Read the FULL article in format

Journal of Experimental Medical & Surgical Research
Cercetãri Experimentale & Medico-Chirurgicale
Year XVII · Nr.1/2010 · Pag.18 - 22
JOURNAL of
Experimental
Medical
Surgical
R E S E AR C H
EVOLUTION OF PREGNANCIES IN PACIENTS WITH
OVARIAN HYPERSTIMULATION SYNDROME (OHSS)
L. Bran,
L. Stelea,
D.M. Anastasiu,
D. Bran,
I. Munteanu1
SUMMARY:
The ovarian hyperstimulation syndrome is a major complication that occurs in controlled
ovarian stimulation.
In the present study we monitored the evolution of pregnancies following In Vitro
Fertilization (FIV/ET) after previously undergoing a controlled ovarian stimulation,
complicated by the occurrence of the ovarian hyperstimulation syndrome.
The studied group was represented by a number of 45 patients, age between 28 and 41
yeas old, over a period of three years (2005-2008), with pregnancies resulted after a
controlled ovarian stimulation associated with a mild (69 %) or moderate type of ovarian
hyperstimulation syndrome (31%).
The first therapeutic approach was of abeyance, keeping the patient under observation:
blood pressure, pulse, weight, abdominal circumference, diuresis for cases with a mild
hyperstimulation; as for cases of moderate hyperstimulation, besides the parameters
previously measured, we also monitored the biochemical parameters, as well as the
quantity of ascitic fluid in the Douglas pouch.
The cases had a favorable evolution, none of the patients required a pregnancy interruption.
Assessments are to made concerning the therapeutic behavior and the data regarding the
evolution of the pregnancy.
Keywords: ovarian hyperstimulation syndrome, pregnancy, ascitic fluid.
EVOLUTIA SARCINILOR LA PACIENTE CU SINDROM DE HIPERSTIMULARE
OVARIANA
Received for publication: 01.12.2009
Revised: 14.02.2010
Rezumat:
Sindromul de hiperstimulare ovarianã este o complicaþie majorã în cadrul stimulãrii
ovariene controlate.
In studiul de faþã s-a urmarit evoluþia sarcinilor obþinute prin Fertilizare in Vitro (FIV/ET) dupã
ce, în prealabil s-a efectuat o stimulare ovarianã controlatã, complicatã cu sindromul de
hiperstimulare ovarianã.
Lotul luat in studiu a fost reprezentat de un numar de 45 de paciente cu vârsta cuprinsã între
28 si 41 de ani, pe o perioadã de trei ani (2005-2008), cu sarcini obþinute post stimulare
ovarianã controlatã asociate cu o forma usoarã (69 %) sau moderatã de sindrom de
hiperstimulare ovarianã (31%).
Atitudinea terapeuticã de primã intentie a fost de expectativã, pacienta fiind monitorizatã:
T.A, puls, greutate, circumferinþa abdominalã, diureza în cazurile de hiperstimulare usoarã;
în cazul prezenþei hiperstimularii moderate la parametrii monitorizaþi anterior s-a adaugat
urmarirea parametrilor biochimici cât si a cantitaþii de lichid de ascitã din Douglas.
Evolutia cazurilor a fost favorabilã, nefiind necesarã la nici una dintre paciente intreruperea
cursului sarcinii.
Se fac aprecieri asupra conduitei terapeutice si a rezultatelor obtinute privind evolutia
sarcinii.
1. - U.M.F. „Victor Babes” Timisoara
Correspondence to: Lavinia Bran. Tel. 0745091202, E-mail: laviniabran@yahoo.com,
Timisoara str. V. Braniste nr. 5 jud. Timis
18
INTRODUCTION
The ovarian hyperstimulation syndrome (OHSS)
represents the most important complication of the
ovarian stimulation treatments used in cases of human
assisted reproduction techniques (artificial insemination,
in vitro fertilization/embriotransfer). Any protocol of
ovarian stimulation can lead to an ovarian
hyperstimulation syndrome.
The ovarian hyperstimulation syndromes can be of
various degees, depending on the symptom complex
developed by the pacient.
Degree I patients (mild hyperstimulation) display
abdominal discomfort and an increase of the both ovaries
in dimensions on ultrasonography, with a diameter of up
Degree II is one of moderate hyperstimulation. The
patietiens generally display abdominal discomfort,
gastrointestinal symptoms, abdominal pains, meteorism
(bloated), bowel movements disturbances and nausea,
vomiting and diarrhea.
The sudden increase of weight, over 3 kg, can be
considered an early sign of moderate hyperstimulation.
From the ultrasonographic point of view, ascites and an
increase of the ovaries volume can be noticed, with a
diameter of up to 12x12 cm. The complete blood count
and the biochemical parameters are between the normal
limits or slightly modified.
