Department of Obstetrics and Gynaecology, The University of Western Ontario, 339 Windermere Road, London, Ontario N65 5A5, Canada
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Abstract |
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Key words: abdominal compartment syndrome/ovarian hyperstimulation
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Introduction |
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The present case is a description of OHSS uniquely complicated by abdominal compartment syndrome (ACS) resulting in critical, life-threatening illness.
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Case report |
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The day after oocyte retrieval the patient felt unwell and complained of pelvic pain and pressure. She was admitted to hospital and treated with i.v. crystalloid, analgesics and heparin 5000 IU s.c. every 12 h to prevent deep vein thrombosis.
Two days after oocyte retrieval, abdominal pain became generalized, and urine output and ileostomy output decreased. She was afebrile with signs of left lower quadrant peritonitis. Plain abdominal radiographs showed no free air. Ultrasonography 2 days after oocyte retrieval showed the ovaries measured 15.5 cm (right) and 11.1 cm (left) in maximal diameter, with a combined volume of 1341 ml (calculated by lengthxantero-posterior diameterxtransverse diameterx0.526 for a non-spherical volume). The patient was started on i.v. clindamycin and gentamicin on the presumption of pelvic sepsis. Seven embryos were cryopreserved and no fresh embryo transfer was performed.
Three days after oocyte retrieval her left calf and thigh were swollen and tender. Duplex Doppler scans confirmed extensive left ilio-femoral deep vein thrombosis and she was placed on i.v. heparin to maintain a therapeutic partial thromboplastin time.
During days 47 after oocyte retrieval abdominal girth increased and leukocytes rose from 23.1x109/l to 32.2x109/l. Repeated intra-ovarian bleeding complicated treatment by intravenous heparin and haemoglobin fell to 66 g/l from a pretreatment baseline of 132 g/l. Renal failure developed with a progressive increase in serum creatinine from 52539 µmol/l and urine output of ~10ml/h despite i.v. fluid replacement. Doppler ultrasound demonstrated patent renal veins with normal renal arterial blood flow bilaterally. There was no evidence of hydronephrosis and the renal parenchyma appeared normal. Urine electrolytes and clinical assessment did not support a pre-renal component to renal insufficiency.
Six days after oocyte retrieval, ultrasonographic measurements of the ovary showed that the ovary had increased to 16.6 cm (right) and 17.1 cm (left) with a combined volume of 2193 ml. Seven days after oocyte retrieval computerized tomography (CT) of the abdomen and pelvis (Figure 1) revealed massively enlarged ovaries lying side by side with combined dimensions of 20x14x20 cm. Many cysts showed evidence of haemorrhage. Neither ascites nor pleural effusions were radiologically evident.
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On day 9, after transfusion, the haemoglobin was 96 g/l, haematocrit 0.28, leukocytes 28x109/l. and creatinine 597 µmol/l. Arterial blood gases showed metabolic acidosis and compensatory respiratory alkalosis with pH 7.25, HCO3 10 mmol/l, and pCO2 (partial pressure) 24 mm Hg. On day 10 after oocyte retrieval i.v. heparin was discontinued, a jugular haemodialysis catheter and an infra-renal inferior vena caval filter were placed. Haemodialysis was initiated for control of metabolic derangement. Repeat CT revealed no change in ovarian size and showed numerous haemorrhagic areas with the ovaries.
On day 11 urine output rose marginally and stabilized at 515 ml/h, minimal ileostomy output resumed and her abdomen progressively became less tense.
Over the course of the next month, the patient displayed steady clinical improvement and significant recovery of renal function with a creatinine of 92 µmol/l. She was discharged 33 days after oocyte retrieval and placed on oral anticoagulation therapy, with a view to return for return of cryopreserved embryos after her convalescence.
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Discussion |
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Diagnosis of ACS is based on symptoms, signs and indirect measurements of IAP. As in this case, IAP is assessed by instilling sterile saline into an indwelling catheter, which is then clamped (Kron et al., 1984). A manometer is placed and a pressure reading is obtained utilizing the symphysis pubis as the zero mark. Such measurements provide an objective criterion to classify IAP. Burch and co-workers proposed a grading classification and defined treatment options (Burch et al., 1996
). Patients with IAP < 15 cm H2O (Grade I) rarely need treatment. Grade II includes IAP 1525 cm H2O; such patients require close monitoring but no intervention in the absence of clinical findings. Patients with IAP of 2535 cm H2O (Grade III) frequently require surgical decompression via laparotomy. Grade IV is defined as IAP > 35 cm H2O and patients in this category usually require decompressive laparotomy. Given the time-limited nature of OHSS and the surgical risk in this unique case, laparotomy may have resulted in either improvement or castration or catastrophe. This patient recovered spontaneously without surgery.
In the age of assisted reproduction it is essential to understand potential hazards of treatment (Mathur and Jenkins, 1999). Abdominal compartment syndrome can be a life-threatening complication of critical OHSS.
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Acknowledgments |
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Notes |
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References |
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Submitted on September 28, 1999; accepted on January 4, 2000.