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is seen after paracentesis. Thoracocentesis may be necessary for patients
with signi¬cant hydrothorax. Interestingly, placement of a chest drainage
tube for bilateral pleural effusion has facilitated resolution of abdominal
ascites without the need for paracentesis (Rinaldi and Spirtos, 1995).
209
ANESTHESIA CONSIDERATIONS IN OHSS PATIENTS




Conversely, Whelan and Vlahos (2000) treated a woman with severe OHSS
complicated by complete right-sided hydrothorax that resolved almost
completely within 48 h of transvaginal paracentesis and evacuation of ascites.
I ¬nd these two cases very interesting and they complement each other.


Adult Respiratory Distress Syndrome
ARDS is encountered after ¬‚uid overload (Abramov et al., 1999b). Delvigne
and Rozenberg (2003) stressed the importance of a strict ¬‚uid input/output
balance in patients with moderate complications of OHSS and suggested the
optimum management would be in an intensive care unit. ARDS subsides after
three to six days with ¬‚uid restriction, forced diuresis and dopamine therapy
(Delvigne and Rozenberg, 2003).
At the present time there is no therapeutic modality that would reverse
the pathophysiologic changes that occur in OHSS that produce ARDS. The
¬rst priority is to reverse the life-threatening hypoxemia (Schenker, 1995).
Positive end-expiratory pressure (PEEP) is the most supportive therapy
(Zosmer et al., 1987).


Pericardiocentesis
Pericardial effusion was observed in 3% of 128 cases in the Belgian multi-
center study (Delvigne et al., 1993). Drainage by specialists has been suggested
(Brinsden et al., 1995; Delvigne and Rozenberg, 2003).


Thromboembolic Complications
Patients with evidence of thromboembolism will need therapeutic anti-
coagulation with clinical monitoring of potential complications and laboratory
adjustment of their anticoagulation therapy (Rizk, 1992, 1993).



ANESTHESIA CONSIDERATIONS IN OHSS PATIENTS

It is likely that patients admitted with severe OHSS may require surgery, such as
laparoscopy, to treat large ovarian cysts or ectopic pregnancy, and paracentesis
may even require intravenous sedation. There are several features of prime
importance for the anesthesiologist (Table VIII.3) before treating such patients
(Reed et al., 1990; Whelan and Vlahos, 2000). Careful positioning of the
patients during surgery is important, as the Trendelenberg position may
further compromise the residual pulmonary functional capacity. Establishment
of access lines may be necessary in patients with contracted vascular
volume. Drainage of pleural effusions may assist in improving the pulmonary
status.
210 TREATMENT OF OVARIAN HYPERSTIMULATION SYNDROME




Table VIII.3 Challenges to the anesthesiologist in OHSS

 Pulmonary compromise
 Severe hemoconcentration
 Pleural effusions
 Restricted IV access
 Infections and febrile morbidity
 Dif¬cult positioning in surgery
 Thrombophilia
 Pelvic masses
 Ascites
 Electrolyte disturbances




Table VIII.4 Indications for aspiration of ascites in OHSS

 Severe abdominal pain
 Pulmonary compromise
 Renal compromise resulting in oliguria
 Renal compromise resulting in an increase in creatinine concentration




ASPIRATION OF ASCITIC FLUID AND PLEURAL
EFFUSION IN SEVERE OHSS

The presence of ascites is indeed the hallmark of ovarian hyperstimulation
syndrome. In fact, symptoms resulting from ascites are often the most common
reason for hospitalization. Aspiration is not indicated in every patient.
Paracentesis by the transabdominal or transvaginal route is indicated for
severe abdominal pain, pulmonary compromise as demonstrated by low
pulsoximetry, and tachypnea and renal compromise as demonstrated by
oliguria and increased creatinine concentration (Table VIII.4). Navot et al.
(1992) suggested that paracentesis constitutes the single most important
treatment modality in life-threatening OHSS not controlled by medical
therapy. Familiarity with transabdominal and transvaginal ultrasound guided
procedures is a prerequisite for the safe accomplishment of the removal of
ascitic ¬‚uid (Rizk et al., 1990c).


