Ob/Gyn Case Challenge: A 33-Year-Old Woman Trying to Conceive Has Dyspnea, Pain

Ziad R. Hubayter, MD, MPH


May 19, 2022

The treatment of OHSS is primarily supportive and includes rehydration with intravenous normal saline, treatment of electrolyte abnormalities, and discontinuation of fertility agents. It is important to remember that a bimanual pelvic examination should not be performed because it may rupture the enlarged, friable ovaries that could result from IVF and transvaginal oocyte retrieval.

The goal of giving intravenous fluids is to achieve a urine output of around 25-30 mL/hr. Overly aggressive fluid resuscitation may worsen the condition because of third spacing. The fluid of choice is normal saline because it maintains fluid within the intravascular volume better than other solutions, such as lactated Ringer solution or half-normal saline.

Once the desired urine output is achieved, the patient is monitored for symptomatic improvement. If ascites is severe, paracentesis may improve both the pain and ventilation. Unfortunately, ascites typically recur within 24-48 hours after paracentesis.[1,3,4]

Pulmonary complications associated with the diagnosis, treatment, and prevention of OHSS deserve special mention. Patients with OHSS almost always have some degree of pleural effusion, most commonly on the right side. Because of the increased permeability of capillary membranes, the patient is at risk for pulmonary edema. This condition reinforces the need for judicious use of intravenous fluids. The most serious pulmonary complication is pulmonary embolism.

Patients with OHSS have an increased risk for thromboembolism caused by supraphysiologic estradiol levels and hyperviscosity from hemoconcentration. Of note, 25% of these thrombotic events are arterial. Moreover, at least one half of the primary sites of these events occur above the level of the umbilicus (eg, internal jugular, subclavian, axillary, and mesenteric vessels).

Upper-extremity deep vein thromboses are observed in 0.11% of women undergoing assisted reproductive techniques. Therefore, administration of prophylactic heparin is recommended once the hematocrit reaches a concentration higher than 48%.[1,3,4]

Although patients with mild cases of OHSS may be discharged home with close follow-up, admission is recommended for patients who demonstrate any of the following markers of severity[3]:

  • Severe abdominal pain or peritoneal signs

  • Severe nausea or vomiting

  • Oliguria (<50 mL/hr)

  • Tense ascites

  • Dyspnea

  • Tachypnea

  • Hypotension

  • Electrolyte imbalance

  • Hemoconcentration

  • Abnormal liver function test findings


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