Launceston General Hospital Clinical Guideline SDMS ID: P2010/0296-001 WACSClinProc8.

1/10 Title: Replaces: Description: Target Audience: Key Words: Policy Supported: Purpose: Ovarian hyperstimulation syndrome (OHSS) is a potential complication of ovarian stimulation in the treatment of infertility. The underlying cause is an increase in the capillary permeability of the ovaries and mesothelial surfaces with extravasation of proteinrich fluid, resulting in extravascular fluid accumulation and intravascular volume depletion. The patient may have fluid and electrolyte disturbances. Pleural or pericardial effusions, ascites, hypovolemia or shock may be present. Oliguria occurs as a result of decreased vascular volume or tense ascites and secondary reduction in renal perfusion. The risk of thromboembolism and disseminated intravascular coagulation is increased due to hemoconcentration, increased blood viscosity, diminished peripheral blood flow and patient inactivity. Acute respiratory distress syndrome, liver and/or kidney dysfunction may also develop. Severe forms of OHSS appear in 0.5 5.0% of in vitro fertilisation cycles. Ovarian hyperstimulation syndrome resolves spontaneously over 10 to 14 days unless pregnancy occurs. Indications for admission Vomiting Ascites Respiratory difficulty pleural effusion Oliguria Hypoalbuminaemia Haemoconcentration Electrolyte imbalance Assessment / Investigations Blood tests FBC (haematocrit > 48% indicates severe disease) Electrolytes, urea and creatinine (sodium > 135 mmol/L, potassium > 5.0 mmol/L or creatinine >0.1 mmol/L indicate severe disease) LFT (Albumin < 25g/L indicates severe disease) Coagulation studies (INR and APTT) HCG if > 9 days post egg collection or ovum pick up (OPU) Radiology Abdominal ultrasound for ovarian volume and ascites Chest Xray Ovarian Hyperstimulation Syndrome New guideline Care of women with ovarian hyperstimulation syndrome Nurses, midwives and medical officers Ovarian hyperstimulation syndrome

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Management Fluid Balance Strict fluid balance monitoring Daily weight Monitor urine output (minimum 30ml/hr) Daily abdominal girth measure (mark abdomen at first measure) Antiemetic therapy as required Observations Four hourly blood pressure, pulse and respiratory rate Daily leg check for signs of deep vein thrombosis Investigations FBC, urea, electrolytes and liver function tests daily INR and APTT if baseline abnormal or disease worsening clinically Quantitative serum hCG 16 days after embryo transfer Thromboprophylaxis Encourage mobilisation TED stockings 5000u subcutaneous heparin twice daily or low molecular weight heparin (enoxaparine 40mg/day) If hypoalbuminaemia is present (<25 g/L) consider intravenous infusion of albumin Analgesia Regular analgesia, if pain severe may require PCA opioids Management of Ascites Draining ascitic fluid improves symptoms and respiratory function in the short term. The optimal volume of fluid to be removed and over what time interval has not been established. Drainage of ascites may be considered in the presences of: Severe abdominal pain and vomiting due to ascites Pulmonary compromised with gross ascites Unresponsive renal compromised (due to renal compression due to gross ascites) with urine output less than 900ml/day despite adequate hydration

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Attachments
Attachment 1

Performance Indicators: Evaluation of compliance with guideline to be achieved through medical record audit annually by clinical Quality improvement Midwife WACS Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years. Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Stakeholders: Developed by:

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Date: 14/01/10

REFERENCES Chen, S, Chen, C & Yan, Y 2008, Ovarian hyperstimulation syndrome (OHSS): New strategies of prevention and treatment, Journal of the Formosan Medical Association, vol. 107, no. 7, pp. 509-512. Hahn, B 2006, Ovarian hyperstimulation syndrome, Journal of Emergency Medicine, vol. 33, no. 2, pp. 191-192. King Edward Memorial Hospital 2007 Ovarian hyperstimulation syndrome clinical guideline, Online: http://www.kemh.health.wa.gov.au/development/manuals/O&G_guidelines/sectionc/index. htm The Royal Womens Hospital 2006 Ovarian hyperstimulation syndrome: management of severe ohss in hdu, Online: http://www.thewomens.org.au/OvarianHyperstimulationSyndromeManagementofSevereO HSSinHDU

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