Treatment of Ovarian Hyperstimulation Syndrome (OHSS)
The best treatment for ovarian hyperstimulation syndrome (OHSS) involves careful monitoring of fluid balance, intravenous crystalloids for intravascular volume replacement, thromboprophylaxis with LMWH, and paracentesis for severe ascites. 1
Classification and Initial Management
OHSS severity determines the treatment approach:
- Mild OHSS: No specific treatment required, outpatient monitoring
- Moderate OHSS: Outpatient follow-up with supportive care
- Severe OHSS: Requires comprehensive evaluation and intervention
Management Protocol for Severe OHSS
1. Monitoring Parameters (Daily)
- Weight
- Abdominal circumference
- Urine output
- Vital signs
- Complete blood count
- Electrolytes
- Liver and renal function tests
- Coagulation profile 1
2. Fluid Management
- Intravenous crystalloids (normal saline) for intravascular volume replacement
- Albumin administration may be considered in severe cases, though evidence shows only borderline benefit (OR 0.67,95% CI 0.45 to 0.99) 2
- Hydroxyethyl starch shows more significant reduction in severe OHSS (OR 0.12,95% CI 0.04 to 0.40) 2
- Avoid diuretics as they may further contract intravascular volume 3
3. Thromboprophylaxis
- LMWH prophylaxis (enoxaparin 40 mg daily) is recommended for severe OHSS 1
- Begin at the start of ovarian stimulation
- Withhold 24-36 hours before oocyte retrieval
- Resume after retrieval
- Continue until estrogen levels return to near-physiologic levels if no pregnancy occurs 1
4. Paracentesis
- Indicated for:
- Severe ascites causing respiratory compromise
- Significant discomfort
- Oliguria despite adequate fluid replacement
- Can be performed transvaginally or transabdominally
- May prevent need for hospitalization in moderate-severe cases 1
- Results in marked symptom improvement, improved diuresis, and shortened hospital stay 3
Outpatient vs. Inpatient Management
Recent evidence supports outpatient management for selected patients with severe OHSS:
- Must have appropriate outpatient setup and protocols
- Includes paracentesis of ascitic fluid and supportive management
- Found to be safe and cost-effective compared to inpatient management 4
Intensive Care Admission Criteria
- Severe respiratory distress
- Major electrolyte imbalance
- Elevated serum creatinine
- Thromboembolic complications
- Refractory oliguria/anuria 3
Common Pitfalls and Caveats
Delayed recognition of complications: Monitor for thromboembolism, which can occur up to 11 weeks after initial presentation 1
Inadequate thromboprophylaxis: Patients with antiphospholipid syndrome or history of thrombosis require therapeutic anticoagulation rather than prophylactic doses 1
Inappropriate use of diuretics: Generally contraindicated as they may worsen intravascular volume depletion 3
Overlooking outpatient management options: Paracentesis can significantly improve symptoms and may prevent hospitalization in appropriate cases 4
Inadequate monitoring: Daily assessment of fluid balance, weight, abdominal circumference, and laboratory parameters is essential 1