Abdominal Paracentesis
Rabau et al. (1967) reported the ¬rst treatment with paracentesis of asci-
tes associated with OHSS. Abdominal paracentesis has been considered
211
ASPIRATION OF ASCITIC FLUID AND PLEURAL EFFUSION IN SEVERE OHSS




controversial in the past but is no longer so. Thaler et al. (1981), in a case
report, showed that paracentesis was followed by increased urinary output
shortly after the procedure, with a concomitant decrease in the patient™s weight,
leg edema and abdominal circumference. They also showed that there was an
increase of 50% in creatinine clearance rate following the procedure.
Bider et al. (1989a) treated 12 patients with severe OHSS, accompanied by
a pleural effusion or ascites causing respiratory discomfort and dyspnea, by
abdominal puncture. Drainage of abdominal or pleural effusion improved the
symptoms in all patients. The amount of ¬‚uid aspirated ranged between
200 and 1400 ml. The risk of injury to an ovarian cyst was minimized by
ultrasonographic guidance. Paracentesis offered temporary relief of respiratory
distress, but, since the ¬‚uid tended to recur, some patients needed repeated
paracentesis and drainage of effusions before spontaneous improvement
ensued. The experience with this group of patients indicates that the actual
risk of paracentesis is negligible. However, a possible drawback is the loss of
¬‚uid that is rich in proteins.
Levin et al. (2002) studied the effect of paracentesis of ascitic ¬‚uids on
urinary output and blood indices in patients with severe OHSS. Paracentesis of
ascitic ¬‚uids in women with severe OHSS had an isolated effect in improving
renal function, as is evident by the increased urinary output and reduced blood
urea nitrogen.
Padilla et al. (1990) demonstrated that abdominal paracentesis is a well-
tolerated treatment to relieve severe pulmonary compromise caused by severe
ascites and pleural effusion in OHSS. The improvement in renal function may
be another bene¬t that deserves further investigation.


Peritoneal Catheter for the Drainage
of Ascitic Fluid
Al-Ramahi et al. (1997) reported three cases in which an indwelling peritoneal
catheter was used to decrease the need for repeated paracentesis. Under
ultrasound guidance, a closed system DawsonÀMueller catheter with ˜simp-loc™
locking design was inserted to allow continuous drainage of the ascitic
¬‚uid. A total of 23, 20 and 28 l were subsequently aspirated from the three
patients. There was a signi¬cant decrease in abdominal discomfort and
improvement of urine output, with no complications. The only possible
drawback to this technique would be depletion of a huge amount of plasma
protein. We believe that monitoring of plasma proteins is essential if this
treatment is applied, and human albumin should be infused whenever
necessary. Abuzeid et al. (2003) studied the ef¬cacy and safety of percutaneous
pigtail catheter drainage for the management of ascites complicating severe
OHSS. A pigtail catheter was inserted under transabdominal ultrasound
guidance and kept in place until drainage ceased. Percutaneous placement of
a pigtail catheter is a safe and effective treatment modality for severe OHSS.
It may represent an attractive alternative to multiple vaginal or abdominal
paracentesis.
212 TREATMENT OF OVARIAN HYPERSTIMULATION SYNDROME




