Ovaries, ascites, bulldogs - oh my!

[Setting the scene: It's a cold, fluorescent lit night in the ED, you've been working overnights and your eyelids are heavy - then the doorway darkens and there she stands; a patient, a woman, a puzzle.]

History

Patient is a 32 year old female, who arrives with dyspnea, abdominal pain and distention, nausea and vomiting. 3 days ago, she developed abdominal pain, followed by nausea, vomiting, and abdominal distention. Today, in addition to her other symptoms, patient began feeling short of breath.

She denies fever, hematemesis, dark tarry stools, or frank blood with stools. She has no history of blood clots and no recent long travel. She denies pleuritic chest pain or leg pain. No known sick contacts.

Patient has no significant past medical history, denies pregnancy and notes she is currently undergoing fertility treatment. Upon chart review you see she was treated with GnRH agonists and gonadotropins in hopes to induce ovulation 5 days ago.

Additionally, patient recently adopted a french bulldog puppy. She is extremely concerned that her pooch has taken a tumble and will not be able to right itself while she away from home in the ED.

Social History:

Non-smoker, denies alcohol or illicit drugs

Lives with her husband and works full time as an attorney

Medications:

Daily prenatal vitamin

NKDA

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Exam:

Vitals: Temp 97.9 F, HR 118, BP 86/52, RR 24, sats 96%

Her abdomen is distended, tense, and tender at the RLQ and LLQ. Patient has lower extremity non-pitting edema, she appears dyspneic and her lungs sounds are diminished. Heart is tachycardic with no murmur or rub.

Differentials:

Negative pregnancy eliminates many possible differentials.

Gastroenteritis. Viral illness. Ovarian cysts. Ovarian torsion. PID. TOA. Acute appendicitis. Acute cholecystitis. Acute hepatitis. Viral URI. Pneumonia. Electrolyte derangement. Renal failure. PE. Heart failure. ARDS. Sepsis.

Labs:

UPT collected in triage is negative

UA: concentrated, LE positive, 8 WBCs, no hematuria

CBC: WBC 21.2, Hgb 10.9, HCT 41

CMP: ALT 95, AST 110, BUN 36, Creatinine 1.6, K 5.3, Na 128, Albumin 3.1, Protein 5.5

EKG: Sinus tachycardia, no right heart strain (no S1, Q3, T3). T waves look peaked

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Next steps:

Get a D-Dimer?

-She’s tachycardic, SOB, no pleuritc CP, no hypoxia. Bilateral LE edema.

-D Dimer positive 0.7 (of course!)

Any other labs?

-Do you trust the negative UPT? Do you get a Quant HCG?

-Quant HCG <1

Imaging:

CT Abd/pelvis: Reveals ascites, enlarged ovaries, free fluid in the pelvis, radiology recommends pelvic US to further evaluate pelvic findings.  Normal appearing appendix. Normal appearing gallbladder.

US: enlarged ovaries bilateral 15 cm, with multiple follicles of varying size bilaterally in a wheel spoke appearance, good arterial and venous blood flow, moderate free fluid in the pelvis. No blush seen to suggest active bleed.

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OHSS

Ovarian hyperstimulation syndrome (OHSS) is a rare, iatrogenic complication for ovarian stimulation by assisted reproduction technology and other infertility treatments. Following gonadotropin therapy, OHSS usually develops several days after oocyte retrieval or assisted ovulation. This syndrome is characterized by ovarian enlargement due to multiple ovarian cysts and an acute fluid shift into the extravascular space. Complications of OHSS include ascites, hemoconcentration, hypovolemia, and electrolyte imbalances.

To read more about OHSS check out this link from emedicine (medscape): http://emedicine.medscape.com/article/1343572-overview

Questions:

1. The risk factors of Ovarian Hyperstimulation Syndrome include:
a. low BMI
b. age <35
c. hx of PCOS
d. all of the above

2. T or F.  Leakage of fluid from large follicles, increased capillary  permeability and/or frank rupture of follicles can all contribute to ascites.

3. Mild Ovarian Hysterstimulation Syndrome includes the following:

a. ascites
b. ovarian enlargement 5-12 cm
c. hydrothorax
d. decreased renal function

4. T or F. Patients with OHSS have an increased risk of developing deep venous thromboses and pulmonary embolisms.

5. T or F. A hallmark U/S finding in OHSS is wheel spoke appearance of the ovaries.

Sources:

• American Society of Reproductive Medicine. Ovarian Hyperstimulation Syndrome. (2008;90:S188-93). 
• Lucidi, R.S. Ovarian Hyperstimulaiton Syndrome. (Medscape 1343572).
• Whelan J, Vlahos N. The ovarian hyperstimulation syndrome. Fertility and Sterility (2000); 7