Diagnostic Ultrasound - Abdomen and Pelvis
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Diagnostic Ultrasound - Abdomen and Pelvis

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Ovarian Hyperstimulation Syndrome TERMINOLOGY Abbreviations • Ovarian hyperstimulation syndrome (OHSS) Definitions • Clinical syndrome generally associated with ovulation induction ○ Hyperstimulated, enlarged ovaries ○ Increased vascular permeability – Ascites – ± pleural effusion IMAGING Ultrasonographic Findings • Bilaterally enlarged, cystic ovaries ○ > 5-10 cm diameter ○ Multiple cysts in ovary ○ Cysts may be simple or complex if hemorrhagic component present • Ascites ○ May have internal echoes due to high protein content • Pleural effusion MR Findings • Not usually required for diagnosis ○ Most often used to distinguish hyperstimulated ovaries from ovarian neoplasm – Cysts typically high signal on T2WI if simple – Cysts may be intermediate to low signal on T2WI ifhemorrhagic components present • Typical "spoke-wheel" appearance of ovaries ○ Enlarged follicles separated by thin septa ○ Centrally located stromal tissue • Ascites ○ May be simple orhemorrhagic secondary to oocyte retrieval or rupture of follicle DIFFERENTIAL DIAGNOSIS Theca Lutein Cysts • Multiple cysts within enlarged ovaries • Not associated with ascites, pleural effusions, or oliguria • Multiple etiologies ○ Multiple gestation ○ Exogenous hormonal stimulation ○ Gestational trophoblastic disease ○ Triploidy Hyperreactio Luteinalis • More mild, indolent course within spectrum of OHSS • Bilateral ovarian enlargement with multiple theca lutein cysts • Always associated with pregnancy • High maternal human chorionic gonadotropin (hCG) serum levels ○ No exogenous hCG administered ○ May be response to chronic exposure to elevated hCG levels Cystic Ovarian Neoplasm • Usually unilateral • Serous cystadenoma/cystadenocarcinoma • Mucinous cystadenoma/cystadenocarcinoma • Cystic germ cell tumors Polycystic Ovarian Syndrome • Bilateral enlarged ovaries with hyperechoic central stroma • Multiple small peripheral follicles ("string of pearls") • Chronic anovulation • Associated with obesity and insulin resistance Heterotopic Pregnancy • Echogenic peritoneal fluid • Adnexal mass • Higher risk in women undergoing ovulation induction PATHOLOGY General Features • Exaggerated response to ovulation induction ○ Almost exclusively associated with exogenous gonadotropin use ○ Numerous potential pathophysiologic mediators – Cytokines – Growth factors • Most likely associated with vascular endothelial growth factor (VEGF) ○ Granulosa cells are 1 site of production ○ hCG and VEGF serum levels correlate with severity of OHSS • Paradoxical arterial dilation and ↓ peripheral vascular resistance ○ Leads to compensatory release of vasoactive substances – Aldosterone – Antidiuretic hormone – Norepinephrine – Renin ○ Increased permeability of peritoneal and pleural surfaces – Protein-rich fluid leaks out of intravascular space – Leads to ascites and pleural effusions Gross Pathologic & Surgical Features • Ovaries appear similar to changes seen with theca lutein cysts ○ Bilaterally enlarged ○ Multiple follicular cysts with prominent luteinization of theca interna layer • Corpus luteum present ○ May be more than 1 CLINICAL ISSUES Presentation • Most common signs/symptoms ○ Abdominal pain ○ Nausea/vomiting/diarrhea ○ Weight gain ○ Oliguria • Other signs/symptoms ○ Abdominal distention from ascites Diagnoses: Female Pelvis 809

