Ver el código de «Ovarian hyperstimulation syndrome»

==Background==
[[File:Blausen 0732 PID-Sites.png|thumb|Female pelvic anatomy.]]
*Fertility treatments causing development of multiple follicles at once
**Exaggerated ovarian response to ovulation induction (esp in IVF when HCG is used to stimulate)
*Fluid shifts out of vasculature (third spacing)
*Typically 5-10d after 1st dose
*Ranges in severity from mild to severe multiorgan dysfunction, relating in part to massive intravascular fluid shifts

==Clinical Features==
*Ovarian enlargement
*Movement of fluid out of vasculature
**[[Ascites]]
**[[Pleural effusions]]
**[[Pericardial effusion]]
**[[Hypotension]]
*[[Electrolyte imbalances]]
*[[DIC]]
*[[Thromboembolism]]
**Both venous and arterial
*Hypervolemic [[hyponatremia]]

==Differential Diagnosis==
*[[Ectopic pregnancy]]
*[[Molar pregnancy]]
*[[Sepsis]]
*[[Pulmonary embolism in pregnancy]]

{{Pelvic pain DDX}}

==Evaluation==
[[File:Vaginal ultrasonography in mild ovarian hyperstimulation syndrome - coronal.jpg|thumb|Vaginal ultrasonography in mild ovarian hyperstimulation syndrome (coronal).]]
[[File:Vaginal ultrasonography in mild ovarian hyperstimulation syndrome - sagittal.jpg|thumb|Pelvic ultrasound (sagittal) in woman with OHSS showing ascites and enlarged ovary (diameter = 6.5mm)]]
===Workup===
*Urine or serum pregnancy
**'''[[Beta-HCG]] may be positive if [[beta-HCG]] injection given as part of fertility treatment, consider obtaining beta quantitative instead of qualitative'''
*CBC
*Chem 10
*PT/PTT
*[[Pelvic ultrasound]]
*Consider:
**[[CXR]] (rule out [[pleural effusion]])
**Cardiac [[ultrasound]] (rule out [[pericardial effusion]])
**Progesterone level
**Estradiol level
**Fibrinogen (rule out [[DIC]])

===Evaluation<ref>Navot D, Bergh PA, Laufer N. Ovarian hyperstimulation syndrome in novel reproductive technologies: prevention and treatment. Fertil steril 1992; 58:249. From: Fiedler K, Ezcurra D. Predicting and preventing ovarian hyperstimulation syndrome (OHSS): the need for individualized not standardized treatment. Reprod Biol Endocrinol 2012; 10:32. Copyright © 2012 Fiedler and Ezcurra. Reproduced from BioMed Central Ltd</ref>.===
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Classification'''
| align="center" style="background:#f0f0f0;"|'''Clinical features'''
| align="center" style="background:#f0f0f0;"|'''Lab findings'''
|-
| Mild
||
*Abdominal distention/discomfort 
*Mild [[nausea/vomiting]] 
*[[Diarrhea ]]
*Enlarged ovaries
||Normal
|-
| Moderate||Above plus: 
*Ultrasonographic evidence of [[ascites]]
||
*Elevated hematocrit (>41%) 
*Elevated WBC (>15,000/mL) 
*Hypoproteinemia
|-
| Severe
||Above plus: 
*Clinical evidence of ascites (can be tense ascites) 
*Severe [[abdominal pain ]]
*Intractable [[nausea and vomiting ]]
*Rapid weight gain (>1 kg in 24 hours) 
*[[Pleural effusion ]]
*Severe [[dyspnea]] 
*Oliguria/anuria 
*Low blood/central venous pressure 
*[[Syncope]] 
*[[Venous thrombosis]]
||
*Hemoconcentration (hematocrit >55%) 
*WBC >25,000/mL 
*Serum creatinine >1.6mg/dL 
*Creatinine clearance <50 mL/min 
*[[Hyponatremia]] (Na+ <135 mEq/L) 
*[[Hyperkalemia]] (K+ >5 mEq/L) 
*Elevated liver enzymes
|-
| Critical
||Above plus: 
*Anuria/[[acute renal failure ]]
*[[Arrhythmia ]]
*[[Pericardial effusion ]]
*Massive hydrothorax 
*Thromboembolism 
*Arterial thrombosis 
*[[ARDS]] 
*[[Sepsis]]
||Worsening findings
|}

==Management==
''Pregnant patients must be followed very closely, as they are likely to worsen''
*Urgent GYN consultation for all

===Mild===
*Pain control
**[[Acetaminophen]], [[Norco]], or [[morphine]]
*Encourage oral fluids (1-2 liters/day)
*Ambulate, but avoid other physical activity. Avoid sexual intercourse

===Moderate===
*[[IV fluids]] (e.g normal saline)
*Therapeutic [[paracentesis]] if [[ascites]] (aspirate 0.5-4 L)
*Thromboembolic prophylaxis (e.g. [[LMWH]])
**All hospitalized patients
**Outpatients with 2-3 risk factors:
***Age >35 years
***Obesity
***Immobility
***Personal or family history of thrombosis
***Thrombophilias
***Pregnancy

===Severe===
*As above + consider need to drain [[pleural effusion|pleural]] or [[pericardial effusion]]

===Critical===
*As above + resuscitative care

==Disposition==
*Mild: outpatient
**Avoid heavy physical activity 
**Return for
***Worsening abdominal pain
***Weight gain (>1 kg/day)
***Increasing abdominal girth
*Moderate: outpatient if close follow-up (discuss with GYN)
*Severe: admit
*Critical: ICU

==Complications==
*[[Ovarian torsion]]
*[[Venous thromboembolism]]
*[[Hydrothorax]]
*[[Pericardial effusion]]
*Arterial thrombosis
*[[Pulmonary embolism]]
*[[Sepsis]]
*[[Acute renal failure]]
*[[Acute respiratory distress syndrome]] (ARDS)
*[[Disseminated intravascular coagulation]] (DIC)

==See Also==
*[[Ectopic Pregnancy]]
*[[Shock]]

==References==
<references/>

[[Category:OBGYN]]