Degree III of ovarian hyperstimulation is a severe type
and is characterized by the presence of ovarian cysts of
significant dimensions with apparence of ascites and, in
OHSS and pregnancyes
OHSS middle type
to 5x5 cm, multiple follicles and corpus luteum cysts.
The serum levels of estradiol have values higher than
3.000pg/ml and those of progesterone are over 30pg/ml
during the initial lutheal phase.
The urinary levels of estrogen have values higher than
150mg/24hours and those of pregnandiol are over
10mg/24 hours.
OHSS midle type
some cases, hydrothorax and hydropericardium.
In extreme cases patients may develop
hemoconcentration, increase blood viscosity and
thromboembolic events, hydro-electrolite disturbances,
hypovolemia and even hypovolemic shock.
The severe type is represented by serious
complications such as respiratory failure, and
thromboembolic events.
19
MATERIALS AND METHODS
syndrome following the controlled ovarian stimulation.
Out of group of 61 patients:
42 (69 %) developed a mild type of ovarian
hyperstimulation syndrome out of whom 28 (66,6 %) had
positive b-hCG and 14 (33,3 %) had a negative b - hCG.
- 19 (31 %) developed a moderate type of ovarian
hyperstimulation syndrome out of whom 17 (89,4 %)
The present study was conducted on a group of 45
(2,91 %) pregnant women with ovarian hyperstimulation
syndrome from a group of 1544 patients who were
enrolled in the Human Assisted Reproduction program in
our clinic during 2005-2008. The age of the patients was
between 28 and 41 years old, with a mean age of 34,5
years old.
The criteria for the study were represented by the
presence of ovarian hyperstimulation syndrome in
different degrees in patients who had positive b-hCG.
The mean period of infertility of patients who were
enrolled in the present study was of 6,5 years, 27 (60 %)
of them presenting infertility for less than 6 years, and 18
(40 %) suffering from infertility for more than 6 years.
The causes of infertility were:
- chronic anovulation in 29 patients (64 %)
- male factor in 8 patients (18 %)
- no apparent cause in 8 patients (18 %)
had a positive b-hCG and 2 (10,5 % ) had a negative
The glycemia levels were between the normal limits in
b-hCG.
all patients.
The mild type of ovarian hyperstimulation syndrome
Out of the 45 pregnant patients who developed ovarian generally developed in patients with a negative b-hCG or
hyperstimulation syndrome, 15 patients (33,3 %) had it was metter of bio-chemical pregnancy.
regular menstrual cycles and the other 30 (66,6 %)
Out of the patients with positive b-hCG 28 (62,2 % )
developed a mild form of hyperstimulation and 17 ( 37,7
% ) developed a moderate form of hyperstimulation.
30
28
25
20
14
15
B-hCG pozitive
B-hCG negative
10
5
0
OHSS mild type
displayed disturbances of the menstrual cycle:
oligomenorrhea 17 (57 %), amenorrhea 6 (20 %),
hipomenorrhea 4 (13 %), as well as polymenorrhea 3 (10
%).
RESULTS AND DISCUSSION
All of the 45 pregnant patients with ovarian
hyperstimulation syndrome were chosen out of a group
of 61 patients (3,95 %) who had polycystic ovary
20
18
16
14
12
10
8
6
4
2
0
17
B-hCG pozitive
B-hCG negative
2
OHSS midle type
OHSS moderate type
As for the behavior, the pregnant patients with a mild
form of hyperstimulation and who displayed discrete
abdominal discomfort, increase of ovaries’dimensions
with multiple follicles and corpus luteum cysts, estradiol
higher than 3.000pg/ml, progesterone higher than 30
pg/ml, were observed at least two weeks, being
monitored for their body weight, abdominal
circumference, diuresis, bio-chemical parameters. In
these cases, the hyperstimulation presented a remission
in 5-7 days and the pregnancy evolution was favorable.
In those cases of pregnancy associated with moderate
ovarian hyperstimulation syndrome the patients were
advised to rest, to oral hydratation; their diuresis and
body weight were closely monitored. Most of the cases
presented a spontaneous resolution. Out of the study
group 17 (37,7 % ) cases of pregnancy displayed
moderate ovarian hyperstimulation syndrome. All of
them presented ascitic fluid in the Douglas pouch, urinary
retention, difficult respiration, significant increased
weight, increase of the abdominal circumference, as well
as modifications of the bio-chemical samples.
In 3 (6,66 %) cases the quantity of ascetic fluid in the
Douglas pouch was very high, the patients having to
undergo a transvaginal puncture, 500ml/day in 4-6 days.
Also 2 patients (4,44 %) presented urine retention; by
monitoring the diuresis, elimination of 100-120ml/day
was observed, considering the fact that a quantity of
2000-2500ml of liquid/day was administrated. In these
cases loop diuretics were administered (furosemide).
All cases of moderate ovarian hyperstimulation
syndrome were trated with Albumin in order to
re-balance the hidro-electrolite level. The remission of the
symptom complex varied from case to case, sometimes
reaching 30 days.