Transvaginal Ultrasound-guided Aspiration
The aspiration of ascitic ¬‚uid by the transvaginal route was popularized by
Aboulghar et al. (1990, 1992a, 1993). In a prospective randomized clinical trial,
Aboulghar (1990) investigated the effects of transvaginal aspiration of ascitic
¬‚uid under sonographic guidance in patients with severe OHSS (Table VIII.5).
The average hospital stay and the period with severe symptoms and disturbed
electrolyte balance was much shorter in the group in which aspiration of
ascitic ¬‚uid was performed, when compared with the group that underwent
conservative treatment. Rizk and Aboulghar (1991) found that aspiration of the
ascitic ¬‚uid immediately relieved the patients™ symptoms, improved their general
condition and increased urinary output. A marked improvement in the
symptoms was noted after drainage of as little as 900 ml of ascitic ¬‚uid. There
were no adverse hemodynamic effects as a result of the aspiration of large
volumes of ascitic ¬‚uid (Table VIII.6). Replacement of the plasma proteins was
mandatory because of the high protein content of ascitic ¬‚uid. This is essential, as
repeated aspiration was required in 30% of patients. The rate of accumulation of
ascitic ¬‚uid varied signi¬cantly. However, reaccumulation of a large volume of
ascitic ¬‚uid suf¬cient to cause discomfort would require, on average, 3À5 days.
Rizk and Abdalla (2006) urged early and prompt management of ascitic
¬‚uid. Aboulghar et al. (1993) assessed the value of intravenous ¬‚uid therapy and
ascitic ¬‚uid aspiration in the management of severe OHSS. Forty-two women
with severe OHSS were treated by ultrasonically guided transvaginal aspiration of
ascitic ¬‚uid and intravenous ¬‚uid infusion. Ten women with the same condition
treated conservatively constituted a comparison group. The main outcome
measures included percentage change in hematocrit, creatinine clearance and
urine output before and after aspiration. The duration of hospital stay was


Table VIII.5 Clinical characteristics of 21 patients hospitalized for severe OHSS
Reproduced with permission from Aboulghar et al. (1990). Fertil Steril 53:933À5

Group A Group B

Total no. patients 10 11
29.8 + 4.1 31.9 + 5.5
Age*
Indication for ovulation induction
polycystic ovarian disease 3 4
IVF** 5 6
amenorrhea 2 1
Stimulation protocol
CC/hMG/hCG** 5 7
6400 + 2100 6900 + 4500
Serum estradiol on admission* (pg/ml)

* Values are expressed as means + SD
** IVF-in vitro fertilization; CC ¼ clomiphene citrate; hMG ¼ human menopausal gonadotropin;
hCG ¼ human chorionic gonadotropin
213
ASPIRATION OF ASCITIC FLUID AND PLEURAL EFFUSION IN SEVERE OHSS




Table VIII.6 Analysis of aspirated ascitic ¬‚uid.
Clinical characteristics of 21 patients hospitalized
for severe OHSS.
Reproduced with permission from Aboulghar et al.
(1990). Fertil Steril 53:933À5

4.7 + 2.2 (3.2 À 5.1)
Total proteins (mg/100 ml)

6500 + 1554 (5400 À 9500)
Estradiol (pg/ml)
132 + 11 (120 À 145)
Sodium (mEq/l)
4.1 + 1.2 (3.8 À 4.7)
Potassium (mEq/l)




compared between the groups. Marked improvement of symptoms and general
condition followed soon after aspiration. Hematocrit readings decreased by 22%,
creatinine clearance increased by 79.3% and urine output increased by 220.7%.
The average volume of aspirated ¬‚uid was 3900 ml. The average duration of
hospital stay was 3.8 days for the treated women. In the comparison group, severe
symptoms and electrolyte imbalance continued for an average of nine days, and
the average hospital stay was 11 days. Intensive intravenous ¬‚uid therapy and
transvaginal aspiration of ascitic ¬‚uid are safe and effective in improving symp-
toms, preventing complications and shortening the hospital stay in severe OHSS.
Transvaginal ultrasound-guided aspiration is an effective and safe pro-
cedure. Injury to the ovary is easily avoided by puncture under ultrasonic
visualization. No anesthesia is required for the procedure, and better drainage
of the ascitic ¬‚uid is accomplished because the pouch of Douglas is the most
dependent part (Rizk and Aboulghar, 1991; Rizk et al., 1990b, c).


