Ovarian hyperstimulation syndrome in a spontaneous singleton pregnancy / Síndrome da hiperestimulação ovariana em gestação única e espontânea

ABSTRACT The ovarian hyperstimulation syndrome is the combination of increased ovarian volume, due to the presence of multiple cysts and vascular hyperpermeability, with subsequent hypovolemia and hemoconcentration. We report a case of spontaneous syndrome in a singleton pregnancy. This was a spontaneous pregnancy with 12 weeks of gestational age. The pregnancy was uneventful until 11 weeks of gestational age. After that, the pregnant woman complained of progressive abdominal distention associated with abdominal discomfort. She did not report other symptoms. In the first trimester, a routine ultrasonography showed enlarged ovaries, multiples cysts and ascites. Upon admission, the patient was hemodynamically stable, her serum β-hCG was 24,487mIU/mL, thyroid-stimulating hormone was 2.2µUI/mL and free T4 was 1.8ng/dL. All results were within normal parameters. However, levels of estradiol were high (10,562pg/mL). During hospitalization, she received albumin, furosemide and prophylactic dose of enoxaparin. The patient was discharged on the sixth hospital day.

RESUMO A síndrome de hiperestimulação ovariana é a combinação do aumento dos ovários, devido à presença de múltiplos cistos e de hiperpermeabilidade vascular, com subsequente hipovolemia e hemoconcentração. Relata-se um caso de síndrome espontânea em uma gestação única. Trata-se de gravidez espontânea com 12 semanas de idade gestacional. A gravidez ocorreu sem intercorrências até 11 semanas de idade gestacional. Após, a gestante passou a se queixar de distensão abdominal progressiva, associada com desconforto abdominal. A paciente não relatava outros sintomas. A ultrassonografia de rotina no primeiro trimestre mostrou ovários aumentados com múltiplos cistos e ascite. No momento da internação, a paciente apresentava-se hemodinamicamente estável, com β-hCG sérico de 24.487mUI/mL, hormônio estimulante da tireoide de 2,2µUI/m e T4 livre de 1,8ng/dL, ou seja, valores dentro dos parâmetros normais. Porém, os níveis de estradiol estavam elevados (10.562pg/mL). Durante a internação, a paciente recebeu albumina, furosemida e enoxaparina profilática. A alta hospitalar ocorreu no sexto dia de internação.

Riesgos y complicaciones de los tratamientos de infertilidad / Risks and complications of infertility treatments

El desarrollo y uso masivo de técnicas de fecundación asistida desde hace 30 años ha permitido el nacimiento de más de 3 millones de niños en el mundo; sin embargo, estos procedimientos no están exentos de riesgos. La complicación más frecuente es el embarazo múltiple determinado por el desarrollo de múltiples folículos en la inseminación intrauterina y la transferencia de 2 ó más embriones en la fecundación in-vitro. El síndrome de hiperestimulación ovárica constituye una complicación menos frecuente, pero potencialmente grave para la cual detallamos las estrategias de prevención y manejo clínico. Se discuten además las complicaciones derivadas de la aspiración folicular tales como hemorragia e infección entre otras.

The widespread use of fertility treatments such as in-vitro fertilization has determined the birth of more than 3 million babies worldwide, however, these procedures can derive into medical complications. The most frequent complication of assisted reproductive techniques is multiple pregnancy. Single embryo transfer has been avdocated as the best strategy to prevent this complication. Ovarian hyperstimulation syndrome constitutes a life threathening complication of ovarian stimulation. Detailed information on prevention and treatment strategies are given. Other complications after oocyte retrieval such as bleeding and infection are also discussed.

Spontaneous ovarian hyper stimulation syndrome and deep vein thrombosis in a non pregnant woman: case report

To assess aetiological factors and complications in a patient with severe ovarian hyperstimulation syndrome [OHSS] and internal jugular vein thrombosis

Case: A 27-year-old non pregnant woman with bilateral ovarian masses who had underwent laparotomy for suspicion of malignant tumor. The pathological examination disclosed malignancy and the diagnosis of OHSS were confirmed. The postoperative evolution was complicated by internal jugular, subclavian vein thrombosis and pulmonary embolism. All biological parameters were negative. The evolution was good

Conclusion: The incidence of thromboembolism in women with OHSS is low and the typical finding is deep venous thrombosis in the neck area. Preventive measure of OHSS is very important, and the patients must be treated timely and correctly once OHSS occurs

