Febrile morbidity in severe and critical ovarian hyperstimulation syndrome: a multicentre study

Venous Thromboembolism Associated with Assisted Reproductive Technology: A Systematic Review and Meta-analysis

BACKGROUND

 Hormonal exposure leads to an increased risk of venous thromboembolism (VTE) but the risk of VTE associated with assisted reproductive technology (ART) is not clearly determined.

METHODS

 We searched in PubMed, EMBASE, Web of Science, and the Cochrane Library databases and identified all relevant articles published up to February 1, 2021. The primary objective was to determine the frequency of VTE associated with ART. Secondary objectives were to determine (1) the risk of VTE associated with ART as compared to pregnancy without ART; (2) the risk of VTE associated with ovarian hyperstimulation syndrome (OHSS); and (3) to determine potential risk factors of VTE related to ART.

RESULTS

 Fourteen studies were included. The overall frequency of VTE associated with ART was 0.23% (95% confidence interval [CI]: 0.07-0.46). Women undergoing ART had a two- to threefold increased risk of VTE as compared to spontaneous pregnancy (relative risk [RR]: 2.66; 95% CI: 1.60-4.43). The overall frequency of VTE specifically related to OHSS was <0.001%. The risk of VTE after ART complicated by OHSS, as compared to ART without OHSS, was higher but not statistically significant (RR: 14.83; 95% CI: 0.86-255.62). Risk factors of VTE associated with ART were in vitro fertilization procedure (RR, odds ratio [OR], and hazard ratio varying from 1.77, 95% CI: 1.41-2.23 to 4.99, 95% CI: 1.24-20.05), hyperhomocysteinemia (OR: 15.2; 95% CI: 2.0-115.0), polycystic ovarian syndrome (PCOS) (RR: 4.8; 95% CI: 1.7-13.4), successful ART leading to pregnancy (OR: 13.94; 95% CI: 1.41-137.45).

CONCLUSION

 Further large prospective studies on risk factors of VTE in women undergoing ART are needed in order to optimize thromboprophylaxis in this context.

Transcatheter Arterial Embolization in the Management of Postpartum Hemorrhage due to Genital Tract Injury after Vaginal Delivery

PURPOSE

To evaluate efficacy and safety of transcatheter arterial embolization (TAE) in managing postpartum hemorrhage (PPH) due to genital tract injury after vaginal delivery and to investigate factors associated with outcome of TAE.

MATERIALS AND METHODS

A retrospective review of 43 women (mean age, 32.6 years) who underwent TAE to manage PPH secondary to genital tract injury after vaginal delivery was performed at a single institution between January 2007 and December 2018. Clinical data and outcomes were obtained. Patients were classified into clinical success (n = 39) and failure (n = 4) groups, and comparisons between the groups were performed.

RESULTS

The clinical success rate of TAE for PPH due to genital tract injury was 90.7%. In the clinical failure group, transfusion volumes were higher (failure vs success: packed red blood cells, 14 pt ± 3.37 vs 6.26 pt ± 4.52, P = .003; platelets, 10.33 pt ± 4.04 vs 2.92 pt ± 6.15, P = .036); hemoglobin levels before the procedure were lower (failure vs success: 7.3 g/dL vs 10.7, P = .016). Periprocedural complications included pulmonary edema (25.6%), fever (23.3%), and pain (9.3%). Twenty-four patients were either followed for > 6 months or answered a telephone survey; 23 (95.8%) recovered regular menstruation, and pregnancy was confirmed in 11 (45.8%). Regarding fertility desires, 7 women attempted to conceive, 6 of whom (85.7%) became pregnant.

CONCLUSIONS

TAE is an effective and safe method for managing PPH due to genital tract injury after vaginal delivery. Lower hemoglobin levels before the procedure and higher transfusion volumes were associated with clinical failure of TAE.

Ovarian hyperstimulation syndrome: A review for emergency clinicians

INTRODUCTION

A great deal of literature has recently evaluated the prevention and management of ovarian hyperstimulation syndrome (OHSS) in the outpatient setting, but there remains a dearth of research evaluating OHSS in the emergency department (ED) and its management.

