From the Guidelines
The management of Ovarian Hyperstimulation Syndrome (OHSS) should prioritize supportive care, prevention of complications, and thromboprophylaxis with low molecular weight heparin (LMWH) for severe cases, as recommended by the most recent guidelines 1.
Management Options
The treatment of OHSS varies based on severity, with mild cases managed on an outpatient basis and severe cases requiring hospitalization. Key management options include:
- Oral hydration (2-3 liters daily) and analgesics like acetaminophen for pain in mild OHSS
- Closer monitoring with daily weight checks, abdominal circumference measurements, and possibly antiemetics like ondansetron 4-8mg every 8 hours for nausea in moderate OHSS
- Hospitalization for intravenous fluid management (typically crystalloids like normal saline), thromboprophylaxis with LMWH (enoxaparin 40mg daily), and possibly paracentesis for significant ascites causing respiratory distress in severe OHSS
- Albumin infusion (25g IV) may be considered for severe cases with hypoalbuminemia
Prevention Strategies
Prevention strategies are crucial in high-risk patients, including:
- Using GnRH antagonist protocols
- Coasting (withholding gonadotropins while continuing GnRH antagonist)
- Using GnRH agonist instead of hCG for triggering ovulation
- Cabergoline 0.5mg daily for 8 days starting on the day of ovulation trigger to reduce OHSS severity by inhibiting VEGF-mediated vascular permeability
Thromboprophylaxis
Thromboprophylaxis is essential in patients at risk for thrombosis or ovarian hyperstimulation syndrome, with LMWH being the most commonly used option 1. The optimal duration of prophylactic LMWH has not been studied, but it is often continued until estrogen levels return to near-physiologic levels if no pregnancy occurs. Patients with obstetric antiphospholipid syndrome (OB APS) will continue therapy throughout pregnancy.
From the Research
Management Options for Ovarian Hyperstimulation Syndrome (OHSS)
- The management of OHSS can be done on an outpatient basis for mild to moderate cases, while severe cases require hospitalization for proper monitoring and treatment 2, 3.
- The standard management includes supportive care, monitoring of fluid balance, and thrombosis prophylaxis to prevent severe morbidity 4.
- Inpatient management may involve rehydration, monitoring of fluid balance, and eventual drainage of ascitic fluid 3.
- The use of low-dose aspirin as a preventive measure for thromboprophylaxis is still a topic of controversy 3.
- Cabergoline has been shown to reduce the onset of OHSS by inhibiting VEGF receptor 2 phosphorylation levels and associated vascular permeability 5.
- Prophylactic albumin administration may also help prevent OHSS by increasing plasma oncotic pressure and binding mediators of ovarian origin 5.
- Subcutaneous heparin can be used to prevent thrombosis in patients with OHSS, with a dose of 5000-7500 U/d started on the first day of admission 5.
Prevention of OHSS
- Identification of high-risk patients and modification of stimulation strategies can help reduce the risk of OHSS 3, 6.
- The use of gonadotropin-releasing hormone (GnRH) agonists or the freeze-all strategy can also help prevent OHSS 3.
- Low-dose gonadotrophin protocols have been implemented to reduce the risks of fertility treatment in polycystic ovary syndrome patients 5.
- Antagonist protocols have been shown to have a lower risk of OHSS compared to agonist protocols 5.
Monitoring and Treatment
- Monitoring of clinical parameters, fluid balance, and thrombosis risk is crucial in the management of OHSS 4.
- Ascites treatment and drainage of ascitic fluid may be necessary in severe cases 2, 3.
- Patients with critical OHSS may require admission to an intensive care unit for close monitoring and treatment 5.