A 31-year-old lady came to us with evidence of spontaneous abortion at 14 weeks of her pregnancy, which was conceived following in vitro fertilization. An ultrasound scan done showed an empty uterine cavity, indicating a complete abortion. She had fever at the time, and hence a course of antibiotics was given. Her hemoglobin levels were low, for which she was given a unit of packed red blood cells.
She was a booked case with us and had a past history of two episodes of ascites (OHSS) following the embryo transfer. The first episode was within 12 days of embryo transfer, and the second episode was at 9-10 weeks of gestation. Both episodes were diagnosed as OHSS and treated symptomatically with albumin infusion. At 14 weeks of gestation, she had fever and recurrence of ascites. Ascites did not subside even with albumin and Cabergoline; hence other causes of ascites were evaluated by Mantoux test and chest X-ray, which were negative for tuberculosis.
Her bleeding per vaginum persisted, for which a scan was done again which showed some retained products of conception for which she underwent dilatation and evacuation. The tissue obtained was sent for histopathology examination and came back as only degenerated products of conception and negative for mycobacterium tuberculosis by PCR.
When the ascites did not disappear after the regular treatment, the ascitic fluid was tapped thrice. It was green in color, leading to suspicion of presence of bile salts or pigments in it though her liver function tests were normal. When analyzed for the same, there were no bile salts or pigments found. Upon culturing it, no growth was found after 7 days. The ascitic fluid was negative for malignancy, and Ca 125 was normal. Her hematocrit persisted at the same values (19.8%) as before. She had lost significant weight within two weeks. The ascitic fluid was further investigated with acid fast staining, which showed no acid fast bacilli. A PCR sent for mycobacterium tuberculosis came back negative. Further evaluation showed its Adenosine DeAminase (ADA) level was 78 IU/L and rose to 110 IU/L in 3 days (normal: <39 IU/L). Based on the ADA levels, she was started on antitubercular treatment with HRZE (Isoniazid + Rifampicin + Pyrazinamide + Ethambutol), which finally resolved the ascites within a week.