A unilateral hydrothorax as the only manifestation of ovarian hyperstimulation syndrome: a case report

Diagnostic Complexities in a Case of Ovarian Hyperstimulation Syndrome Presented Solely as a Unilateral Massive Hydrothorax

To describe a rare case of unilateral massive hydrothorax after controlled ovarian stimulation for IVF and to analyze the diagnostic complexities in a patient lacking both risk factors and typical features of ovarian hyperstimulation syndrome (OHSS). We present a case of a 35-year-old woman suffering from primary infertility due to a severe male factor. Admitted to hospital for dyspnea, the patient initially underwent a thoracentesis. Later, due to the recurrence of massive hydrothorax, permanent pleural drainage was placed. Recognized as a severe manifestation of the OHSS, it was treated by pleural drainage, hydration, albumin perfusion, and management of the intercurrent pregnancy, up to improvement in clinical and hematological laboratory parameters and resolution of pleural effusion and respiratory symptoms. A total of 42 l of pleural fluid was drained during the 40 days of hospitalization. Since the pathogenesis of isolated acute hydrothorax in ovarian stimulation probably lies in the presence of anatomical defects of the diaphragm, this may justify that the relationship between this pathology and the OHSS risk factors may be less close. Massive pleural effusion may exceptionally be the only clinical presentation of OHSS. A high index of suspicion is necessary to make the correct diagnosis and to promptly administer treatment.

Isolated Unilateral Pleural Effusion Without Ascites in Late Onset Ovarian Hyperstimulation Syndrome: A Case Report and Review of Literature

Isolated pleural effusion is a rare presentation of severe OHSS. Two to four percent of women of reproductive age have subclinical hypothyroidism which is an uncommon association of late onset iatrogenic OHSS. This report describes an unusual patient with isolated unilateral pleural effusion and subclinical hypothyroidism as the only manifestation of late onset OHSS in a singleton pregnancy following in vitro fertilization (IVF). We have summarized current literature related to isolated pleural effusion in late OHSS and evaluated its pathophysiology and treatment options. Albumin infusion may be considered as a plasma expander whenever there is a planned third space drainage. Thyroid profile test in asymptomatic patients planning IVF will help to identify subclinical hypothyroidism. OHSS is a self-limiting condition and a timely diagnosis with aggressive management can be lifesaving.

Unilateral pleural effusion as the sole clinical presentation of severe ovarian hyperstimulation syndrome: a systematic review

The pathophysiology of isolated pleural effusion in ovarian hyperstimulation syndrome (OHSS) is not well defined. The objective of the current review is to delineate the pathophysiology, risk factors, preventive measures, and therapeutic options of isolated pleural effusion in severe OHSS. Major databases were searched until June 2016. Studies evaluating women who presented with pleural effusion as the sole extra-ovarian manifestation of severe OHSS were included. Data were extracted from 24 articles encompassing 30 reported cases. Values were expressed as mean ± SEM. Patients were young (31.5 ± 0.8 years old) and 29.1% of them were diagnosed with polycystic ovary syndrome. All the patients received human chorionic gonadotropin to trigger oocyte maturation. Estradiol level was 3110 ± 330 pg/mL on the day of the ovulatory trigger. Dyspnea was the presenting symptom in 86.6% of the patients. Pleural effusion was predominantly on the right side (80%). Ninety percent of the patients underwent thoracentesis (4332 ± 769 mL): 66.7% exudate and 33.3% transudate. Fluid initially accumulates in the peritoneal cavity then enters the pleural space due to the pressure gradient through the thoracic duct and diaphragmatic defects, which are more common on the right side. The risk factors, prevention, and management, which are also discussed in this review, are similar to those of severe OHSS.

Symptomatic isolated pleural effusion as an atypical presentation of ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome (OHSS) presents in ~33% of ovarian stimulation cycles with clinical manifestations varying from mild to severe. Its pathogenesis is unknown. Pleural effusion is reported in ~10% of severe OHSS cases and is usually associated with marked ascites. The isolated finding of pleural effusions without ascites, as the main presenting symptom of OHSS is not frequently reported and its pathogenesis is also unknown. We describe two unusual cases of OHSS where dyspnea secondary to unilateral pleural effusion was the only presenting symptom. By reporting our experience, we would like to heighten physicians' awareness in detecting these cases early, as it is our belief that the incidence of pleural effusion in the absence of most commonly recognized risk factors for OHSS may be underestimated and may significantly compromise the health of the patient if treatment is not initiated in a reasonable amount of time.

