A 23-year-old woman died during an egg donation procedure at a fertility clinic, with a cardiac arrest as the clinical cause of death. She had been married for seven years and has a four-year-old daughter born via normal childbirth. Her menarche happened at the age of 13, and her cycles were regular, occurring every 28 to 30 days. There was no history of abortion/pregnancy loss, diabetes, hypertension, asthma, allergy/drug allergy, thyroid disorder, epilepsy, tuberculosis and cardiac disorders, tobacco, alcohol, and illicit drug use. Family history was unremarkable. Her weight was 58 kg, her height was 148 cm (BMI-26.5), her blood pressure was 120/80 mmHg, and her pulse rate was 80 beats per minute when she was admitted for the egg donation. Her heart and breath sounds were normal. Laboratory results revealed hemoglobin level 12.0 g/dL (RR:12-15 g/dL), random blood sugar 81mg/dL (RR: 70-140mg/dL), SGPT 16 U/L(RR:6-55 U/L), serum creatinine 0.74 mg/dL(RR:0.57-1.11mg/dL), prolactin 8.37 ng/ml(RR:5.18-26.53ng/ml), TSH 1.45 mU/L (RR: 0.35-5.50 mU/L), and antimullerian hormone 4.69ng/ml(RR:1.66-9.49 ng/ml). Lipid profiles were normal. Serum serology for HIV, HBsAg, HCV, VDRL, and Rubella IgM was non-reactive. Serum IgG test for rubella showed an adequate immune response. A baseline transvaginal ultrasonography showed normal uterus and ovaries without any features of polycystic ovaries. There was not any risk factor for coronary artery disease. The clinical history, physical examination, and test results indicated that the patient was a healthy young woman.
After taking her informed consent, an antagonist ovarian stimulation protocol was scheduled. She received oral contraceptives during her menstruation. From the 6th to 8th day of the menstrual cycle, recombinant FSH (rFSH 300 IU s/c, daily) was given. From the 9th to 14th day of the menstrual cycle, HMG 300 IU IM was given every day, and on the 15th day of her menstrual cycle, a dose of HMG 75 IU IM was administered. On the 11th day of the menstrual cycle, she began taking a GnRH antagonist (0.25 IU) and continued until the 15th day of the menstrual cycle. Serum E2 and P4 levels were measured on the 15th day of the menstrual cycle and determined to be 2048 pg/ml and 0.89 ng/ml, respectively. On the same day, ultrasonography showed five follicles in the right ovary with a 17-18 mm diameter and five follicles in the left ovary with 17-19 mm. Triggering was done on the same day (the 15th day of the menstrual cycle) at 10.30pm with decapeptyl 0.2mg s/c (GnRH agonist). Oocyte aspiration through transvaginal ultrasound was planned.
On the morning of the 17th day of the menstrual cycle, a pre-anesthetic check-up revealed no risk factors. Her blood pressure was 120/80 mm Hg. Her pulse rate was 86 beats per minute. Her arterial oxygen saturation was 100%. She was given 1L of Ringer's lactate I.V., followed by 500 ml I.V. slowly as maintenance. Pyrolate and fentanyl were given as premedication. Injection midazolam 1mg was given intravenously. Injection Dynapar 75mg I.V was given slowly. Propofol 120 mg intravenously was used to induce anesthesia, then maintained with sevoflurane. At the start of anesthesia, her blood pressure was 110/68 mmHg, her heart rate was 97/minute, and her SPO2 was 100%. An ECG showed normal sinus rhythm. An ultrasound-guided aspiration of follicles started in the right ovary after confirming no vasculature in between. According to anaesthetic information, after the ovum was picked up from the right ovary, the patient had hypotension (blood pressure decreased from 110/68 mmHg to 70/40 mmHg), bradycardia (heart rate dropped from 97 to 50 per minute), arterial oxygen saturation (SAO2) dropped from 100 to 80%, and the ECG showed bradyarrhythmia. The procedure was immediately abandoned. On auscultation, the heartbeat could not be heard. Air entry was normal. Per vagina examination lacked to detect bleeding. A trans-vaginal ultrasound also showed no intrapelvic or intrabdominal bleeding. Cardiopulmonary resuscitation (CPR) was started. The patient was intubated with a 7.0 mm cuffed endotracheal tube. Position-conformed breaths were given at a rate of 10-12 per minute. Pharmacologic support, including atropine and adrenaline, was given. One 200J DC shock was given. However, her ECG rhythm remained asystole throughout. Unfortunately, she could not be saved, and an autopsy was performed because she died suddenly and unexpectedly.