Free Fluid In Pelvis Research Articles

Clinical and CT features of ovarian torsion in infants, children and adolescents.

To investigate the clinical features and computed tomography (CT) findings of pediatric ovarian torsion. A retrospective analysis of the clinical and CT data of 61 newborns, infants, children, and adolescents with ovarian torsion confirmed by histopathology was performed. Clinical features included abdominal mass, abdominal pain, nausea and vomiting, and fever. The tumor marker α-fetoprotein was increased in five cases. Ovarian enlargement was found in 26 cases, and follicles were detected in the peripheral region of the ovary in 21 cases. Twenty-one cases presented as solid mixed-density masses on CT images. A total of 30 cases of ovarian torsion were associated with a benign ovarian mass. Among 27 cases of cystic or predominantly cystic masses, the mass had a thickened wall in 26 cases and showed an uneven density in 23 cases. Among all 61 patients, a torsed pedicle was detected in 47 cases. A torsed ovary or mass exhibited mild contrast enhancement in seven cases. Uterine deviation toward the involved side, blurred fat space around lesions, and pelvic free fluid were also found. Pediatric ovarian torsion presents a relatively characteristic CT appearance. Correct diagnosis can be established based on clinical and imaging features.

English

BACKGROUND Ovarian torsion occurs when the ovary twists on its fibrovascular pedicle resulting in vascular compromise. Initially, there is twisting of the ovary, fallopian tube, or both structures, causing venous, lymphatic and arterial compromise with resultant ovarian oedema and adnexal enlargement. We wanted to determine the most common ultrasonography (USG) and magnetic resonance imaging (MRI) findings in surgically proven cases of ovarian torsion. METHODS We present a series of cases obtained on retrospective review of USG and MRI findings in 10 surgically proven cases of ovarian torsion between June 2018 to June 2020 in the Department of Radiology, MVJ Medical College & Research Hospital, Hoskote. RESULTS Significant enlargement of the ovary with size ranging from 5 to 15 cms with peripherally displaced follicles and free fluid in the pelvis in noted in all the patients on USG and MRI. Other common MRI features include ‘twisted vascular pedicle’ sign seen in 7 (70 %) cases, areas of haemorrhage within the ovarian stroma in 7 (70 %) cases and abnormal ovarian enhancement in 9 (90 %) cases. CONCLUSIONS Ultrasound and MRI are the main diagnostic imaging modalities prior to treatment. Improved detection and characterisation of pelvic mass contributes to better diagnostic accuracy. The most common findings in US and MRI features of ovarian torsion include ovarian enlargement with peripherally displaced follicles and free fluid in pelvis. Other common MRI features include ovarian haemorrhage, twisted vascular pedicle, abnormal ovarian enhancement and deviation of the uterus towards the same side. KEYWORDS Ovarian torsion, USG, MRI

AIUM Practice Parameter for the Performance of Sonohysterography and Hysterosalpingo-Contrast Sonography.

AIUM Practice Parameter for the Performance of Sonohysterography and Hysterosalpingo-Contrast Sonography.

Ovarian serous eystadenofibroma: Towards a preoperative diagnosis

Background: Ovarian cystadenofibromas are rare benign ovarian neoplasms which contain epithelial and fibrous stromal components which give rise to complex cystic and solid areas which will be visualized sonographically as malignant tumours. The management of cystadenofibroma of ovary is complete surgical removal of the tumour. The prognosis is generally excellent with prompt and appropriate treatment as there is a very low risk of recurrence. Case Presentation: A 45-year-old woman presented to the gynaecology clinic complaining of irregular menstrual bleeding, secondary dysmenorrhea and left sided lower abdominal pain of one month duration. On bimanual examination a cystic, nontender, left adnexal mass was found. Imaging revealed a complex cystic mass in left ovary (10 x 9.6 x 8 cm). There was a thin film of pelvic free fluid adjacent to the inferior margin of the lesion. Few non-specific subcentrimetric para aortic, left iliac lymph nodes were seen. CA-125 level was 179 U/ml. A staging laparotomy was performed and included total abdominal hysterectomy, bilateral salphyngoophorectomy and infracolic omentectomy. Bilateral multilocular ovarian cysts (left cyst – 10 x 8cm and right cyst – 3 x 4cm) were present. Histology revealed bilateral serous cystadenofibromas. No atypical or malignant cells were observed in peritoneal washings. Conclusion: Ovarian cystadenofibromas appear malignant on imaging and macroscopy. Frozen sections does not appear to be reliable indicator and only MRI appears to be dependable in predicting the diagnosis of a cystadenofibroma prior to histological confirmation.

