumin remains the plasma expander of choice
Interval..?? when large volume (>5 litre) paracentesis 7
<5 litre : Synthetic plasma expander; does not require albumin
- Removal of 4–6 litres is usually enough for symptomatic relief (usually only removing 2-4
litres maximum)
- Removal of more than 4-6 litres increases the risk of hypovolemia and adverse effects.

8
9
HES FFP ALBUMIN
Derived from a waxy starch 250 ml plasma & 500 mg Isotonic solutions: 4.5 and
mainly amylopectin fibrinogen 5% in 50 – 500 ml in Aq.
Clotting factors, Plasma Diluent
proteins (5.5 gm with 60 % Burns, pancreatitis,
albumin), electrolytes, added replacement fluid in plasma
anticoagulants exchange

100 ml contains: Massive blood transfusion Concentrated solution 20 %

Hetastarch 6 gm Documented clotting factor in vol of 50 -100 ml (96%)
Nacl 0.9 g , CaCL2 defc
Na lactate Massive ascites with
Water Not to be used as a general hypoproteinemia,
Electrolytes volume expander Nephrotic syn

Volume expander, 200-250 ml 50ml – 10gm

provide electrolytes 100ml -20g
500 – 1000 mL

Avoid in pts with renal Relatively low in electrolytes

dysfuntion

20 ml / kg / day (500- 12 – 15 mL / kg 20% in doses of 50ml–100ml

1000ml ) over 4 hours
10
PARAMETER DAY 12 (12/09/21) DAY 13 (13/09/21) DAY 14 (14/09/21)

Symptoms Appetite improved Appetite improved; Appetite improved;

Vulval oedema Vulval oedema

Pulse 100 /min 110 / min 100 /min

BP 100 / 70 100 / 70 110 / 70

SPO2 99 % ( room air) 99 % 99 %

P/A Distension +; AG- 39 in Mild Distension; AG- Mild Distension; AG-

38 in 38 in

Urine Output @ 60ml / hr @ 70 ml / hr @ 100ml / hr

Body weight 65.6 kg 65.5 kg 64.4 kg

Invstg Routine blood investig

B-hCG – 34.4

Intervention T. LASIX 20mg stat

DISCHARGED 
11
 BASELINE DAY 8 (OPU) DAY 11 DAY 13

Hb 12.7g/dL 14.6 15.2 13.1

PCV 45.7 % 47 % 39 %

TLC 8200 / mm3 17,100 22,100 14,800

Platelet count 2.27 L/mm3 2.57 3.74 3.30

TSB / OT /PT 0.3 / 21 / 19 0.3 / 58 / 56 0.5 / 64 / 63 0.2 / 149 / 137

Sr. Albumin 3.3 (3.4 – 5.4 2.2 2.5

g/dL)

RFT 8.0 / 0.6 12.0 / 0.7 12.0 / 0.7 9.0 / 0.5

Sr. electrolytes 134 / 4.5 / 102 136 / 4.8 / 98 132 / 4.5 / 99

CRP 19.5
12
 CLASSIFICATION : TIME OF ONSET
EARLY LATE
- Usually presents between 3 - -Typically presents ≥ 10 after
7 days of the hCG injection the hCG injection
- Due to excessive ovarian - Due to endogenous hCG
response derived from an early
pregnancy
-More prolonged and severe

13
14
 Ascitic fluid analysis
• Culture : sterile
• Cytology : Moderate cellularity predominantly
polymorphs with few mesothelial cells and
lymphocytes; Negative for malignant cells
• Routine
PROTEINS 3.4 gm /dl Transudate : <3
Exudate : > 3
TOTAL COUNT 600 cells / mm3 < 500
NEUTROPHILS 78 % < 50
LYMPHOCYTES 05 % 0
Monocytes + 17 > 50
Macrophages +
Mesothelial cells
RBC + 0
15
Follow up : Day 17 of General & Systemic examination
OPU •Weight : 69.5 kg
• Vitals stable
C/o: Abdominal pain and • SPO2 – 96% (room air)
distension
• RS - B/L Chest clear
-Pedal oedema
• P/A : Distension + AG : 39.5 in
BhCG : 83 USG : Enlarged ovaries with fluid all around
the uterus and adnexa; Ascitis ++

