35-year-old woman with mild ovarian hyperstimulation syndrome

Author: Mikael Häggström

This is a case report of a 35-year-old Swedish woman who presented to Gävle Hospital in 2014 with mild ovarian hyperstimulation syndrome.

Background
This otherwise healthy woman underwent IVF because of male factor. The IVF cycle included nafarelin as GnRH agonist and a recombinant FSH preparation (follitropin alfa). 11 days after co-incubation she started having squeezing pain in her entire abdomen. This was accompanied by a feeling of abdominal distension, dyspnea on exertion and nausea. However, there was no vomiting or impression of decreased urine output.

Examination and blood test
Physical examination 16 days after co-incubation included a mildly distended abdomen. A venipuncture showed a sodium level of 133 mmol/l (normally at least 135 mmol/l) and an albumin level of 35 g/L (normally at least 35 g/L) Other blood parameters were normal, including blood panel and liver panel.

Ultrasonography
Ultrasonography was performed in mainly two planes, the sagittal plane and the coronal plane as detailed below:

Sagittal plane
 The sagittal plane is a vertical plane which passes from ventral (front) to dorsal (rear). Vaginal ultrasonography in this plane showed a 33 mm wide anechogenic area behind the uterus in the recto-uterine pouch, which means there was ascites, that is, free fluid in the peritoneal cavity. Normally, there is up to 5 ml of fluid in the recto-uterine pouch, corresponding approximately to a an area up to 10 mm wide.

Coronal plane
 A coronal plane divides the body into ventral and dorsal (belly and back) sections. Vaginal ultrasonography in this plane showed enlarged ovaries, both with a mean diameter of approximately 6 cm. Both contained large follicles. Normally, an ovary is about 4 cm x 3 cm x 2 cm in size.

Management
The patient was recommended an intake of plenty of fluids, addition of salt in her food, acetaminophen for pain relief rather than NSAIDs (because of the risk of kidney dysfunction by usage of the latter), as well as avoidance of strenuous activities, including sexual intercourse because of risk of ovarian torsion.

A follow-up two days later demonstrated an improvement in symptoms, amount of ascites as well as laboratory parameters.