No case of pregnancy associated with severe
hyperstimulation was registered.
Out of all cases included in the study, there was no
pregnancy loss, all of them presenting a favorable
evolution.
Any case of pregnancy associated with ovarian
hyperstimulation syndrome do not need for pregnancy's
interruption ( no case threatened the patient’s life).
From the total of 45 patients, a number of 34 (75,5 % )
presented unique pregnancies, and gave birth to alive,
eutrophic children.
A number of 5 (11,1 % ) patients presented triple
pregnancy, from which 4 (8,88 % ) gave birth
prematurely between the weeks 32-34 of gestation with
a good evolution of children; in one single case (2,22% )
the birth took place at 28 weeks with postpartum death of
the children.
Tween pregnancy appeared at a number of 6 (13,3 % )
patients, they gave birth bewteen 34 and 35 weeks of
gestation, to alive children with a good evolution.
CONCLUSIONS
1. The ovarian hyperstimulation syndrome was present
at patients with polichystic ovarian syndrome who
have undergone a controlled stimulation.
2. It is of high importance that the patients with
excessive ovarian response to be closely
monitorised.
3. The ovarian hyperstimulation syndrome is more
frequent in the case of patiens with positive b-hCG.
4. During the analysis of the ovarian hyperstimulation
syndrome present in pregnant patients, it is higly
important to monitorise all the parameters in order to
keep the volemia in balance and to correct the
hidro-electrolyte disturbances.
5. A treatment protocol must be used for patients who
have undergone a process of In Vitro
Fertilization/Embrio Transfer. Using this treatment
we must obtain and maintain the pregnancy during
21
the mild or moderate ovarian hyperstimulation 7. The evolution of treated pregnancy in ovarian
syndrome.
hyperstimulation syndrome can be carried until the
6. Regardless of the clinical form of the actual ovarian
last month, with birth of alive eutrophic children
hyperstimulation syndrome the pregnant patients
(75,5 % ), but sometimes can be misscarried before
will be monitorised and followed-up like pregnant
the term (24,6 % ).
patients with high obstetrical risk.
8. In our group study the incidence of premature
pregnancy was 24,6 %.
REFERENCES
1. Aboulghar H, Aboulgar M, Mansour R, Serour G, Amin Y, Al-Inany H A perspective controlled study of kariotyping for 430
consecutived babiesconceived through intracito-plasmic sperm injection. Fertil steril 2001 ;76:249-253.
2. Abravov Y, Elchalal U, Schenker JG, Pulmonary manifestations of severe ovarian hyperstimulation syndrome : a
multicenter study. Fertil Steril 1999; 13:2406-2410.
3. Abu Louz SK ,Ahmed AA, Swam RV Spontaneous ovarian hyperstimulation syndrome with pregnancy. Am J
Obstetric-Gynecol 1997; 12:127-132.
4. Bernasko J ,Lynch L , Lapinski R, Berkovitz RL Twin pregnancies conceived by assisted reproductive techniques:
maternal and neonatal outcomes. Obstet Gynecologies 1997 ;
89: 368-372.
5. Bodis J, Torok A, Tinnenberg HR. LH/FSH ratios as a predictor of ovarian hyperstimulations syndrome. Human Reprod
1996; 11: 1597-1599.
6. Devigne A, Rozenberg S,. Epidemilogy and prevention of ovarian hyperstimulation syndrome : a review Human Reprod
2002; 6:559-577.
7. Golan A, Ron-el R, Herman A,et al. Ovarian hyperstimulation syndrome: an updata review. Obstet Ginecol Surv 1989;
44:430-440.
8. Jung BG, Kim H. Severe spontaneuos ovarian hyperstimulations syndrome with MR findings. J Comput Assist Tomogr
2001; 25:215-217.
9. Weisman A, Barash A, Shapiro H, et al. Ovarian hyperstimulations followingthe sole administration of agonistic analogues
of gonadotrophin releasing hormone. Human Reprod 1998; 13:3421-3424.
10. Navot D, Bergh PA, Laufer N. Ovarian hyperstimilation syndrome in novel reproductive technologies: prevention and
tratament. Fertil Steril 1992; 58:249-261.
11. Navot D, Relou A, Birkenfeld A , et al. Risk factors and prognostic variables in the ovarian hyperstimulations sindrome.
Am J Obstet Gynecol 1988; 159:210-215.
12. Stolwijk AM, Straatman H, Zielhuis GA, et al.External validation of prognostic models for ongoingn pregnancy after in
vitro fertilizations. Human Reprod 1998; 13:3542-3549.
13. The Practice Committee of the American Society for reproductive Syndrome. Fertil Steril 2003; 80:1309-1314.
14.Tibi C, Alvarez S, Cornet D, et al. Predictions des hyperstimulations ovariennes. Contracept Fertil Sex 1989; 17:751-752.
22