READMITTED
Routine investigations sent

- Ascitic Tapping
TREATMENT STARTED : -Pleural tapping
- Thromboprophylaxis (Inj Evaparin )
- Albumin infusion
-I/V antibiotics (Inj Ceftriaxone 1gm)
- Antiemetics & PPIs - Inj Methotrexate 75mg IM
-Inj Piptaz 4.5gm
-Diuretics
16
PARAMETER DAY 17 (17/09/21) DAY 19 (19/09/21) DAY 20 (20/09/21)
DAY 18 (18/09/21)

Symptoms / Signs Abdominal pain; General condition Abdominal

Bleeding Pv; improved discomfort;
Pedal oedema ++ Minimal bleeding Pv;
Pedal oedema +
Pulse 100 /min 92 /min 100 /min

BP 100 / 80 100 / 70 110 /80

SPO2 ( room air) 96 % 97 % 98 %

P/A Distension +; AG- 39.5 in Distension +; AG- Distension +;

39 in AG- 40 in
Urine Output @ 80- 100mL / hr @ 80ml / hr @ 80ml / hr

Body Wt 69.5 kg 68.6 kg 66.2 kg

68.6 kg
Invstg Routine investg Routine investg
B-hCG : 124.5

Intervention -Ascitic tapping 1500 cc

-Inj MTX 75mg IM
17
 RCOG :

FLUID
REPLACEMENT
• Oral route, guided by thirst : most physiological
approach (Fluid intake of at least 1 litre / day )
• I/V Fluids: For acutely dehydrated patients OR
Poor oral intake (AVOID vigorous I/V fluid therapy :
may worsen ascites )
• Evidence to support specific regimen of fluid
replacement : Lacking
18
 FLUID REPLACEMENT……continued

CYSTALLOIDS (NS, DNS): Fluids

of choice for INITIAL Correction
Alternate colloid solution
(HETASTARCH, ALBUMIN,
Infused @ 125- 150 mL/h with
periodic urine output monitoring.
FFP)

• Urine output < 1000ml per Persistent haemoconcentration

OR
24 hours Low urine output
OR
• POSITIVE fluid balance INDICATES NEED OF
>1000ml over 24 hours MULTIDISCIPLINARY ASSISTANCE ±
REVIEW TO ASSESS SEVERITY INVASIVE HAEMODYNAMIC
MONITORING
19
PARAMETER D 21 (21/09/21) D 22(22/09/21) D 23 (23/09/21)

Symptoms / Signs Abdominal pain; General condition Severe epigastric pain &
No Bleeding Pv; improved backache
Pedal oedema + Fever 99.2 F No Bleeding Pv;
Fever 99.2 F  Pedal oedema +

Pulse 90 / min 90 - 100 /min 100-110 /min

BP 100 / 70 100 / 70 100 / 80
SPO2 ( room air) 98 % 97 % 89-92 % (↓ air entry in
basal areas)
P/A AG- 39.5 in AG- 39.2 in AG- 38.5 in

Urine Output @ 100 ml / hr @ 200 ml / hr @ 150 ml / hr 

Body weight 65.1 kg 63.6 kg  62 kg 
Invstg BhCG : 139.7; RFT RFT + Sr El Routine; CXR; USG abd
B-hCG : 85.9
Intervention Chest consultation: Inj Piptaz Albumin infusion;
-Albumin infusion x Pleural tapping 25cc
3 days Review Chest consultation
- T. Lasilactone OD
20
• Mechanisms: Effective plasma expander when
crystalloids fail to achieve
- Binds & inactivaties hemodynamic stability.
vasoactive peptides  Human albumin solution 20% in doses of
50–100 g, infused over 4 hours and repeated
VEGF and factors related to 4- to 12-hourly.
RAS. Fresh frozen plasma may be used
alternatively
- ↑ plasma oncotic pressure
 Counteracts the
permeability effect of Note:
Albumin is a blood-derived product
angiotensin II  drawing -Allergic reactions
fluid from the third -Anaphylaxis
-Transmission of viral or unidentified diseases.
compartment. 21
 LASILACTONE
GRADE 2 ASCITES (FIRST EPISODE) : SPIRONOLACTONE

