Role of Steroids in OHSS with Mild Ascites and Minimal Pleural Effusion
Steroids have no established role in the routine management of ovarian hyperstimulation syndrome (OHSS) with mild ascites and minimal pleural effusion, and should not be used. The evidence-based management focuses on thromboprophylaxis, supportive care, and monitoring rather than corticosteroid therapy.
Primary Management Approach
Immediate thromboprophylaxis is the critical intervention for moderate-to-severe OHSS due to the hypercoagulable state created by hemoconcentration, elevated estrogen, and immobility 1. The American College of Chest Physicians recommends:
- Initiate LMWH (enoxaparin 40 mg subcutaneously daily) immediately in moderate-to-severe OHSS 1
- Continue prophylaxis for 3 months post-resolution of clinical OHSS symptoms 1
- Thrombotic events can occur days to weeks (range 2 days to 11 weeks) after OHSS resolution 1
Supportive Care for Mild-to-Moderate OHSS
For patients with mild ascites and minimal pleural effusion, conservative outpatient management is appropriate 2, 3:
- Intravenous fluids (crystalloids such as normal saline) to expand intravascular volume 2
- Colloids (albumin or hydroxyethyl starch) for volume expansion 2
- Close monitoring of hematocrit, electrolytes, and kidney/liver function 2
- NSAIDs (naproxen 550 mg or ibuprofen 600-800 mg) for mild-to-moderate pain 1
Critical Management Principles
Diuretics are contraindicated in OHSS because they may further contract intravascular volume and worsen the condition 2. This is a fundamental difference from cirrhotic ascites management, where diuretics are first-line therapy 4.
Paracentesis is reserved for severe cases with tense ascites causing respiratory distress or marked discomfort 2, 3. When performed, abdominal or vaginal aspiration results in marked symptom improvement, improved diuresis, and shortened hospital stay 2.
Why Steroids Are Not Indicated
The provided evidence does not support corticosteroid use for typical OHSS management. The only mention of steroids in the context of ascites appears in a highly specific scenario: patients with Fontan-type circulation and protein-losing enteropathy (PLE), where oral glucocorticoids may be considered as part of a complex multifactorial treatment 4. This is completely unrelated to OHSS pathophysiology.
OHSS pathophysiology involves increased capillary permeability from vasoactive ovarian factors produced by multiple corpora lutea 5, not an inflammatory or immune-mediated process that would respond to corticosteroids.
Monitoring and Escalation
Hospitalization is indicated for 2:
- Severe respiratory distress from pleural effusions
- Major electrolyte imbalance
- Elevated serum creatinine
- Hemoconcentration requiring intensive monitoring
Common Pitfalls to Avoid
- Never use diuretics in OHSS, as they worsen intravascular volume depletion 2
- Do not delay thromboprophylaxis even in mild-to-moderate cases, as thrombotic risk is present throughout the clinical course 1
- Avoid aspirin before oocyte retrieval due to bleeding risk, though it may be considered post-retrieval 1
- Do not assume pleural effusion requires ascites to be present—isolated pleural effusion can occur in OHSS 6