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2014,&7:56
Pregnancy outcome in severe OHSS patients following
ascitic/plerural fluid drainage
AccessBrief communication
First Online:&
10.15-7-56
Cite this article as:
J., Yinon, Y., Meridor, K. et al. J Ovarian Res (.
doi:10.15-7-56
Background
Various inflammatory cytokines have been implicated in the
pathophysiology of severe ovarian hyperstimulation syndrome, as
well as, various pregnancy complications, including preterm labor,
pregnancy induced hypertension/preeclampsia and intra-uterine
growth restriction. We aim to determine whether severe OHSS,
complicated by third space fluid accumulation necessitating
drainage, is associated with increased risk of late obstetrics
complications.
We assessed the obstetrics and neonatal outcome measures of 16
patients admitted to our gynecology ward during a 6-year period,
with severe OHSS complicated by third space fluid accumulation
necessitating drainage.
Patients delivered at 37.3&±&5.9weeks, with a mean birth weight of
3062&±&757 gr. There was no single case of gestational diabetes,
hypertensive diseases of pregnancy, nor placental abruption. Two
(12.5%) patients had preterm delivery: one at 23 weeks’ gestation
and one at 28 weeks’ gestation following preterm premature rupture
of membrane. Another patient experienced an unexplained antepartum
fetal death at 27 weeks’ gestation.
Conclusions
Severe OHSS, complicated by third space fluid sequestration
necessitating drainage, is not associated with adverse late
pregnancy outcome, except probably for preterm labor. Following
resolution of the OHSS, pregnancies should be regarded as any
pregnancy resulting from IVF treatment, with special attention to
prevent preterm labor.
hyperstimulation syndrome&Singleton&Hyper-permeability&Drainage&Pregnancy
Abbreviations
Controlled ovarian hyperstimulation
Human chorionic gonadotropin
vitro fertilization
Ovarian hyperstimulation syndrome.
Background
Ovarian hyperstimulation syndrome (OHSS) is a serious complication
of controlled ovarian hyperstimulation (COH), almost always
presents either after human chorionic gonadotropin (hCG)
administration or during early pregnancy. Its co-morbidities result
from the marked ovarian enlargement and the increase in capillary
permeability, with the consequent acute third-space fluid
sequestration [,&].
Moreover, despite many years of clinical experience, the
pathophysiology of OHSS is poorly understood [].
While direct action of excessive gonadotropins on ovarian tissue
accounts for the ovarian enlargement, none of the hitherto reported
studies have identified the cause of the third space fluid-shifting
phenomenon. While the enlarged hyperstimulated ovaries are
responsible for the observed increased prevalence of adnexal
torsion, usually occurring during the first trimester of pregnancy
the most accepted hypothesis assumes that hCG induces the release
of a mediator by gonadotropin-hyperstimulated ovaries, causing
endothelial activation resulting in increased capillary
permeability [&].
Several inflammatory cytokines are present in ascitic fluid of
severe OHSS patients []
and were shown to correlate with OHSS severity [].
Moreover, inflammatory mediators, namely, C-reactive protein,
leukocyte and endothelial selectins and vascular endothelial growth
factor are increased after hCG administration in vivo, reflecting
an inflammatory state, neutrophil and endothelial activations,
respectively [,&].
However, no significant evidence exists to prove any role of these
regulators as a culprit of OHSS.
Various inflammatory cytokines, including vascular endothelial
growth factor, have been implicated in the pathophysiology of
several late pregnancy complications, including preterm labor
pregnancy induced hypertension/preeclampsia []
and intra-uterine growth restriction [].
Since OHSS was also related to a massive increase in systemic
inflammatory cytokines that induces a systemic inflammatory
response [],
a common cause/mechanism may attribute to both severe OHSS with
vascular hyper-permeability and the aforementioned pregnancy
complications.
The hitherto published literature regarding the relation between
OHSS and pregnancy complications is limited and controversial
This disparity in the observed outcomes probably results from the
inclusion of patients with OHSS, not exclusively limited to those
with significant increase in vascular permeability, as reflected by
third space fluid accumulation necessitating drainage.
Prompted by the aforementioned observations, we sought to address
whether severe OHSS, complicated by third space fluid accumulation
necessitating drainage), is associated with increased risk of late
obstetrical complications.
We reviewed the medical files of all consecutive women admitted to
our gynecology ward, during a 6&year period, due
to severe OHSS following an in-vitro fertilization (IVF) treatment.
Severe OHSS was defined according to Golan et al. []
and Navot et al. []
criteria, while early and late OHSS were defined according to Lyons
et al. []:
3&7 days and 12&17 days following HCG ovulation triggering,
respectively.
The elimination of bias in this selection, for the purposes of this
study, was achieved by analyzing only those admitted with Hct level
&40%, whose medical condition necessitated ascitic or pleural
fluid drainage. Moreover, only those with singleton pregnancy that
continued beyond the first trimester were included.
Data on patients’ demographics, infertility, obstetrical and
neonatal related variables were collected from the files.
