Ovarian hyperstimulation syndrome (OHSS)
1.Grading of OHSS.
Classification of ovarian hyperstimulation syndrome
Mild
Moderate
Severe
Critical
I: Abdominal distension and discomfort
II: Grade I symptoms plus nausea, vomiting and/or diarrhea
Ovaries of varying degrees of enlargement, ≤5cm in diameter
III: Mild OHSS symptoms exacerbated
Ultrasound evidence of ascites
Ovaries 5-10 cm in diameter
IV: Severe OHSS features
Clinical evidence of ascites
V: hematocrit ≥45% (≥30% elevation from baseline,, WBC ≥15×10^9/L, oliguria, blood creatinine 1,0-1,5mg/dl, creatinine clearance ≥50ml/min
VI: Tonic ascites +/0 ascites
Hematocrit≥55%
WBC≥25×10^9/L
Creatinine ≥1,6mg/dl
Creatinine clearance 50ml/min
Thromboembolism
Acute respiratory distress syndrome (ARDS,)
2.Prevention of OHSS.
1, vigilance in patients with high-risk factors.
2.Adjustment of ovulation promotion protocols: e.g. long-acting GnRHa to enhance descending regulation and delay the initiation of Gn; low-dose Gn taper or tapering protocols; GnRH-ant protocols.
3, control the application of exogenous HCG: 1, cancel the cycle, cancel or reduce the use of HCG; 2, GnRHa or recombinant LH instead of HCG to induce ovulation; 3, use progesterone instead of HCG for luteal support.
4, “coasting therapy” or delayed HCG injection: i.e., in patients at high risk of OHSS with abdominal discomfort, large number of follicular collections (>10 follicles developing on each side, serum E2 >18350 pmol/L, and dominant follicles of 16-18 mm, coasting Therapy: stop Gn and continue GnRHa for 1-2 days until the serum E2 drops to a safe range, i.e. 9177-13760 pmol/L or less before using HCG.
5. early retrieval of unilateral follicles: 10-12 hours after HCG, retrieve follicles from one ovary first and the other side 36 hours later.
6, single embryo transfer or cancellation of transfer and freezing of all embryos.
7. prophylactic treatment with albumin and immunoglobulin.
3. Treatment of OHSS
Treatment principles: mild observation, moderate appropriate intervention, severe active treatment. Pay high attention to dyspnea, decreased urine output, lower limb edema, dizziness, numbness, and neurological symptoms. Severe OHSS must be hospitalized.
1.First of all, pay attention to spiritual encouragement and establish confidence to overcome the disease: pay attention to rest and avoid drastic changes in position to prevent ovarian rupture or torsion; move the limbs appropriately to prevent thrombosis; prohibit pelvic examination and heavy pressure on the abdomen; eat high-protein food in small amounts several times.
2.Monitoring: fluid intake and output, abdominal circumference, weight and vital signs; timely monitoring of blood routine, hematocrit, coagulation function, electrolytes, liver function, creatinine, urea nitrogen and hemodynamic examination; pregnancy test and abdominal ultrasound.
3. Correct blood volume and electrolyte balance: maintain blood volume during extravasation of body fluids and correct hypovolemia early; expand blood volume according to the condition, use albumin and dextrose 40, and use diuretics with caution. In case of hemoconcentration, hypertension and hyponatremia, diuretics are prohibited. in OHSS patients with a tendency of hyperkalemia and hyponatremia, the use of Ringer’s solution is not advocated, and saline can be supplemented. Monitor acid-base balance and blood coagulation status; stop rehydration after the condition is stabilized; in patients with severe oliguria, under the premise of adequate volume expansion, dopamine is administered intravenously to dilate renal blood vessels, increase urine volume and improve renal function.
4, prevention of thrombosis Patients with severe OHSS are in a hypercoagulable state, heparin anticoagulation if necessary, to prevent thrombosis.
5, management of thoraco-abdominal fluid Indications for peritoneal puncture for ascites drainage: abdominal distension causing severe abdominal discomfort or pain; pulmonary involvement (persistent shortness of breath, reduced partial pressure of oxygen, pleural fluid,; renal involvement with inadequate response to drug therapy (persistent oliguria, elevated blood creatinine, decreased creatinine clearance,. The operation needs to be performed under ultrasound monitoring. Most pleural effusions can be absorbed spontaneously; severe pleural fluid can be released by puncture, paying attention to pulmonary complications and the occurrence of ARDS. In severe cases, ovarian flavin cyst fluid can be withdrawn simultaneously during abdominal puncture to reduce the amount of E2 entering the circulation, but attention to the combined pregnancy is prone to abortion due to sudden drop in hormone levels. Repeated release of fluid prophylactic use of antibiotics.
6, other drugs Some scholars use 6% hydroxyethyl starch (HES, instead of albumin; glucocorticoids such as Bonisolone, which can improve capillary permeability and reduce capillary exudation; immunoglobulin helps to prevent infection; subcutaneous injection of heparin sodium to prevent thrombosis.
7.Usually enlarged ovaries can subside on their own without surgery, but attention should be paid to ovarian cyst rupture, bleeding or torsion, as well as the occurrence of ectopic pregnancy, which should be treated surgically if necessary, and the ovaries should be preserved as much as possible.
8. In case of multiple organ failure, pregnancy should be decisively interrupted.