1 Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology and Departments of 2 Internal Medicine and 3 Surgery, Loyola University Stritch School of Medicine, Maywood, Illinois, USA
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Abstract |
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Key words: assisted reproduction/critical care/duodenal ulcer/ovarian stimulation
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Introduction |
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Case report |
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Two days later the patient complained of abdominal distension, shortness of breath and mid-to-upper abdominal pain. She presented to her physician's office for assessment for possible OHSS. Physical examination revealed stable vital signs, clear lung fields and a distended abdomen. Transvaginal ultrasound demonstrated bilateral ovarian enlargement, each approximately 10x10 cm, with a small amount of free peritoneal fluid. Laboratory evaluation showed WBC = 26 000 IU/l,haemoglobin = 15.2 g/dl, haematocrit = 45.6%, platelet = 487 000 IU/l, sodium = 131 mEq/l, protime = 12.9 s. The patient was admitted to a nearby hospital for observation and i.v. hydration.
On hospital day 2, the patient was noted to have increasing difficulty breathing with a marked increase in abdominal distension and decrease in urinary output. She underwent transvaginal ultrasound guided aspiration of 5400 ml of peritoneal fluid. She was subsequently transferred to the intensive care unit where she required ventilatory support and i.v. dopamine. Because of the deterioration in her status, arrangements were made for transfer of this patient to a tertiary care centre, and she was air evacuated to our hospital the same evening.
Upon admission to our intensive care unit and over the ensuing several days, the patient continued to show decline in her respiratory and renal status. On hospital day 8, she developed a fever with further elevation of her WBC and her physical exam showed a markedly distended abdomen. She underwent paracentesis, yielding yellow cloudy fluid, with pH = 7.00, WBC = 6000 IU/l, 95% polymorphonuclear cells, LDH = 1176 IU/l, amylase = 1889 IU/l. It was unclear whether this reflected abdominal sepsis or an inflammatory ascitic fluid related to her OHSS, thus a repeat paracentesis was performed 12 h later that showed an increase in LDH to 1791 IU/l. An emergent computed tomography scan of her abdomen and pelvis raised the possibility of extravasated contrast, thus a ruptured viscus was suspected. On hospital day 10, the patient underwent exploratory laparotomy at which time posterior perforation of the duodenum was found and her ovaries were noted to be massively enlarged extending to her umbilicus. Given the location of the perforation, a Graham patch could not be performed and she required antrectomy, gastrojejunostomy and lateral tube duodenostomy for control of her disease. The final pathology report confirmed chronic gastritis and H. pylori in the resected antrum.
Postoperatively, the patient remained critically ill for several weeks with sepsis, adult respiratory distress syndrome, pneumonia and renal insufficiency. She was placed on multiple i.v. antibiotics and received total parenteral nutrition. She was transfused a total of 4 units of packed red blood cells. On hospital day 22, she required tracheostomy tube placement. She was weaned to a tracheostomy collar of humidified air and her nutritional support was via a feeding tube. Because of her prolonged hospitalization and extreme muscle atrophy, she was a candidate for transfer to a nearby rehabilitation centre which occurred on hospital day 47.
The patient had removal of her tracheostomy tube during her 2 week stay at a rehabilitation facility. She was subsequently transferred to another rehabilitation centre for an additional 2 weeks for intensive physical and occupational therapy. She was finally discharged to her home 86 days after her IVF cycle.
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Discussion |
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This case illustrates once again that OHSS can be a serious and life-threatening complication of controlled ovarian stimulation. In particular, this patient developed critical OHSS despite the avoidance of pregnancy and lack of further luteal exposure to HCG. Close vigilance on the potential of OHSS as well as on the variable appearance of its possible sequelae is imperative in providing care to otherwise young and healthy women. The natural course of OHSS is eventually to improve over time, and a marked worsening in status should prompt an aggressive search for secondary complications. Preventative strategies (Fluker et al., 2000) are still needed more effectively to avoid or attenuate the course of clinically significant OHSS.
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Notes |
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References |
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Submitted on July 3, 2000; accepted on October 9, 2000.