OBJECTIVE

This narrative review evaluates the underlying pathophysiology and clinical manifestations of OHSS and discusses approaches to patient care in the ED based on current literature.

DISCUSSION

OHSS is an iatrogenic complication caused by an excessive response to controlled ovarian stimulation during assisted reproductive cycles (ART). OHSS complicates up to 30% of ART cycles, and many of these patients seek initial care in the ED. Risk factors for the development of OHSS include age < 35, history of polycystic ovarian syndrome or previous OHSS, and pregnancy. Emergency physicians will be faced with several complications including ascites, abdominal compartment syndrome, renal dysfunction, acute respiratory distress syndrome, thromboembolic disease, and hemodynamic instability. Critical patients should be evaluated in the resuscitation bay, and consultation with the primary obstetrics/gynecology team is needed, which improves patient outcomes. This review provides several guiding principles for management of OHSS and associated complications.

CONCLUSIONS

OHSS occurs in up to 30% of IVF cycles and carries a high morbidity. Effective care of the OHSS patient begins with early diagnosis while evaluating for other diseases and complications. Understanding these complications and an approach to the management of OHSS is essential to optimizing patient care.

Acute Kidney Injury Due to Ovarian Hyperstimulation Syndrome

Ovarian hyperstimulation syndrome (OHSS) is a complication of assisted reproductive treatments such as in vitro fertilization (IVF). The pathophysiology of severe OHSS includes a humorally mediated capillary leak syndrome that is predominantly centered on the intra-abdominal space. Severe OHSS is frequently complicated by acute kidney injury (AKI), which can be due to any of a variety of mechanisms, each requiring a different management strategy. Mechanisms of AKI in severe OHSS include intravascular volume depletion, kidney edema due to capillary leak, intra-abdominal hypertension or compartment syndrome, and obstructive uropathy due to ovarian enlargement. We present a teaching case of severe OHSS complicated by AKI in a woman with underlying stage 4 chronic kidney disease. She had been undergoing IVF with plans to subsequently use a gestational carrier (surrogate) for pregnancy. We use this case to review the presentation and pathophysiology of OHSS complicated by AKI. In addition, we review the management of AKI in OHSS, in particular, the role of paracentesis and/or culdocentesis to manage tense ascites. Last, we highlight that similar cases may occur more frequently in the future given that IVF with subsequent use of a gestational carrier is increasingly being used for patients with comorbid conditions that can be exacerbated by pregnancy, such as advanced chronic kidney disease.

Capillary leak syndrome: etiologies, pathophysiology, and management

In various human diseases, an increase in capillary permeability to proteins leads to the loss of protein-rich fluid from the intravascular to the interstitial space. Although sepsis is the disease most commonly associated with this phenomenon, many other diseases can lead to a "sepsis-like" syndrome with manifestations of diffuse pitting edema, exudative serous cavity effusions, noncardiogenic pulmonary edema, hypotension, and, in some cases, hypovolemic shock with multiple-organ failure. The term capillary leak syndrome has been used to describe this constellation of disease manifestations associated with an increased capillary permeability to proteins. Diseases other than sepsis that can result in capillary leak syndrome include the idiopathic systemic capillary leak syndrome or Clarkson's disease, engraftment syndrome, differentiation syndrome, the ovarian hyperstimulation syndrome, hemophagocytic lymphohistiocytosis, viral hemorrhagic fevers, autoimmune diseases, snakebite envenomation, and ricin poisoning. Drugs including some interleukins, some monoclonal antibodies, and gemcitabine can also cause capillary leak syndrome. Acute kidney injury is commonly seen in all of these diseases. In addition to hypotension, cytokines are likely to be important in the pathophysiology of acute kidney injury in capillary leak syndrome. Fluid management is a critical part of the treatment of capillary leak syndrome; hypovolemia and hypotension can cause organ injury, whereas capillary leakage of administered fluid can worsen organ edema leading to progressive organ injury. The purpose of this article is to discuss the diseases other than sepsis that produce capillary leak and review their collective pathophysiology and treatment.

