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Gaby’s Green Top Guidelines > 2016 5 OHSS > Flashcards

2016 5 OHSS Flashcards

1
Q

** What are the reporting responsibilities in relation to OHSS? **

A
  1. Licensed centres need to report severe & critical cases to HFEA
  2. Verbally within 12 working hours, form within 24
  3. Gynae units need to inform fertility centre
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2
Q

** What information should women be provided about OHSS? **

A
  1. Verbal & written
  2. To all women undergoing fertility treatment
  3. Including 24-hour contact number
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3
Q

** Which women with OHSS can be managed as outpatients? **

A
  1. Mild & moderate
  2. Severe in select cases
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4
Q

** What outpatient management is suitable for OHSS? **

A
  1. Fluid intake & output monitoring
  2. Avoid NSAIDs
  3. LWMH for all severe, some moderate
  4. Paracentesis can be done
  5. Review every 2-3 days unless signs of worsening
  6. Bloods if signs of worsening, particularly haematocrit as sign of intravascular volume depletion
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5
Q

** In what situations should women with OHSS be admitted? **

A
  1. Unable to achieve satisfactory pain control
  2. Unable to maintain adequate fluid intake
  3. Signs of worsening
  4. Unable to attend OP F/U
  5. Critical OHSS
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6
Q

** How should fluid balance be managed in OHSS? **

A
  1. Oral, guided by thirst as 1st line
  2. IV fluids 2nd line
  3. If persistent haemoconcentration despite colloid volume replacement, consider invasive monitoring
  4. Avoid diuretics unless oliguria once fluid replete & ascites drained
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7
Q

** What are the indications for paracentesis in OHSS? **

A
  1. Severe abdo distension & pain
  2. SOB & resp compromise
  3. Oliguria despite adequate volume replacement
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8
Q

** How should paracentesis be carried out in OHSS? **

A
  1. Under US guidance
  2. Abdominally or vaginally
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9
Q

** What additional signs & symptoms should prompt investigation for thromboembolism in OHSS? **

A

Unusual neurology inc headache, visual disturbance, dizziness, neck pain
Esp as tends upwards & to arterial system
Even if several weeks after OHSS improved

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10
Q

** What are the increased risks for pregnancy following OHSS? **

A
  1. Pre-eclampsia
  2. Preterm delivery
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11
Q

** When is surgical management indicated in OHSS? **

A

Coincident problem eg
1. Adnexal torsion
2. Ovarian rupture
3. Ectopic pregnancy

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12
Q

How does OHSS develop?

A
  1. Excessive ovarian response
  2. Proinflammatory mediators: VEGF & cytokines
  3. Increased vascular permeability
  4. Loss of fluid into 3rd space as ascites, pleural & pericardial effusions
  5. Hypovolaemia with paradoxical hypo-osmoloality & hyponatraemia
  6. Prothrombotic effect
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13
Q

What is the incidence of OHSS?

A

Mild: 1/3
Moderate or severe: 1-8%
Hospitalisation: 0.3%

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14
Q

What are the risk factors for OHSS?

A
  1. Previous Hx OHSS
  2. PCOS
  3. Increased antral follicle count
  4. High levels AMH
  5. GnRH agonists rather than antagonists to stimulate
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15
Q

What is the history needed to assess OHSS?

A
  1. Timing of trigger & onset
  2. Medication used as trigger
  3. Number of follicles on scan
  4. Number of embryos collected
  5. If/how many embryos replaced
  6. PCOS diagnosis
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16
Q

What are the symptoms of OHSS?

A
  1. Abdominal bloating
  2. Abdominal pain
  3. N&V
  4. SOB, inability to lie flat
  5. Reduced urine output
  6. Leg swelling
  7. Vulval swelling
  8. Comorbidities eg thrombosis
17
Q

What examination is needed for OHSS?

A
  1. General: dehydration, oedema, HR, BP, RR, weight
  2. Abdominal: ascites, palpable mass, peritonism, girth
  3. Respiratory: pleural effusion, pneumonia, pulmonary oedema
18
Q

What investigations are needed for OHSS & findings expected?

A
  1. FBC, haematocrit rise
  2. CRP, rise in severity
  3. U&E, hypoNa+ & hyperK+
  4. Serum osmolality, hypo
  5. LFTs, rise enzymes, drop albumin
  6. Clotting, rise fibrinogen, drop antithrombin
  7. hCG
  8. USS: ovarian size, pelvic & abdo free fluid, Doppler if torsion suspected
19
Q

What additional tests may be indicated in OHSS?

A
  1. ABG
  2. D-dimers
  3. ECG
  4. CXR
  5. CTPA or V/Q
20
Q

When is OHSS expected to present?

A

Early: within 7 days of injection
Late: 10+ days after injection, usually due to endogenous hCG from early pregnancy, usually more severe

21
Q

What symptoms would not be expected in OHSS?

A
  1. Severe pain
  2. Pyrexia
  3. Peritonism
22
Q

What are the differential diagnoses for OHSS?

A
  1. Pelvic infection
  2. Pelvic abscess
  3. Appendicitis
  4. Ovarian torsion
  5. Cyst rupture
  6. Bowel perforation
  7. Ectopic pregnancy
23
Q

What are the features of mild OHSS?

A
  1. Abdominal bloating
  2. Mild abdominal pain
  3. Ovarian size < 8cm3
24
Q

What are the features of moderate OHSS?

A
  1. Moderate abdominal pain
  2. N&V
  3. US evidence of ascites
  4. Ovarian size 8-12cm3
25
Q

What are the features of severe OHSS?

A
  1. Clinical ascites +/- hydrothorax
  2. Oliguria <300ml/day or <30ml/hr
  3. Haematocrit >0.45
  4. Hyponatraemia <135
  5. Hypo-osmolality <282
  6. Hyperkalaemia >5
  7. Hypoalbuminaemia <35
  8. Ovarian size >12cm3
26
Q

What are the features of critical OHSS?

A
  1. Tense ascites/large hydrothorax
  2. Haematocrit >0.55
  3. WCC >25
  4. Oliguria/anuria
  5. Thromboembolism
  6. ARDS
27
Q

What life-threatening complications can result from OHSS?

A
  1. Renal failure
  2. ARDS
  3. Haemorrhage from ovarian rupture
  4. Thromboembolism
28
Q

How long does OHSS typically take to resolve?

A

7-10 days
Usually complete by time of withdrawal bleed, if not pregnant

29
Q

What are the fluid choices for OHSS?

A
  1. Oral ideally
  2. Crystalloid initially
  3. Colloid to avoid worsening ascites; HAS 25%, 50-100g over 4 hours, 4-12•; not hydroxyethyl starch
30
Q

How is the risk of VTE in the 1st trimester affected in IVF & OHSS?

A
  1. Non-IVF 0.2:1000
  2. IVF 0.8:1000
  3. OHSS 17:1000

Gaby’s Green Top Guidelines (23 decks)

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