The "Speckle Sign" in the Diagnosis of Posterior Compartment Endometriosis.

To determine usefulness of the "speckle sign" in the diagnosis of deep invasive endometriosis. This HIPAA-compliant, institutional review board-approved retrospective study with informed consent waived included 25 women (mean age 20-69 years) with histopathologically confirmed posterior cul-de-sac endometriosis between 2013 and 2018. Transvaginal ultrasound exams of these patients were reviewed by 2 expert radiologists searching for the "speckle sign," defined as irregular obliteration of the posterior cul-de-sac and bright (hyperechoic) internal echoes. The frequency of additional findings such as "kissing ovaries," endometriomas in the adnexa, bowel tethering in the posterior pelvic compartment, retroflexed uterus, adenomyosis, and pelvic free fluid were also analyzed. Data regarding clinical features, histopathologic findings and management were collected through a review of the medical record. Reader one identified posterior compartment endometriosis in 20/25 patients, and reader two in 22/25 patients, with 96% agreement. Adnexal endometriomas were found in 21/25 patients for both readers (k=0.70) and were bilateral in 23% of patients. The ovaries were adherent to each other in the midline ("kissing ovaries") in 50% of patients; the bowel was tethered anteriorly in 20%; the presence of adenomyosis was seen in about 27%, and a retroflexed uterus was seen in 24% of patients. The speckle sign could be helpful in making the diagnosis of posterior compartment endometriosis, and the sign is often found in conjunction with other imaging features of endometriosis.

Ultrasound Measured Depth of Pelvic Free Fluid Correlates Well with Blood Loss Volume in Patients with Ectopic Pregnancy

Purpose The ultrasonic finding of pelvic free fluid which suggests the possibility of internal haemorrhage helps the determination of the severity of patients. Methods We conducted a retrospective study investigating ultrasonic measurements and haemorrhage volumes in patients having an ectopic pregnancy in a single centre from January 2013 to November 2016. The logistic regression model was used to establish the prediction model for haemorrhage volumes. The diagnostic accuracy was evaluated by area under ROC curve (AUC) analysis. We employed 800 ml as the cut-off point of the haemorrhage and further set it to 1000 ml and 1200 ml in the sensitivity analysis. Results The mean pelvic free fluid depths measured by TVS and TAS were 4.45 ± 2.15 cm and 4.45 ± 2.56 cm in the haemorrhage ≥800 ml group, while they were 2.48 ± 1.51 cm and 2.55 ± 1.19 cm in <800 ml group. AUCs and the corresponding cut-off points were 0.741 (95% CI 0.677 to 0.804) and 0.118 when predicted by the standardised depths of TVS and TAS, 0.784 (95% CI 0.696–0.872) and 2.95 cm by the raw depths of TVS, and 0.748 (95% CI 0.665–0.831) and 3.35 cm by the raw depths of TAS. Conclusions The depth of pelvic free fluid measured by TVS and TAS can be used to predict blood loss volume in patients having an ectopic pregnancy. TVS may perform better than TAS.

O01 Adult onset PIMS-TS with secondary haemophagocytic lymphistiocytosis: into the eye of the cytokine storm

O01 Adult onset PIMS-TS with secondary haemophagocytic lymphistiocytosis: into the eye of the cytokine storm

Cancer risk associated with fluid observed during transvaginal ultrasound

Objective: Incidental pelvic free fluid is occasionally observed during transvaginal ultrasonography (TVS). There is little information in the literature regarding the importance of free fluid and its relationship to underlying pathology. This study reviews the malignant and nonmalignant findings related to the presence of free fluid on ultrasound.

Point-of-Care Emergency Ultrasonography in Non-Traumatic Cardiac Arrest and Near-Arrest Emergency Patients; A Pilot Trial