Ovarian Hyperstimulation Syndrome 810 Diagnoses: Female Pelvis ○ Shortness of breath from pleural effusion ○ Hypotension ○ Electrolyte imbalance ○ Hepatic dysfunction • Relative hemoconcentration due to fluid leaking into peritoneal/pleural spaces ○ Oliguria ○ Hypercoagulability • Rarely associated with venous occlusive disease or thromboembolic events ○ Usually only with severe OHSS Demographics • Epidemiology ○ Typically seen in women undergoing ovulation induction – More commonly with gonadotropin stimulation for in vitro fertilization (IVF) – Less commonly seen with clomiphene induction □ Severe form rarely seen ○ Mild OHSS: 20-33%of IVF cases ○ Moderate OHSS: 3-6% of IVF cases ○ Severe OHSS: 0.1-2.0% of IVF cases • Risk factors ○ Polycystic ovarian syndrome major risk factor – May be related to increased number of follicles/oocytes produced when stimulated – Oligomenorrhea itself also risk factor ○ Greater number of follicles stimulated during IVF – High or rapidly increasing serum estradiol ○ Younger age ○ Previous OHSS history ○ Low body mass index Natural History & Prognosis • Occurs after ovulation ○ Early type occurs < 5 days after oocyte retrieval – Induced by exogenous hCG administration ○ Late type occurs ≥ 5 days (range 5-15 days) after oocyte retrieval – Induced by endogenous hCG from implanted pregnancy – Late type always associated with pregnancy • Should be self-limiting as long as supportive care started early in process • Usually regresses over 10-14 days unless pregnancy implantation occurs ○ Subsequently can have increase in endogenous hCG ○ May prolong OHSS or initiate late form of OHSS • More severe in patients who become pregnant • Severe OHSS potentially life-threatening ○ Mortality estimated at 1:45,000 cases of OHSS Treatment • No known therapy to immediately reverse OHSS • Avoid pelvic trauma to ovaries ○ No intercourse, pelvic exams, strenuous exercise • Conservative therapy with observation warranted ○ May be monitored as outpatient – Frequent vital sign and electrolyte checks ○ Maintain intravascular volume and urine output – 24 urine volume measurements – Daily weights ○ Consider US-guided paracentesis or thoracentesis for symptoms – Serial abdominal girth measurements ○ Prophylactic anticoagulation – Useful due to relative hemoconcentration • Some advocate proactive management to shorten course of symptoms ○ Most often considered if moderate to severe OHSS ○ Actively administer fluids &/or albumin – Diuretics considered when adequate intravascular volume achieved ○ Benefits of US-guided paracentesis – ↓ hospitalization – ↓ hemoconcentration – ↑ urine output – Ameliorates electrolyte abnormalities • May require hospitalization for management of severe symptoms ○ Intractable pain ○ Intractable nausea/vomiting ○ Respiratory difficulties ○ Suspected infection/hemorrhage • Surgical intervention only rarely required ○ Ovarian torsion ○ Cyst rupture with hemoperitoneum • Partial oophorectomy for severe cases reported DIAGNOSTIC CHECKLIST Image Interpretation Pearls • Avoid aggressive transvaginal imaging as ovaries can be friable • Correlate imaging appearance of ovaries with clinical history for diagnosis SELECTED REFERENCES 1. Mathur RS et al: British fertility society policy and practice committee: prevention of ovarian hyperstimulation syndrome. Hum Fertil (Camb). 17(4):257-68, 2014 2. Nastri CO et al: Ovarian hyperstimulation syndrome: physiopathology, staging, prediction and prevention. Ultrasound Obstet Gynecol. ePub, 2014 3. Thornton KG et al: Ovarian Hyperstimulation Syndrome and Arterial Stroke. Stroke. ePub, 2014 4. Baron KT et al: Emergent complications of assisted reproduction: expecting the unexpected. Radiographics. 33(1):229-44, 2013 5. Tan BK et al: Management of ovarian hyperstimulation syndrome guidelines. Produced on behalf of the BFS Policy and Practice Committee. Hum Fertil (Camb). 16(3):160-1, 2013 6. Kumar P et al: Ovarian hyperstimulation syndrome. J Hum Reprod Sci. 4(2):70-5, 2011 7. Nastri CO et al: Ovarian hyperstimulation syndrome: pathophysiology and prevention. J Assist Reprod Genet. 27(2-3):121-8, 2010 8. Zivi E et al: Ovarian hyperstimulation syndrome: definition, incidence, and classification. Semin Reprod Med. 28(6):441-7, 2010 9. Bartkova A et al: Acute ischaemic stroke in pregnancy: a severe complication of ovarian hyperstimulation syndrome. Neurol Sci. 29(6):463-6, 2008 10. Kim IY et al: Ovarian hyperstimulation syndrome. US and CT appearances. Clin Imaging. 21(4):284-6, 1997