Gestational age was calculated based on the day of ovum pick-up (2
weeks gestation) and was correlated to a first trimester ultrasound
exam. Results are presented as mean&±&standard deviation. The study
was approved by the Institutional Research Ethics Board of our
During the study period 16 patients were hospitalized following IVF
treatments due to severe OHSS necessitating ascetic or pleural
fluid drainage. Mean patients’ age and body mass index were
30.8&±&4.7&years and
21.8&±&3.0&kg/m2,
respectively. Causes of infertility were anovulation/ polycystic
ovary syndrome in 25%, male factor infertility in 31.25% and others
(unexplained, endometriosis, etc.) in 43.75% of the study group,
with 10 (62.5%) of whom suffering from primary infertility. All
underwent an IVF treatment with retrievals of 18&±&5.9 oocytes and
transfers of 2.2&±&6 embryos.
Patients were admitted to our gynecology wards
14.5&+&4.7&days after HCG administration, 13 with
late and 3 with early and late severe OHSS. They were hospitalized
for 11.9&+&4.8&days, with a mean hematocrit level
on admission of 43.8%&+&2.0%.
During hospitalization, 14 underwent ascitic and 2 pleural fluid
drainages. Moreover, 6 patients showed abnormally elevated liver
enzymes, one suffered from oliguria, 2 had adnexal torsion and
another pair suffered from thromboembolic complications (jugular
and subclavian thrombosis).
Regarding the perinatal outcome, patients delivered at mean
gestational age of 37.3&±&5.9 weeks, with a mean birth weight of
3062&±&757 gr and 1 and 5&minutes APGAR scores of
8.4&±&2.3 and 9.3&±&2.6, respectively. There was no single case of
gestational diabetes, hypertensive diseases of pregnancy, nor
placental abruption. Two (12.5%) patients had preterm delivery
(&37 weeks): one at 23 weeks’ gestation and one at 28 weeks’
gestation following preterm premature rupture of membrane. A
healthy baby was born, weighing 1202 gr with an APGAR score of
9/10. Another patient experienced an unexplained antepartum fetal
death at 27 weeks’ gestation (with no gross fetal anomalies, normal
thrombophilia evaluation and no autopsy due to parents
While 8 (50%) patients experienced a spontaneous vaginal delivery,
7 (43.75%) delivered by cesarean section and one by instrumental
delivery. The indications for cesarean deliveries were either
non-reassuring fetal status (n&=&6), or maternal request
Discussion
the present study of patients with severe OHSS undergoing ascitic
or pleural fluid drainage, we actually evaluated patients with the
most severe form of OHSS, as reflected by the highest number of
oocytes retrieved during their IVF treatment (18&±&5.9 vs 13&±&5.2,
13.7&±&5.2 and 16.8&±&5.9 oocytes) and the longest hospitalization
period (11.9&±&4.8 vs 10.2&±&7.2 and 4.5&±&2.9 and
6.6&±&4.71&days), as compared to the hitherto
published studies [,&,&],
respectively. Moreover, a closer look at the aforementioned studies
reveals that none of them related exclusively to patients who
underwent ascitic or pleural fluid drainage, with no mention on the
prevalence of those (with singleton pregnancy) undergoing drainage
Moreover, two studies did not differentiate between singleton and
twin pregnancies [,&].
Summary of the hitherto
published studies relating to pregnancy complications in patients
with severe OHSS
Abramov et al.[]
Wiser et al.[]
Courbiere et al.[]
Haas et al.[]
Present study
All pregnancies
Number of pregnancies
Gestational age at delivery (weeks)
35.8&±&3.0
Birth weight (grams)
2221&±&252
Cesarean Section rate (%)
Preterm labor&&&37 wks (%)
Hypertensive diseases of pregnancy (%)
Gestational Diabetes (%)
Adnexal torsion (%)
Thromboembolism (%)
Paracentesis (%)
Singleton pregnancies
Number of pregnancies
Gestational age at delivery (weeks)
37.2&±&3.2
37.9&±&3.3
Birth weight (grams)
2785&±&356
3045&±&544
3032&±&545
2854&±&610
37.3&±&5.9
Cesarean Section rate (%)
Preterm labor&&&37 wks (%)
Hypertensive diseases of pregnancy (%)
Gestational Diabetes (%)
Adnexal torstion (%)
Thromboembolism (%)
Paracentesis (%)
While our study group of patients with the most severe form of OHSS
demonstrated all the well-documented complications, namely,
elevated liver enzymes, oliguria, adnexal torsion and
thromboembolism, no single case of gestational diabetes,
hypertensive diseases of pregnancy, or placental abruption was
The findings reported herein, therefore, indicate that singleton
pregnancies complicated by severe OHSS, necessitating ascitic or
pleural fluid drainage, are not at risk for obstetric
complications, except probably for preterm labor. While, studies
relating to hypertensive diseases of pregnancy, gestational
diabetes and IUGR show contradictory results [&],
the observed increased prevalence of preterm labor (12.5%) in our
study, is in accordance with previous studies [,&,&],
and is also a well-known complication of IVF pregnancies in general
Moreover, the observed single case of unexplained antepartum fetal
death requires attention and raises the question whether it is
accidental or is associated to severe OHSS.