Background: In this study, we evaluated the applicability and interpretation of point-of-care emergency ultrasound (POCEUS) performed by an emergency physician (EP) in non-traumatic adult cardiac arrest and near-arrest patients at presentation to the Emergency Department (ED). Methods: POCEUS was performed in 5 steps on 73 adults to assess; 1. Qualitative global cardiac function, cardiac chambers and presence of pericardial effusion; 2. Presence of pleural sliding, B-lines, A-lines or consolidation on anterior-superior; 3. Presence of an abdominal aorta aneurysm and pelvic free fluid; 4. Presence of pleural effusion, consolidation, free fluid on lateral-inferior; 5. Qualitative width and collapsibility of the inferior vena cava. A fulfilled checklist and real-time images of ultrasonography were sent by WhatsApp to the head of the study to generate the evidence and collect the data. The process of patient care, in-hospital diagnosis and survival were retrieved from digital hospital records. This prospective multicenter sample study was conducted from November 16, 2015, to January 5, 2016. Results: The most common findings of POCEUS were performed and interpreted to have a first prediction of patients’ acute clinic problem by EPs were compatible with global systolic dysfunction (n = 16, 22.9%), pulmonary edema (n = 17, 23.3%), pulmonary embolus (n = 6, 8.2%), distributive/hypovolemic shock (n = 12, 16.4%), cardiac tamponade or pericardial effusion (n = 5, 6.8%), and pneumonia (n = 31, 42.5%) at presentation. The kappa correlation coefficient value of the POCEUS at presentation versus the final, traditional clinical diagnosis of the admitted ward, was 0.773 (95% CI, 0.747–0.892; p = 0.064, McNemar). Conclusions: POCEUS performed by an EP at presentation had a good agreement between in qualitative prediction of the first differential diagnosis in life-threatened patients and the last diagnosis obtained during hospitalization. Furthermore, this study showed the requirement of evidence in comparison of measurements to the qualitative manner and new descriptive processes in POCEUS for unexplained situations and questions.

Perforated isolated jejunal diverticulum: a rare cause of acute abdomen

A 45-year-old female presented with pain in peri-umbilical region for past one day along with history of non-bilious vomiting and non passage of stool and flatus for past one day. On physical examination, patient was afebrile, mild dehydration was present, tachycardia of 102 beats per minute with normal blood pressure. On clinical examination, the abdomen was diffusely tender with rebound tenderness. Bowel sounds were absent. Laboratory investigations revealed leucocytosis. An erect plain chest X-ray was done, didn’t reveal any gas under the diaphragm. Contrast enhanced computed tomography abdomen was done which showed a hollow viscus perforation with intra-abdominal free air and pelvic free fluid. Patient was resuscitated with IV fluid, broad-spectrum antibiotics were started and immediately taken up for exploratory laparotomy. Three jejunal diverticula identified at mesenteric border, with pin-head perforation in one of the diverticula. Small bowel resection including the three diverticula and primary end-to-end anastomosis was performed. Post-operative period was uneventful. Patient discharged on satisfactory conditions. This case stresses the importance to consider this entity in cases of unexplained gastrointestinal symptoms because any treatment delay may lead to unsuccessful clinical outcome.

Endometrial CD138 count appears to be a negative prognostic indicator for patients who have experienced previous embryo transfer failure

To explore the predictive value of endometrial CD138 expression in the natural cycle preceding frozen embryo transfer in patients with normal endometrial dating and histopathologic features, who previously failed the transfer of two high-quality fresh embryos. Retrospective analysis. University-affiliated hospital. Women with normal endometrial dating and histopathologic features who previously failed the transfer of two high-quality fresh embryos, and who then underwent an endometrial scratching operation preceding a natural cycle. Paraffin-embedded endometrial samples cut into sections for immunohistochemistry staining of CD138 (syndecan-1) expression, then clinical information for these patients reviewed and analyzed. Clinical rates of pregnancy and implantation. A total of 141 women met the inclusion criteria. Of these patients, about 31.2% (44 of 141) were positive for CD138 expression, with CD138 counts ranging from 0 to 33. Receiver operating characteristic (ROC) curves were analyzed to determine whether the number of cells expressing CD138 (CD138+ cells) predicted a successful pregnancy. The areas under the ROC curves based on CD138+ cell density and CD138+ cell count were 0.660 and 0.658, respectively. The clinical pregnancy and embryo implantation rates in patients not expressing CD138 (80.04% and 64.9%, respectively) were statistically significantly higher than rates in CD138+ patients (52.7% and 46.8%, respectively). In addition, the higher the number of cells expressing CD138, the worse the outcome of the pregnancy. Finally, clinical data showed that free pelvic fluid on the day of endometrial sampling (identified using transvaginal ultrasound) might be a risk factor for CD138 expression. Endometrial CD138+ count might be a valuable marker predicting pregnancy outcomes after frozen embryo transfer in patients with normal endometrial dating and histopathologic features who previously failed the transfer of two high-quality fresh embryos.

T2 hyperintense myometrial tumors: can MRI features differentiate leiomyomas from leiomyosarcomas?

