Question 13

College comments

Syllabus topic/section: 2.1.12: Obstetric Intensive Care: Ovarian Hyperstimulation Syndrome L2

Discussion: 

Ovarian hyperstimulation syndrome is a condition associated with assisted reproductive treatment. It is characterised by severe capillary leak due to hormone induced vascular permeability and the features of severe disease are well defined.

Candidates whose answers demonstrated familiarity with the condition and an understanding of the pathophysiology generally did well. Information on specific investigations and their relevance was rewarded over a “scatter gun” approach.    For example: FBE: expect haemoconcentration and high white cell count; ultrasound looking at ovary dimensions, number of follicles, presence of torsion, and ascites. CXR looking for pleural effusions.

Candidates should attempt to differentiate in their clinical practice heart failure, fluid overload and capillary leak syndrome.

Some candidates either ran out of time or knew little of the topic because they wrote very little or nothing. Candidates are encouraged to allow enough time to write something for ALL questions in the exam. In addition, candidates should develop a technique for writing something down to gain some marks when knowledge is lacking about a particular topic – some marks are better than no marks.
 

Interpretation

a) Risk factors - assuming "being female and getting IVF" is not going to score marks -

• previous OHSS
• Young age
• Black race
• Lean
• PCOS/PCOM
• Hyperinsulinemia
• Hyperandrogenism
• High peak of oestradiol 
• Multifollicular development (>18-20)
• High number of oocytes retrieved (>24)

b) Examination features:

• Airway (oedema, plus also because intubation may be imminent)
• Features of pleural effusion and pulmonary oedema: creps, dull percussion note, etc. 
• Features of distributive or obstructive shock (the latter due to PE or tamponade), eg, tachycardia, distended neck veins, pulsus paradoxus, and so on.
• Level of consciousness (may be depressed due to cerebral oedema)
• Oliguria and generalised oedema
• Features that suggest ascites (eg. shifting dullness); a tense abdomen
• The absence of features to suggest liver disease
• Evidence of DVTs

Investigations:

• Intra-abdominal pressure measurement
• FBC (haemoconcentration, or worse, anaemia due to haemorrhage)
• EUC (renal failure), 
• LFT (liver failure),
• ABG (lactic acidosis)
• CXR (pleural effusion, but realistically, a bedside US will tell you more)
• Ultrasound of the abdomen and pelvis (to confirm ascites and see the size of the ovaries, plus it could give clues re. ovarian torsion)
• A pregnancy test
• Coags, as well as a group & hold