A 29 year old nulliparous woman with a history of ovulation disorder was diagnosed as having primary infertility at her first visit. She failed to conceive despite receiving multiple courses of clomiphene citrate. Thus, the ovulation stimulation agent was switched from clomiphene to daily human menopausal gonadotropin (hMG) (basal luteinizing hormone, follicle-stimulating hormone, etc. were not calculated and the protocol of ovarian stimulation was unknown). An ultrasound examination revealed that her ovaries had enlarged to 6 cm in size (the follicular size and number were unknown and serum E2 was not calculated) after the initiation of hMG therapy. Human chorionic gonadotropin (hCG) (2500 U) then was used to trigger ovulation. On day 4 of hCG treatment, she presented with mild abdominal distention. An ultrasound examination revealed that the ovaries had enlarged to 11.6 cm in size. She was followed up on an outpatient basis due to the presence of mild ascites. On day 14 of hCG therapy, an ultrasound examination revealed no change in the bilaterally enlarged ovaries and an increase in the mild ascites. A pregnancy test was negative at the time. On day 22 of hCG therapy, the patient was admitted to her former hospital with severe abdominal distention and severe leg edema. An ultrasound examination revealed enlarged ovaries (left, 15.2 cm; right, 12.6 cm) and severe ascites. A chest X-ray showed severe pleural effusion. The patient was diagnosed with OHSS based on the clinical picture and the ultrasonographic evidence. A pregnancy test was positive and hypouresis of 155 mL/d was observed. She was therefore transported to Gifu University Hospital, Gifu, Japan.
The woman's height was 166 cm and her body weight was 62.8 kg, which was 15.8 kg heavier than her usual weight. Her blood pressure was 105/77 mm Hg and her pulse rate was 90-100 beats/min. Her oxygen saturation level was 98% on room air and she was not febrile. She had a tender and markedly distended abdomen with prominent shifting dullness. An ultrasound examination revealed enlarged ovaries and severe ascites (Figure 1). She also had edema in the bilateral lower extremities. The initial laboratory results indicated mild hemoconcentration: hemoglobin, 12.6 g/dL; hematocrit, 36.1% (from a baseline hematocrit of 30%); serum creatinine, 0.64 mg/dL; albumin, 2.8 g/dL; and D-dimer, 2.0 mug/mL (Table 1). A chest X-ray film showed severe right pleural effusion (Figure 2).
At the time of her admission (when her symptoms were mild), a 14 Fr Foley catheter was inserted intravesically and a central venous line was inserted to allow rapid initial hydration and to facilitate the strict monitoring of the patient's fluid intake, central venous pressure, and urinary output. Fluids (100-150 mL/h, extracellular fluid) and albumin (5%) were administered i.v. However, the patient's urinary volume did not increase and her central venous pressure did not recover. Furthermore, she began to experience dyspnea and her IAP, which was measured indirectly based on the intravesical pressure, was found to be significantly elevated (25 mm Hg).
Ultrasound-guided paracentesis was performed and 2000 mL of ascitic fluid was drained. Following a 14 mm Hg decrease in intravesical pressure, the patient's urinary volume increased from 20-30 mL/h to ~150 mL/h. Finally, after the draining of 6000 mL of ascitic fluid, the patient's intravesical pressure dropped to 6 mm Hg and her urinary volume was maintained at 100-150 mL/h (Figure 3). Heparin was administered the following day because her laboratory data revealed that her D-dimer level had risen to 3.9 mug/mL; however, a computed tomography scan revealed no thromboembolic event and her hematocrit level remained at 32.8%.
Subsequently, the patient's urinary volume progressively decreased to 10 mL/h. On day 7 of hospitalization, the patient's intravesical pressure was again found to be significantly elevated, at 24 mm Hg. A further 1500 mL of ascitic fluid was drained and the patient's urinary volume improved to 120 mL/h, following a 13 mm Hg decrease in intravesical pressure (Figure 3). Her condition improved and a fetal heartbeat was confirmed on day 35 of hCG therapy. The patient was discharged on day 25 of hospitalization.
The patient's ovaries were normally sized at the 18th gestational week. Her condition remained favorable as the pregnancy progressed. The onset of labor occurred at 39 weeks and 3 days of pregnancy and she gave birth via natural vaginal delivery to a girl who weighed 3080 g.