To establish MRI features that help differentiate atypical leiomyomas and leiomyomas with degeneration that show hyperintensity on T2WI from leiomyosarcomas. This retrospective study evaluated 41 women who performed MRI before undergoing hysterectomy and had histologically proven atypical leiomyomas, leiomyomas with degeneration or leiomyosarcomas (21 leiomyomas; 20 leiomyosarcomas); only patients with T2 hyperintense myometrial tumors were included. The association between MRI features (contours; free pelvic fluid; intra-tumoral hemorrhagic areas, T2 heterogeneity; T2 dark areas; flow voids; restriction on diffusion-weighted images; signal intensity and heterogeneity after contrast administration; unenhanced areas, localization of unenhanced areas; necrosis; cystic areas) and the histology (leiomyoma vs. leiomyosarcoma) were calculated using Fisher's exact test. For those features that showed a significant association, a univariate linear regression was performed. Five MRI features demonstrated a significant correlation with malignant histology: irregular borders (p = 0.03); "T2 dark" areas (p = 0.02); presence of central necrosis (p = 0.01); presence of high signal on b1000 DWI (p < 0.001); ADC value lower than 0.82 × 10-3mm2/s; hyperenhancement of the tumor relative to the myometrium on post-contrast images (p = 0.02); and type 3 enhancing curve on DCE. Two of these features demonstrated a significant result predicting a malignant histology: lobulated contours and central necrosis [F(3;34) = 8,95; p < 0.001; R2 = 0.506]. The presence of lobulated borders, T2 dark areas, necrosis, hyperintensity relative to the myometrium after contrast administration, central necrosis, presence of high signal on b1000 DWI, ADC value lower than 0.82 × 10-3mm2/s and type 3 enhancing curve on DCE can help distinguish between leiomyoma and leiomyosarcoma. The association of lobulated borders and central necrosis can help predict a malignant histology.

Case Study of a Very Early Diagnosed and Successfully Treated Heterotopic Pregnancy

Spontaneous heterotopic pregnancy (HP) is rare and defined as combination of intrauterine and ectopic embryo implantation in one pregnancy. Most cases present with acute abdominal pain with hemoperitoneum. During the early stages of pregnancy, a HP diagnosis is uncommon. In the following, we present a case report of spontaneous HP, which was diagnosed before tubal rupture, and discuss methods of early diagnosis. A 27-year-old woman was admitted to the clinic complaining of vaginal spotting. An ultrasonography revealed two corpus luteum cysts, as well as a six-week intrauterine pregnancy together with a right tubal pregnancy with no pelvic free fluid. A laparoscopic right salpingectomy was performed. The pregnancy continued with no complications and ended after a gestation period of 38 weeks and four days with a vaginal delivery. In conclusion, it could be beneficial to use a vaginal ultrasound for examining not only uterus but also both adnexal regions at the early pregnancy period.

Spontaneous Rupture of Fibrolamellar Variant Hepatocellular Carcinoma

Fibrolamellar hepatocellular carcinoma (FL-HCC) is a unique variant of hepatocellular carcinoma. The majority of cases present with nonspecific symptoms like vague abdominal pain, weight loss and fatigue. Ruptured FL-HCC occurs rarely and mortality in the acute phase is very high. We report a rare case of a ruptured FL-HCC successfully managed with transarterial embolization for hemostasis. A 37-year-old male previously in good health presented with a severe, sharp epigastric pain that started 1 h prior to the presentation. He denied trauma, fever, nausea, vomiting, or diarrhea. Tenderness in the epigastrium was noted, with no palpable masses, guarding or rigidity. His blood pressure and pulse were 159/105 mm Hg and 105 beats/min. Platelets and coagulation parameters were within normal limits; transaminases were elevated. Abdominal computed tomography (CT) scan with contrast revealed an 8 cm lobulated mass with central hypodensity in the left hepatic lobe with perilesional blood and free pelvic fluid, indicating tumor rupture. CT angiography showed tumor neovascularization from a branch of the left hepatic artery which was embolized using transarterial gelfoam. Liver magnetic resonance imaging (MRI) and biopsy were consistent with fibrolamellar variant hepatocellular carcinoma. After 4 days, as the symptoms resolved, and the lab results were stable, patient was discharged and underwent a left hepatectomy 3 weeks later. FL-HCC occurs commonly in the left lobe of a young and non-cirrhotic liver. Typically, cross sectional imaging reveals a lobulated mass with well-defined margins, areas of hypervascularity and a central calcified scar. Histologic appearance is characterized by eosinophilic polygonal shaped cells separated by lamellar fibrosis. Surgical resection is the treatment of choice with better outcome when compared to conventional HCC. Disease recurrence after complete surgical resection is however high in the first 5 years. Tumors > 5 cm in size are at high risk for rupture with high mortality and recurrence rates secondary to significant spillage of tumor. While an emergency hepatectomy is preferred in unstable patients, those that are hemodynamically stable can undergo radiologic transarterial embolization for hemostasis followed by staged hepatectomy.