Aspectos clínicos e genótipo do receptor do FSH na síndrome de hiperestímulo ovariano induzida por hCG / Clinical aspects and genotype of the FSH receptor in hCG-induced ovarian hyperstimulation syndrome

A síndrome de hiperestímulo ovariano (SHO) pode ocorrer de forma espontânea na gestação ou durante indução da ovulação para fertilização in vitro. Com o objetivo de identificar fatores clínicos e hormonais de risco para a SHO iatrogênica e analisar o papel das variantes alélicas do FSHR na sua etiologia, estudamos 29 pacientes com SHO iatrogênica moderada e grave. Idade < 33,5 anos, FSH basal < 5,2 UI/L e resposta de estradiol > 1757 pg/mL durante a estimulação ovariana atuaram como preditores independentes do risco de desenvolvimento da SHO iatrogênica, sendo a associação dos três fatores capaz de predizer a síndrome com acurácia de 7 por cento. Não foram encontradas mutações nas 29 pacientes com SHO iatrogênica. Entretanto, o alelo Asn680 do polimorfismo Ser680Asn se associou às formas mais graves da SHO iatrogênica / Ovarian hyperstimulation syndrome (OHSS) can occur spontaneously during early pregnancy or as an iatrogenic complication in assisted reproductive medicine. The aim of this study was to identify clinical and hormonal risk factors for iatrogenic OHHS and to evaluate the role of allelic variants of the FSHR in the etiology of this syndrome. We studied 29 patients with moderate and severe iatrogenic OHHS. Age < 33.5 y, basal FSH < 5.2 U/L and estradiol response during ovarian stimulation > 1757 pg/mL were independent risk factors for iatrogenic OHSS and these three factors in association were able to predict the syndrome with accuracy of 78 per cent. We did not find mutations in any patient studied. However, there was a predominance of the Asn680 allele of Ser680Asn polymorphism in patients with the most severe forms of the syndrome...

Effect of the oral contraceptive pill on patients undergoing controlled ovarian hyperstimulation

This is a retrospective analysis of 89 patients who were undergoing controlled ovarian hyperstimulation for in vitro fertilization and embryo transfer in the Fertility Management Unit of the Department of Obstetrics, Gynaecology and Child Health, The University of the West Indies. Twenty-eight patients (Group A), who did not receive oral contraceptive pills prior to controlled ovarian hyperstimulation (COH) were compared with 61 patients in Group B treated with oral contraceptive pills for two months prior to undergoing COH assisted reproduction using the long protocol. The number of follicles, oocytes, estimated oestradiol levels on the day of administration of human chorionic gonadotrophin (hCG), pregnancy rates, miscarriage rates and the incidence of patients who developed ovarian hyperstimulation syndrome (OHSS) were the main outcome measures. The mean age and haematocrit were the same in each group. The number of follicles retrieved tended to be higher in Group A than in Group B (median 8 versus 6, p = 0.06) with significantly more oocytes being retrieved in Group A than Group B (p < 0.05). There were no statistically significant differences between the two groups in oestradiol levels, the proportion of patients with polycystic ovarian disease, the proportion of women who developed ovarian hyper-stimulation syndrome or pregnancy outcomes. There was no difference between the groups in measures of clinical severity of OHSS. In a logistic regression model the significant predictors of OHSS were haematocrit and oestradiol levels. There appeared to be no significant clinical benefit in administering oral contraceptive pills for two months to patients prior to COH

Prevençäo da iatrogenia / Preventing iatrogeny

O principal objetivo no tratamento da infertilidade deve ser aumentar as taxas de gravidez e reduzir os índices de abortamento, resultando em maior taxa de nascimento de crianças saudáveis. Além disso, deve-se procurar reduzir os casos de hiperestimulaçäo, assim como de gestaçöes múltiplas, com uma concomitante reduçäo das complicaçöes gestacionais e obstétricas. Algumas vezes, o especialista se desvia destes objetivos, podendo trazer à paciente uma complicaçäo iatrogênica. Seräo citadas aqui possíveis complicaçöes e condutas para sua prevençäo.