Autotransfusion of Ascitic Fluid
Autoreinfusion of aspirated ascitic ¬‚uid has been suggested by several
investigators (Aboulghar et al., 1992a; Fukaya et al., 1994; Splendiani et al.,
1994; Beck et al., 1995). Aboulghar et al. (1992a) reported three cases of severe
OHSS treated by transvaginal aspiration of the ascitic ¬‚uid and autotrans-
fusion of the aspirated ¬‚uid. Marked improvement of the symptoms, general
condition and urine output followed shortly after the aspiration. No reactions
were noted during or after the autotransfusion. The blood parameters were
corrected, and the general condition and urine output continued to improve.
The procedure is simple, safe and straightforward, and shows a striking
physiological success in correcting the maldistribution of ¬‚uid and proteins
without the use of heterogenous biological material. To avoid transfusion of
concentrated large volumes and bacteria and cells, Fukaya et al. (1994) used
ultra¬ltration with two ¬lters: a cellulose acetate hollow ¬ber ¬lter that
removes the cells and bacteria, and a polyacrylonitrile hollow ¬ber ultra ¬lter
that concentrates the protein before the infusion. The protein concentration
obtained is increased two-fold and albumin ¬ve-fold. Fluid is reinfused
214 TREATMENT OF OVARIAN HYPERSTIMULATION SYNDROME




Fig. VIII.3: The continuous autotransfusion system of ascites (CATSA)
Reproduced with permission from Koike, Araki, Minakami et al. (2000).
Hum Reprod 15:113À7


intravenously at the rate of 300À500 ml every 6 h. However, we do not
recommend autotransfusion of ascitic ¬‚uid because of the possible reinjection
of cytokines into the circulation.


Peritoneovenous Shunting of Ascitic Fluid in Severe OHSS
Peritoneovenous shunting has been performed in patients with ascites as a
result of liver cirrhosis (Gines et al., 1991) and has also been reported in
isolated cases of severe OHSS by Splendiani et al. (1994) and Beck et al. (1995).
Koike et al. (2000) investigated prospectively the clinical ef¬cacy of a newly
developed continuous autotransfusion system of ascites (CATSA, Figure VIII.3)
without protein supplement in patients with severe OHSS. CATSA was
performed for 5 h at a rate of 100À200 ml/h once a day. Eighteen patients
were treated with the CATSA (CATSA group) and 36 were treated with an
intravenous 37.5 g/day of albumin supplement (albumin group). Hospital stay
was signi¬cantly shorter in the CATSA group than in the albumin group
(10.0 + 5.7 vs 13.9 + 6.2 days, p < 0.01). Using a single procedure, haemo-
concentration, urinary output and pulse pressure were markedly improved in
the CATSA group compared with the albumin group. Discomfort due to
massive ascites diminished promptly and did not recur in nine of 18 CATSA
group patients, whereas it persisted in all 36 patients in the albumin group. The
serum concentration of protein was maintained in the CATSA group, whereas
it did not increase in the albumin group despite daily supplementation
with 37.5 g of albumin. The mean values of several parameters in the serum
pertinent to the coagulation-¬brinolysis system did not change signi¬cantly in
either group after the procedure. It was concluded that the CATSA procedure
expanded circulating plasma volume without exogenous albumin and appeared
to lead to a prompt recovery from severe conditions of OHSS.
Cytokine levels in a patient with severe OHSS before and after the
ultra¬ltration and reinfusion of ascitic ¬‚uid showed that cytokine
215
SURGICAL TREATMENT




concentrations decline in parallel with the improvement of clinical conditions
and resolution of OHSS.


