What is the best course of treatment for a 35-year-old female (f) experiencing nausea, vomiting, bloating, regurgitation, loss of appetite, and low energy levels after an egg retrieval protocol, with inability to keep liquids and solids down, and a sore throat of 1 day duration?

Post-Egg Retrieval Ovarian Hyperstimulation Syndrome (OHSS) with Severe Nausea and Vomiting

Immediate Assessment and Hospitalization

This patient requires urgent evaluation for ovarian hyperstimulation syndrome (OHSS) with immediate hospitalization for intravenous fluid resuscitation and antiemetic therapy. The inability to tolerate oral intake combined with bloating, regurgitation, and low energy after egg retrieval strongly suggests moderate-to-severe OHSS with dehydration and potential electrolyte abnormalities.

Critical Initial Steps

• Assess hydration status and correct fluid/electrolyte imbalances immediately with intravenous crystalloid or colloid fluids 1
• Check serum electrolytes (sodium, potassium, chloride), complete blood count with hematocrit, liver function tests, and renal function 2
• Measure abdominal girth and assess for ascites or pleural effusion
• Rule out surgical emergencies including ovarian torsion or ruptured cyst

Antiemetic Management Protocol

First-Line Therapy (Start Immediately)

Begin with dopamine receptor antagonists as the primary antiemetic:

• Metoclopramide 10 mg IV every 6-8 hours 1, 3
  • Most effective first-line agent for non-chemotherapy nausea with strongest evidence 3
  • Promotes gastric emptying which addresses the bloating and regurgitation
  • Monitor for extrapyramidal side effects

Add proton pump inhibitor for gastroesophageal reflux symptoms:

• Omeprazole 40 mg IV daily or pantoprazole 40 mg IV daily 4, 1
  • Addresses regurgitation and potential gastritis from vomiting
  • Patients often cannot discriminate heartburn from nausea 4

Second-Line Therapy (If Symptoms Persist After 24 Hours)

Add 5-HT3 receptor antagonist:

• Ondansetron 8 mg IV every 8 hours 3, 5
  • More effective than metoclopramide for severe nausea/vomiting 3
  • Can be given as continuous infusion if needed 4

Consider adding:

• Dexamethasone 8 mg IV once daily 4
  • Reduces nausea through anti-inflammatory mechanisms
  • Particularly effective in combination therapy

Third-Line Therapy (For Refractory Symptoms)

If nausea persists despite above measures:

• Haloperidol 0.5-1 mg IV every 6 hours 1, 3
  • Alternative dopamine antagonist with different side effect profile
  • Lower doses appropriate given patient age

Or consider:

• Olanzapine 2.5-5 mg PO/IV daily 4, 1
  • Effective for refractory nausea in severe cases
  • May cause sedation which could help with rest

For anxiety-related component:

• Lorazepam 0.5-1 mg IV every 6 hours as needed 1, 3
  • Addresses anxiety that may worsen nausea
  • Use cautiously and short-term only

Hydration and Nutritional Support

Intravenous Fluid Management

• Administer IV crystalloids (normal saline or lactated Ringer's) at 125-150 mL/hour initially 2, 6
• Dextrose saline may be more effective than normal saline for reducing nausea 4
• Monitor urine output, aim for >30 mL/hour
• Correct electrolyte abnormalities (hyponatremia, hypokalemia common) 2
• Add thiamine (vitamin B1) 100 mg IV daily to prevent Wernicke's encephalopathy 2, 6

Nutritional Advancement

Once vomiting controlled (typically 24-48 hours):

• Start with small sips of clear liquids
• Advance to bland, low-fat diet as tolerated
• If unable to tolerate oral intake after 3-5 days, consider nasogastric enteral feeding 7, 8
  • 8-Fr Dobbhoff tube with continuous infusion starting at 25 mL/hour 7
  • Increase incrementally to meet caloric requirements
  • More effective and safer than total parenteral nutrition 7, 8
  • Symptoms typically improve within 24 hours of tube placement 7

Monitoring and Reassessment

• Reassess antiemetic efficacy every 24 hours 3
• If no improvement after 48 hours with first-line therapy, escalate to combination therapy 3
• Monitor for complications: thromboembolism (hemoconcentration increases risk), renal dysfunction, respiratory compromise
• Daily weights and abdominal girth measurements
• Consider ultrasound if ascites suspected

Common Pitfalls to Avoid

• Do not use PRN antiemetics only - around-the-clock scheduled dosing prevents breakthrough symptoms more effectively than treating established vomiting 4
• Do not delay IV hydration - dehydration worsens nausea and can lead to serious complications including renal failure and thrombosis 2, 6
• Do not withhold antiemetics due to pregnancy concerns - severe hyperemesis poses greater risk to mother and fetus than appropriate antiemetic use 2, 9
• Do not use oral route initially - patient cannot tolerate oral intake, requiring IV/IM administration 4

Sore Throat Management

The 1-day sore throat is likely secondary to:

• Dehydration causing dry mucous membranes
• Trauma from repeated vomiting
• Will improve with hydration and symptom control
• No specific treatment needed unless bacterial pharyngitis suspected

Expected Timeline

• Nausea/vomiting should improve within 24-48 hours of IV fluids and antiemetics 7
• Most patients can transition to oral intake within 3-5 days 6
• OHSS symptoms typically peak at 7-10 days post-retrieval then gradually resolve
• Hospital stay typically 3-8 days depending on severity 7