Use of Point-of-Care Ultrasound for the Diagnosis of Ovarian Hyperstimulation Syndrome

BACKGROUND

Ovarian hyperstimulation syndrome (OHSS) occurs when ovaries are overstimulated and enlarged due to fertility treatments resulting in a shift of serum from the intravascular space to the third space, mainly the abdominal cavity. It is the most serious complication of ovarian hyperstimulation for assisted reproduction.

CASE REPORT

We present the case of a 40-year-old woman who presented with abdominal bloating and nausea 2 weeks after undergoing in vitro fertilization (IVF); she was diagnosed by an outside radiology ultrasound as having a ruptured ovarian cyst. A point-of-care emergency ultrasound performed by the emergency physician made the diagnosis of ovarian hyperstimulation syndrome. This led to more expedient management and obstetrical consultation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Abdominal bloating and nausea are common presenting complaints in pregnant women. OHSS is a rare but potentially fatal complication of IVF. Recognition and early diagnosis by the emergency physician can lead to appropriate intervention and consultation.

C-reactive protein response is higher in early than in late ovarian hyperstimulation syndrome

OBJECTIVES

Many in vitro fertilization (IVF) complications are inflammatory by nature, some of which are even life-threatening. We evaluated the response of C-reactive protein (CRP) in IVF complications, especially in early and late ovarian hyperstimulation syndrome (OHSS), to support clinical decision making in gynecological emergency policlinics.

STUDY DESIGN

In a prospective two-year study at Helsinki University Hospital, Finland, we recruited patients with IVF complications including moderate or severe OHSS (n=47 patients: 36 early and 14 late OHSS cases), or other IVF complications (n=13). As controls, we recruited women in an uncomplicated IVF cycle (n=27). Serial blood samples (CRP, blood count, platelets, albumin, estradiol, creatinine, and electrolytes) were collected from patients upon admission to the emergency polyclinic and during and after treatment on the ward, and from the controls prior, during, and after the IVF protocol. All samples were categorized according to oocyte pick-up (OPU). The statistics included comparisons between and within the study groups, and receiver-operating characteristic (ROC) curve analysis for diagnostic accuracy of CRP for early OHSS at emergency polyclinics.

RESULTS

On admission, CRP did not differentiate OHSS from other IVF complications, but CRP was higher in early (median 21; IQR 8-33mg/L) than in late (6; 3-9mg/L, p=0.001) OHSS. In ROC analysis for CRP (12mg/L), the area under the curve (AUC) was 0.74 (p=0.001) with sensitivity of 69% and specificity of 71% for early OHSS. CRP was significantly higher (28; 10-46mg/L) in patients with early OHSS two days after oocyte pick-up (OPU) than in the controls (5; <3-9mg/L, p<0.001). The level normalized by 12 days, similarly to the controls. On the ward, the peak CRP was higher if early OHSS was complicated with infection (108; 49-166mg/L) than without infection (20; 8-32mg/L, p=0.001). Late OHSS was associated with hypoalbuminemia (19.6; 16.2-23.1g/L, p<0.001) and thrombocytosis (494; 427-561 E9/L, p=0.004; comparisons to early OHSS).

CONCLUSIONS

Early OHSS associates with a distinct rise in CRP level beyond that induced by uncomplicated oocyte pick-up, whereas the CRP levels in late OHSS are comparable to those in the control cycles. CRP identifies, but cannot distinguish IVF complications.

Spontaneous Bacterial Peritonitis and Anasarca in a Female Patient with Ovarian Hyperstimulation Syndrome Complicated by Respiratory and Kidney Failure

Ovarian hyperstimulation syndrome (OHSS) was first described in 1960. It may occur as a complication of gonadotropin hormone therapy during assisted pregnancy or for primary infertility. A 26-year-old female patient with polycystic ovarian syndrome and primary infertility was treated to conceive. She received intravenous gonadotropin-releasing hormone (GnRH) along with follicle-stimulating hormone in an outside private clinic. She presented to the emergency department with abdominal and chest pain, loose stool, vomiting, shortness of breath and decreasing urine output. She was found to have edema, ascites, effusion and acute kidney injury (AKI). Considering the symptoms preceding the drug history and anasarca, a diagnosis of severe OHSS was made. Ascites was further complicated by spontaneous bacterial peritonitis (SBP), which had already been reported before. We speculate that low immunity due to decreased immunoglobulin in patients with OHSS makes them prone to SBP. In our case, septicemia secondary to SBP and fluid loss due to capillary leakage from OHSS resulted in AKI and respiratory failure. This critically ill patient was treated in a special care unit, and she fully recovered with supportive measures. Severe OHSS may present as anasarca including ascites which can develop SBP leading to sepsis and multiorgan failure.

