European Journal of Case Reports in Internal Medicine | 2019
Immunoglobulin Treatment in Severe Ovarian Hyperstimulation Syndrome
Abstract
A 32-year-old woman undergoing an in vitro fertilization program was admitted to our hospital with the diagnosis of severe ovarian hyperstimulation syndrome (OHSS). Transvaginal ultrasonography showed two gestational sacs. Treatment with fluid restriction, serum albumin and intravenous furosemide was started, and repeated thoracentesis and paracenteses were performed. In the absence of clinical improvement, the patient was transferred to the intensive care unit and a therapeutic abortion was suggested. Due to the similarities between OHSS and idiopathic systemic capillary leak syndrome, we offered the patient compassionate treatment with intravenous immunoglobulins. After administration, the patient showed rapid improvement and we were able to suspend intravenous furosemide and serum albumin. She was discharged, and pregnancy has continued normally to date. \n \nLEARNING POINTS \n \nOHSS is an infrequent yet serious complication of assisted reproductive treatment that involves increased capillary permeability. \n \n \nIn severe refractory cases, immunoglobulins may be a useful and safe treatment to reverse this syndrome. \n \n \n \n \n \nKeywords: Severe ovarian hyperstimulation syndrome, immunoglobulins \n \n \nCASE DESCRIPTION \nA 32-year-old woman with hereditary optic atrophy due to mutation of the OPA1 gene was admitted to hospital for dyspnoea. The patient was in an in vitro fertilization program. She had been treated with FSHr and GnRH for ovarian stimulation with subsequent administration of HCGr and implantation of two embryos free of the OPA1 mutation, 5 days before admission. Physical examination revealed grade 2 ascites and bilateral lower limb oedema. Blood analysis showed haemoglobin of 16.6 g/dl, sodium 133 mmol/l, albumin 3.3 g/l and βHCG 200 mU/ml, with preserved renal and hepatic function. Transvaginal ultrasonography demonstrated enlarged ovaries with free fluid in the pelvis and two gestational sacs. Following the diagnosis of OHSS, fluid restriction and thromboembolic prophylaxis were started. On the sixth day after admission, abdominal distension and dyspnoea increased, together with hypotension and signs of haemoconcentration. Ultrasonography demonstrated severe pleural effusion and ascites. Electrocardiogram and echocardiogram findings were within the normal range. Serum albumin and intravenous furosemide were added, alongside repeated paracentesis and thoracentesis. Given the persistence of dyspnoea with refractory pleural effusion, a thoracic drainage tube was placed, and the patient was transferred to the intensive care unit. \n \nIn the following days symptoms persisted and a therapeutic abortion was suggested. Given the similarities between OHSS and idiopathic systemic capillary leak syndrome (SCLS), we offered the patient compassionate treatment with intravenous immunoglobulins (IVIG) which has previously proven useful in SCLS. After administration of IVIG (0.5 g/kg/day for 3 consecutive days), the patient showed rapid improvement, and we were able to suspend intravenous furosemide and serum albumin and to remove the thoracic drainage tube. The patient was discharged, and pregnancy has continued normally to date.