Despite the small sample size and the inherent disadvantages of a
retrospective study design, we would expect a significantly higher
prevalence of these obstetric complications among this subgroup of
severe OHSS patients with ”endothelial” activation, as reflected by
the third space fluid sequestration, necessitating drainage. The
observed lack of association between severe OHSS complicated with
third space fluid sequestration and an increased prevalence of the
aforementioned obstetric complications, except probably for preterm
labor, actually excludes the possibility of a common mechanism
responsible for these abnormalities.
Conclusions
To conclude, we have demonstrated that severe OHSS, complicated by
third space fluid sequestration necessitating drainage, is not
associated with adverse late pregnancy outcome (i.e. intrauterine
growth restriction and pregnancy induced
hypertension/preeclampsia), except for preterm labor. Following
resolution of the OHSS, pregnancies should be regarded as any
pregnancy resulting from IVF treatment, with special attention to
identify and treat preterm birth. Further large prospective studies
are required in order to determine whether severe OHSS complicated
with third space fluid sequestration, is associated with late
pregnancy complications or whether there are preexisting factors
predisposing women to develop both OHSS and various pregnancy
complications.
Competing interests
The authors
declare that they have no competing interests.
Authors’ contributions
JH- Collected
the data, performed the statistical evaluations, assisted in
writing the paper and edited it in all its revisions. YY- Collected
the data and edited the paper in all its revisions. KM- Collected
the data and edited the paper in all its revisions. RO- The
principal investigator, designed the study, analyzed the data,
assisted in writing the paper and edited it in all its revisions.
All authors read and approved the final manuscript.
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取卵后胸腔积液？我可以理解成结
取卵后胸腔积液？我可以理解成结核性胸膜炎吗？
共1条医生回复
因不能面诊，医生的建议仅供参考
职称：护士
专长：外科
&&已帮助用户：124377
指导意见：胸腔出现积液是和炎症的感染导致的，要注意进行积极的抗炎及进行引流就好，注意避免感染。
问你好！取卵后胸部疼痛，胸闷，已经第6天了，怎么办？？
职称：医生会员
专长：高血压，心脏病，月经不调，儿科
&&已帮助用户：157703
问题分析：胸闷感觉呼吸困难这种情况可见于心肌缺血导致，另外肺部病变、休息不好、心情压抑等也可以导致。意见建议：您好，如果是偶发胸疼的话，考虑可能是由于劳累、体质、天气等等原因引起的，建议按时休息，避免劳累，注意保暖，必要时建议检查心电图、X线等等。排除心肺疾病，在接诊医生的指导下用药。
有胸痛症状应该检查是否是有肺部感染，胸膜炎，乳腺增生、肺结核等，另外还要考虑是否是有肋间神经炎，肋软骨炎。
问你好，我是7月25号取卵过多，引起腹水胸水，住了9天院...
职称：副主任医师
专长：妇产科、
&&已帮助用户：5356
病情分析： 您好，您的情况可能是卵巢过度刺激症，是由于辅助生殖过程中，超排卵所引起的。意见建议：您的这种情况如果没有其它的不适，是可以观察的，大部分人可以自然恢复，如果有明显的自觉症状如呼吸困难，腹胀难忍等情况，则需要住院治疗。就您现在的情况来看，病情比较稳定，可以先观察，不必特殊的药物治疗。那些腹水，胸水都是可以自已吸收的。
问我准备做试管婴儿，取卵后胸部胀痛和肚子胀痛已经好几...
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病情分析： 你好，这个情况，可以服用一些补脾益胃中成药来调理，比如参苓白术散和补中益气丸，应该有比较好的效果意见建议：可以结合自己按摩一些穴位来调理，建议选取足三里，天枢，内关等穴位，每天按摩半小时，以局部酸胀感为度，坚持一段时间，效果也不错
问做试管取卵后胸部长了积液怎么办
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专长：高血压、心脑血管病
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指导意见：目前的症状，还是可以配合一点消炎治疗，输液消炎试试，可能会好转的， 中西结合吧
问试管婴儿取卵后有点腹水
职称：医生会员
专长：高血压、糖尿病、心血管疾病
&&已帮助用户：27578
病情分析： 你好,在取卵后约1周左右，有个别患者会出现以下症状：在临床上会表现为腹胀、腹水（甚至胸水）、卵巢增大、胃肠道不适、少尿等症状，称为卵巢过度刺激综合症，一旦妊娠该症状会持续二个多月才逐渐消除，这种病人术后禁止使用HCG安胎，并要密切和医生联系。意见建议：病人可以正常饮食、腹胀的患者以少食多餐为好。以低糖易消化易吸收食物为主。避免过度疲累、过强运动。不要腹部受压及撞伤。绝大多数病人经过积极的心理调整和一般的临床处理均可以安全度过。
问得了胸腔积液吃什么好
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专长：宫颈炎,宫颈糜烂,盆腔炎
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指导意见：胸腔积液一般都是结核性的在治疗上也要用抗结核药物建议点滴菌必治和清开灵左氧氟沙星及抗结核的药物进行治疗注意休息和营养不要吃辛辣的食物如果是结核需要半年的时间康复
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