Management of severe ovarian hyperstimulation syndrome with thawed plasma
A 27-year-old female with primary infertility was seen in our unit in March 2011. She had regular periods and her body mass index was 25 kg/m2. Her baseline investigations were normal and ultrasound report revealed polycystic ovaries. Her husband's semen-analysis report revealed azoospermia. His clinical and biochemical findings were suggestive of obstructive azoospermia. After counseling regarding the treatment options available, a diagnostic percutanous epididymal sperm aspiration was performed which revealed presence of motile sperms. The couple decided to go ahead with ART.\nCycle programming was done using combined oral contraceptive pills and controlled ovarian hyperstimulation was started after onset of menstruation using with recombinant follicle stimulating hormone (FSH) and multiple dose flexible antagonist (0.25 mg) regimen was followed. Injection human chorionic gonadotrophin (hCG) 5000 international units (IU) intramuscular was administered once more than three follicles reached a diameter of 17 mm. Serum estradiol (E2) on the day of hCG trigger was more than 3800 pg/mL and expected number of follicles was 14-15. She underwent ultrasound guided transvaginal oocyte retrieval and a total of 13 metaphase II oocytes were retrieved. She received 100 ml infusion of human albumin (20% solution) over 4 h, prophylactically after oocyte retrieval. Intracytoplasmic sperm injection was performed using surgically retrieved sperms and 10 fertilized oocytes were obtained the next day. On day 2, three grade 2 cleavage embryos were transferred.[] Supernumerary embryos were cultured and eventually two blastocysts were cryopreserved.\nPatient received luteal support in the form of daily vaginal micronized progesterone 400 mg twice daily and was given intramuscular injection of progesterone 100 mg weekly twice. The patient was advised to take high protein diet and to maintain the total fluid intake/output records which was evaluated once in 3 days for signs and symptoms of OHSS.\nOn post-retrieval, day 9, the patient presented with complaints of severe abdominal discomfort, vomiting, difficulty in breathing and decreased urine output. Her abdominal girth had increased from 72 cm to 84 cm. Her blood test revealed hemoconcentration (hematocrit was 54%), raised liver enzymes, and low sodium (122 mEq/L). An ultrasound of the abdomen revealed bilateral enlarged ovaries (right ovarian size was 11 × 10 × 9 cm and left ovarian size was 10 × 8 × 8 cm) with significant ascitis []. Chest X-ray (an abdominal shield was used) showed bilateral pleural effusion. The patient was diagnosed with severe OHSS and admitted to the intensive care unit. Intravenous fluid administration, analgesics, anti-emetics, and prophylactic anti-coagulation with low molecular weight heparin 2500 IU subcutaneously were initiated. After stabilization, patient underwent therapeutic pleural tap and ultrasound-guided abdominal paracentesis. A total of 2.5 L of ascitic fluid was drained. The patient's symptoms were relieved temporarily. The patient's clinical and biochemical parameters were monitored on a daily basis. The patient was advised to wear elastic stockings and high protein diet intake. Infusion of human albumin was also given once daily.\nHowever, within 2 days the patient had recurrence of abdominal discomfort and difficulty in breathing due to collection of ascitic fluid. A repeat paracentesis was carried out and further 2.5 L of fluid was drained out. Barring low albumin levels (2.1 g/dL) rest of the biochemical parameters were stabilizing (hematocrit 34%). However, despite a high protein diet and daily infusion of albumin, the albumin levels kept deteriorating. Further she developed severe anaphylactic reaction after human albumin infusion on day 13 post-retrieval, which necessitated discontinuation of infusion. Despite all prophylactic measures prompt recognition and early aggressive treatment of OHSS, the patient's condition did not show any signs of improvement. She had rapid re-accumulation of ascitic fluid and due to worsening of symptoms, we had to resort to repeated paracentesis in order to relieve her of her discomfort. However, the serum albumin levels had fallen to alarming levels (1.7 g/dL) partly due to ascitic fluid tapping. The patient developed signs and symptoms hypoalbuminemia in the form of generalized puffiness of the body, face and limbs, and developed vulval edema. Her serum beta HCGs levels were 30 mIU/L (day 10, post-retrieval). With early pregnancy, worsening late OHSS, and severe hypoalbuminemia, rapid re-accumulating of ascites and drainage lead to loss of protein rich fluid, inadequate replacement of protein lead to further lowering of albumin, further contributing to rapid re accumulation of ascitis. Abdominal paracentesis was done 6 times and on day 20, after consulting the medical oncologist, who was familiar with treatment of rapidly accumulating ascitis, as a last resort we decided to transfuse the patient with thawed plasma.\nPatient was transfused four units of thawed plasma in 48 h. The transfusion volume was calculated (10-15 mL/kilo body weight). This resulted in a dramatic improvement in the patient's condition as reflected by significant increase in urine output and stabilization of abdominal girth (indicating no clinically significant re-accumulation of ascitic fluid). Most importantly her serum albumin level started rising (2.5 g/dL immediate post-transfusion). No further paracentesis was required and patient was discharged day 26 post-retrieval.\nThe patient's serum beta HCG levels on day 18 after oocyte retrieval was 522.4 mIU/L and after 14 days the transvaginal ultrasound revealed twin intrauterine gestation sacs with a yolk sac and a fetal pole in each sac but no cardiac activity []. Subsequently, a repeat ultrasound was done a week later and the patient was diagnosed with missed abortion and the pregnancy terminated. The patient was discharged and planned for frozen embryo transfer at a later date.