Ovarian Hyperstimulation Syndrome<br />

TERMINOLOGY<br />

Abbreviations<br />

• Ovarian hyperstimulation syndrome (OHSS)<br />

Definitions<br />

• Clinical syndrome generally associated with ovulation<br />

induction<br />

○ Hyperstimulated, enlarged ovaries<br />

○ Increased vascular permeability<br />

– Ascites<br />

– ± pleural effusion<br />

IMAGING<br />

Ultrasonographic Findings<br />

• Bilaterally enlarged, cystic ovaries<br />

○ > 5-10 cm diameter<br />

○ Multiple cysts in ovary<br />

○ Cysts may be simple or complex if hemorrhagic<br />

component present<br />

• Ascites<br />

○ May have internal echoes due to high protein content<br />

• Pleural effusion<br />

MR Findings<br />

• Not usually required for diagnosis<br />

○ Most often used to distinguish hyperstimulated ovaries<br />

from ovarian neoplasm<br />

– Cysts typically high signal on T2WI if simple<br />

– Cysts may be intermediate to low signal on T2WI<br />

ifhemorrhagic components present<br />

• Typical "spoke-wheel" appearance of ovaries<br />

○ Enlarged follicles separated by thin septa<br />

○ Centrally located stromal tissue<br />

• Ascites<br />

○ May be simple orhemorrhagic secondary to oocyte<br />

retrieval or rupture of follicle<br />

DIFFERENTIAL DIAGNOSIS<br />

Theca Lutein Cysts<br />

• Multiple cysts within enlarged ovaries<br />

• Not associated with ascites, pleural effusions, or oliguria<br />

• Multiple etiologies<br />

○ Multiple gestation<br />

○ Exogenous hormonal stimulation<br />

○ Gestational trophoblastic disease<br />

○ Triploidy<br />

Hyperreactio Luteinalis<br />

• More mild, indolent course within spectrum of OHSS<br />

• Bilateral ovarian enlargement with multiple theca lutein<br />

cysts<br />

• Always associated with pregnancy<br />

• High maternal human chorionic gonadotropin (hCG) serum<br />

levels<br />

○ No exogenous hCG administered<br />

○ May be response to chronic exposure to elevated hCG<br />

levels<br />

Cystic Ovarian Neoplasm<br />

• Usually unilateral<br />

• Serous cystadenoma/cystadenocarcinoma<br />

• Mucinous cystadenoma/cystadenocarcinoma<br />

• Cystic germ cell tumors<br />

Polycystic Ovarian Syndrome<br />

• Bilateral enlarged ovaries with hyperechoic central stroma<br />

• Multiple small peripheral follicles ("string of pearls")<br />

• Chronic anovulation<br />

• Associated with obesity <strong>and</strong> insulin resistance<br />

Heterotopic Pregnancy<br />

• Echogenic peritoneal fluid<br />

• Adnexal mass<br />

• Higher risk in women undergoing ovulation induction<br />

PATHOLOGY<br />

General Features<br />

• Exaggerated response to ovulation induction<br />

○ Almost exclusively associated with exogenous<br />

gonadotropin use<br />

○ Numerous potential pathophysiologic mediators<br />

– Cytokines<br />

– Growth factors<br />

• Most likely associated with vascular endothelial growth<br />

factor (VEGF)<br />

○ Granulosa cells are 1 site of production<br />

○ hCG <strong>and</strong> VEGF serum levels correlate with severity of<br />

OHSS<br />

• Paradoxical arterial dilation <strong>and</strong> ↓ peripheral vascular<br />

resistance<br />

○ Leads to compensatory release of vasoactive substances<br />

– Aldosterone<br />

– Antidiuretic hormone<br />

– Norepinephrine<br />

– Renin<br />

○ Increased permeability of peritoneal <strong>and</strong> pleural surfaces<br />

– Protein-rich fluid leaks out of intravascular space<br />

– Leads to ascites <strong>and</strong> pleural effusions<br />

Gross Pathologic & Surgical Features<br />

• Ovaries appear similar to changes seen with theca lutein<br />

cysts<br />

○ Bilaterally enlarged<br />

○ Multiple follicular cysts with prominent luteinization of<br />

theca interna layer<br />

• Corpus luteum present<br />

○ May be more than 1<br />

CLINICAL ISSUES<br />

Presentation<br />

• Most common signs/symptoms<br />

○ Abdominal pain<br />

○ Nausea/vomiting/diarrhea<br />

○ Weight gain<br />

○ Oliguria<br />

• Other signs/symptoms<br />

○ Abdominal distention from ascites<br />

Diagnoses: Female <strong>Pelvis</strong><br />

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