Interstitial Pregnancy a Rare form of Ectopic Pregnancy: Case Report

Interstitial pregnancy is a rare variety of ectopic pregnancy, it can have disturbed 8-16 weeks of amenorrhea (later than the distal tubal ectopic pregnancy), due to the dispensability of the myometrium covering the interstitial segment of the fallopian tube, with subsequent massive internal hemorrhage.A 29-years-old female, Gravida 3, Para 2, presented with severe abdominal pain, vomiting, and syncope 3 days after her missing period, and positive pregnancy test. Trans-vaginal ultrasound showed empty uterine cavity, free pelvic fluid with severe cervical motion tenderness. She was diagnosed with ruptured ectopic pregnancy. Ruptured ectopic pregnancy in the proximal segment of right fallopian tube was confirmed with laparotomy.The ruptured pregnancy was managed by right salpingectomy, and hemostatic stitches at the right uterine corn. Her hemoglobin was 8 gr on admission, and she received 3 units of packed RBCs (one intra-operative, and two post-operative). Her post-operative hemoglobin was 10.5 gr, and she was discharged from the hospital on the 3rd post-operative day in good general condition for follow up in the outpatients` department. This case report represents a rare variety of ectopic pregnancy, which is the interstitial pregnancy, because it can rupture few days or weeks after the missed period with subsequent massive internal hemorrhage. Interstitial pregnancy is a rare form of ectopic pregnancy, the obstetricians should be aware of rare forms of ectopic pregnancies, it can have disturbed few days or weeks after the missed period leading to subsequent significant morbidity.

Bowel Wall Thickening on Emergency Room CT Scans - Is It Always IBD?

Introduction: Patients presenting to Emergency Room with abdominal pain frequently undergo urgent CT scans, often revealing bowel wall thickening (BWT). In the absence of guidelines, endoscopic evaluation is performed in most of them. The study aims to evaluate the significance of such BWT and assess predictors of significant pathology on endoscopic evaluation Methods: Medical Records of patients referred to Gastroenterology Service with BWT on Emergency Department CT scans between July 2015-July 2017 at Hamad General Hospital, Qatar were retrospectively analyzed. Correlation of endoscopic findings to clinical presentation, laboratory parameters and histopathology was studied. Exclusion Criteria: 1. Endoscopy done after 4 weeks of CT scan reporting of BWT. 2. Patients with known GI Pathology (IBD, malignancy). 3. Evidence of luminal obstruction, stricture or mass on CT scan. Results: 109 of 160 referred patients satisfied criteria for study inclusion. Endoscopic appearance was normal in 37/109(33.9%). Significant findings confirmed as chronic pathology were found in 41/109(37.6%) patients. Of these 21(19.1%) had IBD {13 Crohn's Disease (11.9%), 8 Ulcerative Colitis (7.3%)}, 9(8.3%) had Tuberculosis, 11(10.1%) had malignancy. Mucosal abnormalities but normal or acute inflammation on histopathology were observed in 31/109(28.4%) patients.(Table 1) Age or gender had no correlation with significant findings. Symptom duration was the strongest predictor of significant endoscopic findings (> 2 weeks 25/35, 71.4%; < 2weeks 16/74, 21.6%; P< 0.001). Blood diarrhea, fever and weight loss were also positively associated with having significant findings. Laboratory parameters: WBC, Hemoglobin, ESR, Albumin and CRP were not correlated with IBD. Calprotectin was done in 36/109 patients. Mean Calprotectin was significantly higher with IBD and TB (199.5±299.8 vs 809.8±540.8; P< 0.001). Four radiologically reported parameters - fat stranding, lymphadenopathy, vascular engorgement and pelvic free fluid were analyzed from CT reports. Of these only fat stranding was associated with IBD or TB (20/46, 44% vs 10/52, 19%; P=0.009). Conclusion: One Third of the patients in the study had significant pathology (IBD/TB/Malignancy). Two thirds of patients had a negative endoscopy or acute inflammatory findings on endoscopy. Prospective data may guide patient selection for endoscopic evaluation in patients with Bowel Wall Thickening on CT scans.595_A Figure 1. Diagnosis and Distribution595_B Figure 2. Diagnosis595_C Figure 3. Calprotectin has high sensitivity and specificity to detect abnormality

Torsion of fallopian tube in a 13-year-old unmarried girl.

