Gastrointestinal Manifestations of Ovarian Hyperstimulation Syndrome

Abstract

Case: A 24 year old pregnant female, at 3 weeks gestation, presented with RUQ abdominal pain associated with abdominal distention and progressive SOB for 2 weeks. The pregnancy was the product of in-vitro fertilization (IVF). Physical examination showed an anicteric conjunctiva. Chest examination showed a decreased air entry in both lung fields. Abdominal examination revealed a fluid wave with shifting dullness. Levels of aspartate aminotranferase, alanine aminotransferase and albumin at presentation were 120 IU/ml, 114 IU/ml and 2.8 gm/dL, respectively. Serologic tests for autoimmune and viral hepatitis were negative. Serum human chorionic gonadotropin (hCG) was 515 mIU/ml, with a follow up serum hCG over 1000 mIU/ml. Transvaginal ultrasound showed a normal gravid uterus with a detectable gestational sac, prominent ovaries and large amount of ascites. Abdominal ultrasound with doppler revealed normal echogenic liver and patent hepatic vessels. Diagnostic and therapeutic paracentesis showed no evidence for spontaneous bacterial peritonitis. Based on history, clinical findings and lab values, the diagnosis of ovarian hyperstimulation syndrome (OHSS) was made. After conservative management, the patient was discharged 7 days later. On discharge, her liver tests were normalizing, ascites was improving and she felt much better. The patient continued follow up care with her private obstetrician. Discussion: OHSS is a rare iatrogenic complication of ovarian stimulation, which was described in 1943. The overall incidence of OHSS is 1–10% in IVF and embryo transfer cycles. The incidence of deaths is 1 in 500000 cases. OHSS can be divided into mild, moderate or severe forms. The pathophysiology is not completely understood, but the release of vasoactive substances from the stimulated ovaries has been suggested. Specific gastrointestinal (GI) complications include ascites, liver dysfunction, malnutrition and ileus. Liver dysfunction in OHSS was first reported in the 1980's and occurs in 25–30% of severe forms. When present, abnormal liver tests should be considered as an indicator of severity for the syndrome. Prevention and early recognition are the most important factors in treatment. The syndrome is usually self-limiting and conservative management often is sufficient. OHSS needs to be considered in pregnant patients who present with GI manifestations and history of IVF.