Importancia pronóstica de la hiperestimulación ovárica controlada previa a laparoscopica terapéutica en pacientes infértiles / Pronostic importance of controlled ovarian hyperestimulation previous to therapeutic laparoscopy in infertile patients

El uso actual del abordaje laparoscópico como parte de la evolución inicial de la pareja infértil en ausencia de patología evidente es controversial, por lo que algunos centros inician la realización de hiperestimulación ovárica controlada (HOC) como paso terapéutico inicial en este grupo de pacientes. El presente trabajo analiza en forma retrospectiva a dos grupos, el primero incluye a pacientes en las cuales se realiza HOC por cuatro ciclos y posteriormente al abordaje laparoscópico; un segundo es sometido a laparoscopia inicialmente y tratamineto médico en caso de requerirse. Ambos grupos son sometidos a HOC posterior al abordaje laparoscópico. Se analiza la importancia pronóstica que representa el uso de HOC previo a la realización de la laparoscopia y si este afecta las tasas de embarazo finales. Los resultados del presente estudio demuestran que no existe repercusión estadísticamente significativa en las tasas de embarazos si la HOC es usada previo al procedimiento. Sin embargo, los embarazos se presentan en forma más temprana en el segundo grupo P<0.05. En conclusión, en pacientes estériles sin patología evidente que indiquen el abordaje laparoscópico obvio, el uso incial de la HOC previo al procedimiento no representa un impacto deletéreo en las tasas de embarazo finales

"Un nuevo parámetro para evaluar la luteinización prematura: la relación molecular preovulatoria entre las concentraciones séricas de progesterona y estradiol" / A new parameter to evaluates the premature luteinization: the preovulatory molecular ratio between serum progesterone and estradiol

El objetivo fue evaluar la relación molecular entre los niveles séricos preoperatorios de progesterona (P) y estradiol (E2) y determinar el efecto que tienen en los resultados obtenidos con fertilización in vitro. Se estudiaron 62 parejas tratadas con el procedimiento, fue establecida la tasa molecular entre P y E2 inmediatamente antes de administrar la gonadotropina coriónica humana (hCG). La concentración de P el día de la aplicación de hCG fue de 1.45 ñ 0.06 ng/mL, el valor de la relación P: E2 fue 0.63 ñ 0.03. Se observaron embarazos a partir de tasas moleculares de 0.22, no hubo gestaciones con tasa > 1.02. No presentaron luteinización prematura en relación con las que no tuvieron. En cuanto a la tasa de implantación aunque fue menor en pacientes con luteinización prematura, no hubo diferencia significativa con pacientes que no la presentaron. Se concluye que la relación mediante fertilización in vitro. En este trabajo como en otros reportes, la luteinización prematura no tuvo efecto sobre los resultados reproductivos

Hiperandrogenemia e insulinorresistencia / Hyperandrogenemia and insulin-resistance

El hiperandrogenismo ovárico funcional es un trastorno de alta prevalencia en las mujeres de edad fértil; más del 30 por ciento de ellas presenta insulinorresistencia (IR). Estas pacientes están expuestas a desarrollar una diabetes no insulinodependiente (DMNID) a edades más tempranas que en la población general. La etiología de la insulinorresistencia asociada a hiperandrogenemia es parcialmente conocida. Se ha observado que la insulina en altas concentraciones estimula la producción de andrógenos en la teca y el estroma de ovarios obtenidos de mujeres con insulinorresistencia e hiperandrogenismo. Se postula, por lo tanto, que sería la insulinorresistencia la que al condicionar una hiperinsulinemia llevaría a una hiperandrogenemia a través del efecto estimulador de la insulina sobre las células tecales del ovario vía receptor de IGF-I. Además la insulina reduce la SHBG aumentando la fracción libre de andrógeno y disminuye la IGFBP-I, lo que aumenta el efecto de IGF-I sobre el ovario. Debido a que los andrógenos son atretogénicos, la insulina favorece la atresia folicular y la mayor secreción de andrógenos por el ovario lo que tiene como consecuencia una disminución de la producción de estrógenos, lo que crea un desbalance en favor de los andrógenos

Síndrome de hiperestimulaçäo ovariana: relato de um caso / Ovarian hyperestimulation syndrome: a case report

The authors report a case of ovarian hyperstimulation syndrome in ovulation induction with clomifene citrate, HMG and HCG to in vitro fertilization. There was total retum with an albumina I.V. and emphasize the estradiol in a series of dosages and the folicular development by ultrasound

Síndrome da hiperestimulaçäo ovariana / Ovarian hyperstimulation syndrome

No presente trabalho os autores fazem uma revisäo sobre a Síndrome de Hiperestimulaçäo Ovariana (SHO), tecendo consideraçöes sobre classificaçäo, fisiopatologia, quadro clínico e laboratorial, tratamento e prevençäo