A 13-year-old unmarried female presented with severe colicky lower abdominal pain, radiating to left side, not associated with fever. Ultrasound examination showed a dilated left fallopian tube with minimal free fluid in pelvis, and diagnosis of pelvic inflammatory disease was suggested. MRI of the pelvis showed a complex intensity mass in left adnexa, suggesting a germ cell tumour. Patient underwent diagnostic laparoscopy and laparoscopic removal of left fallopian tube. Histopathology finally established the diagnosis of left fallopian tube torsion.

Transverse Colon Appendagitis Clinically Mimicking Acute Appendicitis

A 21 year old single female presented with complain of right iliac fossa and lower abdominal pain with associated low grade fever for the last two days. Laboratory workup from emergency department revealed mild leukocytosis and microscopic hematuria. Ultrasound (US) of pelvis and liver/gall bladder ruled out ovarian pathology, free fluid in pelvis or acute cholecystitis. Appendix wasn’t visualized on US examination. Subsequent, focused abdominal computed tomography (CT FACT) revealed acute epiploic appendagitis along transverse colon (TC - AEA).

Does she have adnexal torsion? Prediction of adnexal torsion in reproductive age women.

The aim of this study was to investigate the association of clinical, laboratory and ultrasound findings with the surgical diagnosis of adnexal torsion in a retrospective cohort of women operated for suspected torsion. The study included 199 reproductive age women>16-year-old who underwent urgent laparoscopy for suspected adnexal torsion between January 2008 and December 2014. The association of various parameters with adnexal torsion was analyzed with a multivariate logistic regression analysis and described as odds ratios (OR)±95% confidence intervals (CI). Adnexal torsion was surgically diagnosed in 111/199 (55.8%) cases. On the multivariate logistic regression analysis, complaints of nausea/vomiting (OR 4.5, 95% CI 1.8-11.1), peritoneal irritation signs (OR 100.9, 95% CI 4.2-2421.9), elevated white blood cell count>11,000 cells/mL (OR 3.7, 95% CI 1.3-10.8), presence of free pelvic fluid on ultrasound (OR 34.4, 95% CI 6.7-177.9), ultrasound findings suggestive of ovarian edema (OR 4.2, 95% CI 1.5-11.6), ultrasound findings suggestive of benign cystic teratoma (OR 7.8. 95% CI 1.2-49.4) and location of the ultrasound pathology on the right side (OR 4.7. 95% CI 1.9-11.9) were positively associated with adnexal torsion, while ultrasound findings suggestive of hemorrhagic corpus luteum cyst (OR 0.04, 95% CI 0.008-0.2) were negatively associated with adnexal torsion. By combining these eight parameters, the ROC curve was calculated, yielding an area under the curve of 0.93, 95% CI 0.90-0.97 (p<0.0001). Routine clinical, laboratory and grayscale ultrasound findings may be incorporated into the emergency room workup of women with suspected adnexal torsion. Laparoscopy should be considered in all patients with suspected adnexal torsion.

Combined modalities for the prevention of ovarian hyperstimulation syndrome following an excessive response to stimulation

Although the classification and management of ovarian hyperstimulation syndrome (OHSS) are well described in the literature, little attention has been given to modalities that aim to prevent its occurrence. In this retrospective study, we sought to investigate whether a combination of modalities in addition to GnRH agonist triggering in GnRH antagonist cycles could result in better prevention of OHSS. The study included 170 hyperresponder patients who were stimulated with GnRH antagonist protocol and were triggered with GnRH agonist for final oocyte maturation. Freeze all embryos was performed in all patients. The intervention group included treatment with dopamine agonist and restarting the GnRH antagonist. Of the 170 patients included, 63 were included in the intervention group. Compared to no intervention, women in the intervention group were more likely to have: menses within 7 days of the oocyte retrieval, smaller ovarian diameter, the absence of free pelvic fluid, less hemoconcentration and higher serum sodium levels. It can be concluded that combining other modalities in addition to triggering with GnRH agonist in GnRH antagonist cycles, results in targeting several pathways that lead to OHSS and result in rapid resolution of signs of ovarian hyperstimulation.