What is the treatment for Ovarian Hyperstimulation Syndrome (OHSS)?

Treatment of Ovarian Hyperstimulation Syndrome (OHSS)

The treatment of Ovarian Hyperstimulation Syndrome (OHSS) should focus on careful monitoring of fluid balance, thromboprophylaxis with low molecular weight heparin, and paracentesis for severe cases with significant ascites. 1

Classification and Initial Assessment

• OHSS severity is categorized as:
  • Mild: Abdominal discomfort, mild nausea, mild ovarian enlargement
  • Moderate: Moderate abdominal pain, nausea/vomiting, ultrasound evidence of ascites
  • Severe: Clinical ascites, oliguria, hemoconcentration, hypoproteinemia, respiratory difficulties

Management Algorithm

1. Outpatient Management (Mild to Moderate OHSS)

• Daily monitoring of:
  • Weight
  • Abdominal circumference
  • Urine output
  • Vital signs 1
• Laboratory tests:
  • Complete blood count
  • Electrolytes
  • Liver and renal function tests
  • Coagulation profile 1
• Supportive care:
  • Maintain adequate fluid intake
  • Avoid excessive physical activity
  • Monitor for worsening symptoms

2. Inpatient Management (Severe OHSS)

• Fluid Management:

  • Intravenous crystalloids for intravascular volume replacement
  • Albumin administration in severe cases 1
  • Avoid diuretics as they can worsen intravascular depletion 2

• Thromboprophylaxis:

  • LMWH prophylaxis (enoxaparin 40 mg daily) 1
  • Continue until estrogen levels return to near-physiologic levels
  • Higher doses for patients with antiphospholipid syndrome or history of thrombosis 1

• Paracentesis:

  • Indicated for severe ascites causing respiratory compromise or significant discomfort
  • Can be performed transvaginally or transabdominally
  • May prevent need for prolonged hospitalization 1
  • Results in rapid improvement of symptoms, renal function, and fluid balance 3, 4

• Laboratory Monitoring:

  • Daily monitoring of hematocrit, electrolytes, renal function
  • Regular assessment of coagulation parameters
  • Stool blood tests to monitor for gastrointestinal complications 1

Special Considerations

• Thromboembolism Risk:

  • Venous thrombosis is more common than arterial events
  • Predominantly occurs in neck and upper extremity veins
  • Increased risk in patients with underlying thrombophilia 1
  • Continue monitoring for thromboembolism for up to 11 weeks after initial presentation

• Renal Complications:

  • Monitor for oliguria or anuria due to decreased renal perfusion
  • Early intervention is crucial to prevent acute kidney injury
  • Paracentesis can rapidly improve renal function in cases with significant ascites 3, 4

Pitfalls and Caveats

• Avoid common treatment errors:

  • Do not use diuretics as they can worsen intravascular depletion 2
  • Do not delay paracentesis in patients with respiratory compromise
  • Do not overlook thromboprophylaxis, as thromboembolism is a major cause of morbidity

• Prevention strategies may fail:

  • Severe OHSS can occur despite implementation of preventive measures 5
  • Continued vigilance is necessary even when preventive strategies are employed

• Outpatient management:

  • Can be safe and cost-effective compared to inpatient management for selected patients
  • Requires appropriate protocols and close follow-up 6
  • Must have clear criteria for when to escalate to inpatient care

The management of OHSS requires careful attention to fluid balance, thromboprophylaxis, and timely intervention with paracentesis for severe cases. Early recognition and appropriate management are essential to prevent serious complications and reduce morbidity and mortality.