Isolated bilateral pleural effusion as the sole manifestation of late onset ovarian hyperstimulation syndrome

To report a case of late onset ovarian hyperstimulation with bilateral pleural effusion and respiratory distress as the sole manifestation after embryo transfer.

Compressive pleural effusion after ovarian hyperstimulation syndrome—a case report and review

OBJECTIVE

To report a case of early onset ovarian hyperstimulation with massive pleural effusion and respiratory failure before IVF.

DESIGN

Case report.

SETTING

University teaching intensive care unit.

PATIENT(S)

A 26-year-old healthy woman with an unexplained infertility transferred to the intensive care unit on day 4 after hCG injection for early severe presentation of ovarian hyperstimulation syndrome with massive compressive pleural effusion before she underwent embryo transfer.

INTERVENTION(S)

Mechanical ventilation, thoracocentesis.

MAIN OUTCOME MEASURE(S)

Resolution of symptoms/stopping of embryos transfer.

RESULT(S)

Drainage of 5,300 mL of sterile exudative pleural fluid for a period of 48 hours, which permitted resolution of symptoms and allowed mechanical weaning. The IVF procedure was stopped.

CONCLUSION(S)

This case described is unusual in that the patient presented with early massive pleural effusion on day 4 after hCG injection and before embryo transfer. This is much earlier than in any case report elsewhere.

Hydrothorax as the sole manifestation of ovarian hyperstimulation syndrome: unusual case and literature review

An unusual case of a unilateral massive hydrothorax after IVF treatment is reported in a 41-year-old patient, which developed as the only manifestation of ovarian hyperstimulation syndrome. The literature on such rare presentation is also reviewed to highlight its diagnostic features and prognosis.

Unilateral pleural effusion as the main presentation of "early onset" severe ovarian hyperstimulation syndrome

OBJECTIVE

To report a case of severe early onset ovarian hyperstimulation syndrome with unilateral pleural effusion and little ascites as the main presenting clinical signs.

DESIGN

Case report.

SETTING

University affiliated teaching hospital and in vitro fertilization (IVF) clinic.

PATIENT(S)

A 33-year-old woman known to have bilateral polycystic ovaries underwent IVF and became pregnant.

INTERVENTION(S)

Pleuracentesis.

MAIN OUTCOME MEASURE(S)

Resolution of symptoms, pregnancy outcome.

RESULT(S)

A total of 4,200 mL of pleural fluid was drained from the right hemithorax. Complete resolution of symptoms did not occur until 16 weeks' gestation. The pregnancy progressed normally until 27 weeks when spontaneous preterm labor resulted in a vaginal delivery of a live female infant weighing 880 grams.

CONCLUSION(S)

This case described is unusual in that the patient presented with significant right-sided pleural effusions on day 2 after embryo transfer and continued to be symptomatic until 16 weeks' gestation. This is much earlier than any previously described case report of isolated unilateral pleural effusion associated with ovarian hyperstimulation syndrome.

Isolated pleural effusion in severe ovarian hyperstimulation: A case report

Assisted reproductive technology programs use controlled ovarian hyperstimulation to maximize pregnancy rates. Severe ovarian hyperstimulation syndrome is a well-known risk. Pleural effusion often accompanies severe ovarian hyperstimulation syndrome. We describe 2 cases of isolated hydrothorax without concomitant ascites and review the literature of this rare finding.

Ovarian hyperstimulation syndrome: facts and fallacies

Severe or critical ovarian hyperstimulation syndrome (OHSS) is a serious complication of ovarian hyperstimulation for assisted reproduction techniques (ART). The syndrome is characterized by cystic enlargement of the ovaries and fluid shifts from the intravascular to the third space. The morbidity in OHSS is mainly determined by the hemodynamic changes caused by increased capillary permeability. The incidence of OHSS depends on definitions, risk factors, ovarian stimulation protocols, luteal support and conception. Currently, research on the pathogenesis of OHSS is focused on increased capillary permeability. Several theories are reviewed. Until the pathogenesis of OHSS becomes clear, treatment is restricted to supportive therapy. The various proposals for management of OHSS are discussed and, based on the available data, directions for the management of various grades of OHSS are summarized. However, prevention and early recognition are still the most important tools to handle OHSS. A flowchart with preventive measures for OHSS is presented derived from the available literature.