HYPERKALEMIA  Add contraindicated

• Diuretics FUROSEMIDEdue to intravascular
volume depletion. Hypothetical risk for further
hemoconcentration.+ FUROSEMIDE
RECURRENT ASCITES : SPIRONOLACTONE
• advantage of preventing oliguria/anuria
• Use only after correction of intravascular
- LOOP diuretics (Furosemide) alone are ineffective.
volume and rehydration with 2 L of IV
- Spironolactone alone maysaline/day
take longer (lookhemoconcentration
correct for Hyper K+) and
- Combination therapy hasalso
more rapid
prevent effect
renal failure.(check RFTs)
• Recommendation to use furosemide only after
• Diuretics should be avoided : further the hematocrit level has decreased to 38% or
lower.
deplete intravascular volume

• Role in a multidisciplinary setting if

oliguria persists despite adequate fluid
replacement and drainage of ascites DIURETICS 22
PARAMETER DAY 24 (24/09/21) DAY 26 (26/09/21) DAY 30 (30/09/21)
Day 25 (25/01/21) OPD
Symptoms / General condition improved Got her periods
Signs Appetite increased

Pulse 90 / min
BP 110 / 70
SPO2 ( room 95 – 97 %
air)
P/A AG- 38 in DISCHARGED BhCG : 8.9
Urine @ 120 ml / hr
Output
Body weight 60.8 kg ---- 59.5 kg 
Invstg BhCG : 63

Intervention

23
 DEFINITION

An iatrogenic complication of assisted

reproduction technology.
Characterized by cystic enlargement of the ovaries
and a fluid shift from the intravascular to the
third space due to increased capillary
permeability and ovarian neoangiogenesis.
24
Systemic condition; hcg
dependent
Ongoing hcg stimulation
(pregnancy)   

Proinflammatory mediators
from GC : VEGF, IL-6, 1b,
TNF-a, Angiotensin II, IGF-
1, PDGF & RAS
(proangiogenic)

Arteriolar vasodilation +
Increased capillary
permeability

25
• Fluid shift from
intravascular to extra-
vascular spaces
• Manifests as Ascites;
 less commonly as
pleural and pericardial
effusions

HYPOVOLAEMIC
HYPONATREMIC STATE
26
Young Age

AFC > 24
RISK FACTORS
Low BMI

PCO
Pregnancy
AMH >
3.4ng / mL

E2 >
3500pg / mL
GnRH agonist
protocol
> 25 follicles

High dose Gn
> 24 oocytes
retrieved
hCG trigger 27
MANAGEMENT

Diagnosis

Classify as
per severity. 28
 • SELF LIMITING : resolves in
OUTPATIENT
- MILD MANAGEMENT
7-10 days
:
- MODERATE
- Selective Cases Who do not
Of SEVERE OHSS O conceive :Resolves by next
menses

- Easy access to P Who conceive: symptoms

may extend till end of 1st TM
hospital facilities
-Ensure adherence D
-COUNSELLING

-SYMPTOMATIC TREATMENT
- PAIN RELIEF (AVOID NSAIDS)
- THROMBOPROPHYLAXIS (SEVERE OHSS)
- PARACENTESIS (to prevent progression)
29
SEVERE
ADMIT
CRITICAL : ICU / CCU
MONITORING

TREATMENT LABORATORY CLINICAL

MODALITIES
-CBC with Hct -Body weight
-RFT -Abd girth
-Intravenous hydration -LFT -Fluid intake
-Pain relief -Sr electrolytes -Urine output
-Thromboprophylaxis - Coagulation profile -Vitals
-Paracentesis - B-hCG - Saturation
-Albumin infusion -USG pelvis
-GnRH antagonists -CXR
-Diuretics

30
 MODERATE
SEVERE / CRITICAL
EVALUATE for Risk factors
PROTHROMBOTIC STATE
Antiembolism stockings / LMWH

THROMBOPROPHYLAXIS

DURATION
LOOK FOR
INDIVIDUALISED - Symptoms and signs of VTE
- Risk factors - Unusual neurological symptoms
- Conception ± (even after several weeks of
apparent improvement in OHSS)
31
Till end of 1st TM
 • Acetaminophen
ANALGESICS (paracetamol) and/or
opioid analgesics.
• AVOID NSAIDs with
ANTI-EMETICS antiplatelet
properties; may
worsen renal function.

