From the Guidelines
Bimanual exam is contraindicated for this patient. The clinical presentation strongly suggests ovarian hyperstimulation syndrome (OHSS), a complication of fertility treatments involving gonadotropins. The patient's recent hormone therapy, hypotension, tachycardia, and abdominal symptoms are classic for OHSS. A bimanual exam could potentially rupture enlarged ovarian cysts or cause torsion of hyperstimulated ovaries, leading to hemorrhage or worsening of the condition. According to the American Society of Hematology 2018 guidelines for management of venous thromboembolism, antithrombotic interventions are not warranted for unselected women undergoing assisted reproduction, but may be beneficial in cases of severe OHSS 1. Pelvic ultrasound is the preferred diagnostic approach as it can safely visualize the enlarged ovaries and assess for ascites without physical manipulation. Pelvic CT, while not first-line, is not contraindicated if needed for further evaluation. Key considerations in managing this patient include:
- Avoiding procedures that could physically disturb the enlarged ovaries
- Focusing on fluid resuscitation, electrolyte monitoring, and supportive care
- Considering anticoagulation therapy due to the increased risk of thromboembolism associated with OHSS, as suggested by the guidelines 1
- Using pelvic ultrasound as the primary diagnostic tool to minimize the risk of complications.
From the Research
Patient Condition
The patient's symptoms, such as worsening nausea, abdominal pain, and abdominal distention, along with her recent history of hormone-based assisted reproductive therapy, suggest a possible diagnosis of ovarian hyperstimulation syndrome (OHSS) 2, 3, 4, 5.
Contraindicated Steps
Considering the patient's condition, the following steps may be contraindicated:
- Pelvic CT: While imaging is crucial for diagnosis, a pelvic CT may not be the best initial choice due to the patient's potential for ovarian hyperstimulation syndrome and the risk of exacerbating the condition or causing unnecessary radiation exposure.
- Bimanual exam: This procedure could potentially cause discomfort or worsen the condition, especially if the patient has enlarged ovaries or ascites, which are common in OHSS 3, 5.
Recommended Steps
In contrast, the following steps are recommended:
- Pelvic ultrasound: This is a safer and more appropriate initial imaging choice for evaluating the patient's condition, especially for assessing ovarian size and detecting ascites 5.
- Anticoagulation: Given the risk of thromboembolic events associated with OHSS, anticoagulation may be considered as part of the patient's management plan, especially if she has risk factors for thrombophilia or develops moderate-to-severe OHSS 6.