Ovarian hyperstimulation syndrome

OBJECTIVE

Ovarian hyperstimulation syndrome (OHSS) is a rare iatrogenic complication of ovarian stimulation usually occurring during the luteal phase or during the early part of pregnancy. OHSS is a potential complication of ovarian induction by almost every agent used for ovarian stimulation. Today, due to aggressive treatment protocols including the development of in vitro fertilization and cryopreservation with the goal of obtaining sufficient numbers of oocytes and embryos, an increased risk of developing OHSS is present. OHSS is now becoming increasingly more recognized due to the higher number of women undergoing assisted reproductive techniques.

DESIGN

Review of the literature regarding ovarian hyperstimulation syndrome.

METHODS

A review of the epidemiology, pathophysiology, risk factors, classification, clinical features, and treatment and prevention of OHSS.

CONCLUSION

OHSS can be thought of as the loss of control over the hyperstimulation of the ovaries. Although the prevalence of the severe form of OHSS is small, it is important to remember that OHSS is usually an iatrogenic complication of a nonvital treatment that has the potential for a fatal outcome. Therefore, critical care physicians play an integral part in the care of these patients and therefore should be familiar with and recognize the various clinical manifestations and potential outcomes of this entity.

Ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic complication that is associated with modern techniques for in vitro fertilization. Extensive efforts have been made to understand the pathophysiology and to improve the management of this entity. The severe and life-threatening forms of the ovarian hyperstimulation syndrome are still challenging for critical care physicians. This article reviews the pathogenesis, epidemiology, classification, clinical manifestations, and complications of these forms of OHSS. The different therapeutic options currently available are reviewed, and a stepwise approach for the management of these patients is provided.

Dynamic changes of the immunoglobulins in patients with severe ovarian hyperstimulation syndrome: efficacy of a novel treatment using peritoneo-venous shunt

PROBLEM

To evaluate the efficacy of continuous auto-transfusion system of ascites (CATSA) for the treatment of patients with severe ovarian hyperstimulation syndrome (OHSS) at the risk of febrile morbidity, the dynamic changes of immunoglobulins in the sera and the peritoneal fluid from patients with severe OHSS treated by CATSA were estimated.

METHOD OF STUDY

Ten patients with severe OHSS after superovulation for in vitro fertilization-embryo transfer (IVF-ET) were treated by CATSA. Immunoglobulin concentrations were examined in the serum and in the peritoneal fluid before and after CATSA. As controls, serum samples from 15 infertile women, who did not develop OHSS after the same superovulation protocol, were obtained on the day of mid-luteal period (Control-1). Serum samples from 15 patients with OHSS, who were treated by albumin infusion without paracentesis, were also obtained before and after the treatment (Control-2).

RESULTS

Before the treatments, serum immunoglobulin G (IgG) concentrations in patients with severe OHSS treated with CATSA and those in patients of Control-2 were significantly lower than those in patients of Control-1 (P < 0.01). Following CATSA, the concentration of IgG increased in the sera, while it decreased in the peritoneal fluid.

CONCLUSIONS

Serum IgG in patients with severe OHSS exuded into their peritoneal cavity, indicating that they might be at the status of immunodeficiency and at the risk of febrile morbidity. However, non-infectious febrile morbidity attributed to endogenous pyrogenic mechanism might be considerable. It is also suggested that CATSA might be effective in improving hypoimmunoglobulinemia of the patients with severe OHSS by the peritoneo-venous shunt.