SURGICAL TREATMENT
Surgery for Ruptured Cysts
Rizk (1993) stated that laparotomy, in general, should be avoided in OHSS. The
ovaries are enlarged, cystic and friable (Figure VIII.4). If deemed necessary, in
cases of hemorrhage, it should be performed by an experienced gynecologist
and only hemostatic measures undertaken to preserve the ovaries (Rizk, 1992,
1993a). Bider et al. (1989a) reported operative procedures in 16 patients with
severe OHSS because of torsion, rupture and bleeding in the ovarian cysts.
Amarin (2003) reported two cases of severe OHSS that did not respond to
conservative treatment. Bilateral partial oophorectomy was performed at



Fig. VIII.4: Rupture of follicular and corpus luteal cysts in a case of severe OHSS
Reproduced with permission from Wallach, Zacur, Eds (1995). Reproductive Medicine and
Surgery. St. Louis: Mosby, Chapter 35, p. 654
216 TREATMENT OF OVARIAN HYPERSTIMULATION SYNDROME




14 and 16 days respectively from oocyte retrieval. The patient made a rapid
recovery. The author proposed this seemingly aggressive prodedure as a
potential useful treatment when faced with patients who are severely or
critically affected with OHSS. We and others believe that this is a very
unfavorable approach and should be avoided (Rizk, 1993).


Unwinding of Twisted Ovary
Torsion of the ovary may be encountered by the gynecologist in cases of
acute abdominal pain in patients with an ovarian cyst, in pregnancy or in the
puerperium. Most general gynecologists used to remove the ovary and avoid
untwisting the ovarian pedicles because of concern about thromboembolism,
while most reproductive endocrinologists and reproductive surgeons attempt
unwinding of the twisted ovary.
Adnexal torsion was encountered in two cases in 2945 IVF cycles in a
Dutch transport IVF group (Roest et al., 1996). Hurwitz et al. (1983) reported
the ¬rst case of unwinding of a cystic ovary which had undergone torsion in a
patient with OHSS. The patient was admitted 10 days after hCG complaining of
lower abdominal distension and pain accompanied by nausea and vomiting.
On the fourth day following admission, the patient developed signs of a surgical
abdomen and the diagnosis of twisted ovary was made at laparotomy. The
pregnancy continued to term, resulting in a normal twin delivery. Since then,
several reports have shown that unwinding of the ischemic and apparently
nonviable ovary by laparotomy (Bider et al., 1989b; Mashiach et al., 1990) or
laparoscopy (Mage et al., 1989; Ben-Rafael et al., 1990) can restore the blood
supply to the ovary.


Ovarian Torsion in Pregnancy
Mashiach et al. (1990) reported twelve pregnant women who presented with
torsion of hyperstimulated ovaries. Although the adnexa appeared dark,
hemorrhagic and ischemic, they suggested that it could be saved by simply
unwinding it. Professor Mashiach™s team has now performed over 100 cases
with success (Mashiach, personal communication). During the second trim-
ester of pregnancy, Levy et al. (1995) reported successful unwinding of
large, hyperstimulated ischemicÀhemorrhagic adnexa by laparoscopy in three
women.


Surgery for Ectopic, Bilateral Ectopic and Abdominal Pregnancy and
OHSS
The association between OHSS and ectopic, bilateral ectopic, heterotopic and
abdominal pregnancies are not commonly encountered (Rizk et al., 1990d, e,
1991b). Abnormal hCG levels may occur in early pregnancy in patients with
ovarian hyperstimulation syndrome. However, these abnormal levels do not
predict poor outcome in pregnancies complicated by OHSS (Abramov et al.,
217
SURGICAL TREATMENT




1998b; Samuel and Grosskinsky, 2004), therefore they are not helpful in
diagnosing ectopic pregnancy or otherwise compromised pregnancies.
Chotiner (1985) reported the non-surgical management of ectopic
pregnancy associated with severe OHSS. Aboulghar et al. (1992b) treated
surgically a case of severe OHSS complicated by ectopic pregnancy. The
diagnosis of ectopic pregnancy in this case was dif¬cult because internal
bleeding occurred when the patient was already complaining of severe OHSS
and the amount of blood loss was not severe enough to be re¬‚ected in her

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