Severe pain : Rule out

-ovarian torsion or rupture
-coincident problem such as ectopic pregnancy or
pelvic infection. 32
 GnRH
Antagonists

Duration: 6-7 days

MECHANISM:
- Direct action on the ovary.
- GnRH receptors are present in
granulosa-lutein cells.
- GnRH antagonists reduces mRNA
expression for VEGF and VEGF receptor GnRH antagonist administration in
in the hyperstimulated ovaries. established severe early OHSS may result in
33
quicker regression.
 DOPAMINE
AGONISTS

There is good evidence that dopamine agonist starting at the time of hCG trigger for
several days reduces the incidence of OHSS.

Dopamine-receptor agonist
such as cabergoline may result
in a reduction of VEGF
production

Gardener’s Textbook of ART

Use of cabergoline from day of hCG

administration to six days post-oocyte
retrieval > 50% reduction in incidence
of moderate OHSS 34
 BASED ON CLINICAL CONDITION:
DAILY BASIS: - Arterial blood gases
• Vitals - ECG / 2D echo
- Chest X-ray
• Body weight -Ultrasound pelvis
• Abdominal girth -B-hCG
- C-reactive protein levels : role in severity
• Fluid intake and Urine output
• LABORATORY SIGNS OF WORSENING
• ↑ abdominal distension &
• Full blood count with Hct
• Serum electrolytes pain
• Osmolality and Renal & Liver • SOB
function tests • Tachycardia or hypotension
• Coagulation profile • ↓ urine output (< 1000ml/24
hrs) OR Positive fluid balance
(>1000 ml/24 hrs)
•Wt gain & increased AG
MONITORING • ↑ Hct ( > 45% ).
35
SURGICAL INTERVENTION

Only indicated in patients

with coincident condition
adnexal torsion
ovarian rupture
ectopic pregnancy

36
 PREVENTION
Type of Stimulation Protocol :
GnRH agonist vs. GnRH antagonist protocols

Choice of Trigger for Final Oocyte Maturation

37
 PREVENTION
Cryopreservation :

Coasting :
-Involves withdrawing exogenous gonadotrophins and
postponing hCG administration until the patient’s serum
estradiol (E2) level decreases to a ‘safer’ level in patients
who are anticipated to be at risk of developing severe
OHSS

There is insufficient evidence to recommend

coasting for the prevention of OHSS
38
ASPIRIN: Women taking aspirin had a lower incidence of severe OHSS requiring hospital
admission (antiplatelet)

METFORMIN : Reduces intraovarian hyperandrogenism  reduces the number of non-

periovulatory follicles  reduces estradiol secretion
There is good evidence that metformin decreases the risk of OHSS risk in PCOS
patients.

DOPAMINE AGONISTS : There is good evidence that dopamine agonist starting at the
time of hCG trigger for several days reduces the incidence of OHSS

I/V CALCIUM: (10 mL of 10% calcium gluconate in 200 mL NS) on the day of OPU & for
next 3 days can decrease OHSS risk. Calcium inhibits cAMP-stimulated RAS 
↓ VEGF production
39
 Autotransfusion of ultrafiltered
SU5416 ascitic fluid into the venous
-Thromboembolism circulation [CART]
-Vomiting reduced haemoconcentration,
-Interference with early pregnancy development
improved urine output
QUINAGOLIDE : DR-2 agonist
 quicker recovery
DOXYCYCLINE : inhibits angiogenesis

Extent of benefit of this treatment is

doubtful…!!!!!
Studies describe autotransfusion of
concentrated ultrafiltered ascetic
fluid protein
 aim to replenish the woman’s
albumin levels using her own protein,
 reducing the risk of infection and
allergic reaction to exogenous
40
albumin.
41