Mortality in a cohort of IVF patients

BACKGROUND

Risks associated with IVF and related assisted reproduction technologies include complications of ovarian stimulation, surgical procedures and pregnancy itself. Serious complications are uncommon but may be potentially life threatening. The aims of this study were to compare the mortality rates of women who received IVF treatment, as well as those who were referred but were not treated, with the mortality rate in the general female population, to determine the maternal mortality rate following IVF conception and to establish whether any deaths had occurred as a result of treatment complications.

METHODS

Deaths were identified in a cohort of 29 700 Australian IVF patients by record-linkage with the National Death Index and a cancer registry.

RESULTS

The all-cause mortality rates in IVF patients (treated and untreated) were significantly lower than in the general female population of the same age. In treated women, 72 deaths were observed and 125 deaths were expected giving an age-standardized mortality ratio of 0.58 (95% confidence interval 0.48-0.69). Two maternal deaths were identified in the 42 days of the puerperium. Complications of ovarian hyperstimulation syndrome could not be directly related to any of the deaths identified in this cohort.

CONCLUSIONS

As well as providing some reassurance about the safety of IVF treatments, the findings point to the existence of a 'healthy patient effect' whereby the unhealthiest women in the population are deterred from pregnancy and infertility treatment.

Perforated duodenal ulcer associated with ovarian hyperstimulation syndrome: Case Report

Ovarian hyperstimulation syndrome (OHSS) remains the most serious medical complication of controlled ovarian stimulation. An unusual case of perforated duodenal ulcer following critical OHSS is presented. A 29 year old nulligravid woman with polycystic ovarian syndrome underwent her first attempt at in-vitro fertilization. She was admitted to the hospital with critical OHSS and subsequently found to have a perforated posterior duodenal ulcer. She underwent exploratory laparotomy, antrectomy and gastrojejunostomy. Pathological analysis of her gastric antrum confirmed chronic gastritis and Helicobacter pylori. She required prolonged assisted ventilation, vasopressor support, multiple i.v. antibiotics, blood product replacement and nutritional support. The patient was hospitalized for a total of 47 days and then transferred to a rehabilitation facility for an additional 30 days before being discharged to home. In this critically ill patient with OHSS, severe stress associated with invasive monitoring and multiple medical therapies in the intensive care unit as well as H. pylori infection appear to be the most probable causative factors of her perforated viscus. Prompt recognition of potential complications and proper medical intervention are essential in the management of patients with OHSS. Avoidance strategies are still needed.

Pulmonary manifestations of severe ovarian hyperstimulation syndrome: a multicenter study

OBJECTIVE

To assess the pulmonary manifestations of severe ovarian hyperstimulation syndrome (OHSS).

DESIGN

A retrospective nationwide 10-year multicenter study.

SETTING

Sixteen of 19 tertiary medical centers in Israel.

PATIENT(S)

All patients hospitalized at these centers for severe OHSS between January 1987 and December 1996.

MAIN OUTCOME MEASURE(S)

Clinical presentation, arterial blood gases on room air, and chest roentgenogram results.

RESULT(S)

Of 209 patients, 4% had lobar pneumonia, 2% had adult respiratory distress syndrome (ARDS), and 2% had pulmonary thromboembolism. Most patients had dyspnea, tachypnea, moderate hypoxemia, increased alveolar-arterial oxygen difference, hypocarbia, respiratory alkalosis, and metabolic compensation. The most common findings on chest roentgenogram were bilateral elevation of the diaphragm, pleural effusion, and pulmonary atelectasis. Patients with pulmonary thromboembolism, ARDS, and pneumonia presented with severe hypoxemia and alveolar-arterial oxygen difference and distinct radiographic findings.

CONCLUSION(S)

Severe OHSS is characterized by an extraparenchymal restrictive type of pulmonary dysfunction, attributed to intraabdominal or pleural fluid accumulation, which limits descent of the diaphragm and expansion of the thoracic cage. This may induce uncoordinated lung ventilation and atelectasis with subsequent ventilation-perfusion mismatch and hypoxemia. The clinical picture may deteriorate further because of pulmonary infection, pulmonary thromboembolism, or ARDS, all of which have distinct clinical, radiographic, and blood gas characteristics.