Young Ischemic Stroke in Association with Ovarian Hyperstimulation Syndrome

Venous Thromboembolism Issues in Women

The lifetime risk of venous thromboembolism (VTE) is slightly higher in women than in men. There are several issues related to VTE that are unique to women. Combined hormonal contraceptives and pregnancy increase the risk of VTE in women of childbearing age, whereas hormone replacement therapy increases the VTE risk of postmenopausal women. Hereditary thrombophilia and risk factors such as older age, obesity, or smoking contribute to the risk increase. In women diagnosed with acute hormone-related VTE who are treated with oral anticoagulants, adequate contraception is mandatory to avoid unwanted pregnancies. According to current knowledge, hormonal contraception may be continued during anticoagulant therapy but must be switched to an estrogen-free contraception method at least 6 weeks before the termination of anticoagulation. VTE is also a major cause of maternal morbidity and mortality during pregnancy and the postpartum period. Currently, assisted reproduction technologies such as in vitro fertilization are widely used to treat couples affected by infertility. Complications of fertility treatment comprise VTE cases, especially in women with ovarian hyperstimulation syndrome. With this review, we intended to focus on VTE issues in women and summarize current evidence and guideline recommendations.

MULTIPLE ACUTE POSTERIOR CIRCULATION STROKE WITH LESIONS IN THE PONS AND BOTH HEMISPHERES OF THE CEREBELLUM ASSOCIATED WITH OVARIAN HYPERSTIMULATION SYNDROME: A CASE REPORT OF A WHITE EUROPEAN ADULT IN UKRAINE

We have presented a brief literature overview of the disease, supported by a clinical case of multiple acute posterior circulation strokes with lesions in the pons and both hemispheres of the cerebellum associated with ovarian hyperstimulation syndrome in a white young European adult in Ukraine. Specific features of posterior circulation stroke associated with ovarian hyperstimulation syndrome were determined, analyzed, and described. Complex posterior circulation cerebral infarction in the pons and both hemispheres of the cerebellum associated with ovarian hyperstimulation syndrome has not been reported before but has devastating consequences for both mother and fetus. Strokes in patients with OHSS must be timely prevented, promptly diagnosed, and treated to avoid high morbidity and mortality associated with it.

Coagulation and Fibrinolysis Biomarkers as Potential Indicators for the Diagnosis and Classification of Ovarian Hyperstimulation Syndrome

Background: Accurate diagnosis and classification of ovarian hyperstimulation syndrome (OHSS) is important for its management. We employed a new high-sensitivity chemiluminescence immunoassay to detect the thrombin-antithrombin complex (TAT), plasmin alpha2-plasmin inhibitor complex (PIC), soluble thrombomodulin (sTM), and tissue plasminogen activator-inhibitor complex (TPAI-C), and evaluated their diagnostic and classification performance for OHSS.

Methods: A total of 106 women were enrolled, including 51 patients with OHSS (25 mild or moderate OHSS, 26 severe OHSS), and 55 without OHSS (control group). TAT, PIC, sTM, and TPAI-C levels were measured using the Sysmex HISCL5000 automated analyzer.

Results: Compared to the control group, TAT, PIC, and TPAI-C levels were significantly higher (P < 0.001, P < 0.001, P < 0.001, respectively), whereas the sTM level was significantly lower (P < 0.001) in the patients with OHSS. The receiver operating characteristic was used to evaluate the diagnostic efficiency. For the diagnosis of OHSS, the area under the curves (AUCs) for TAT, PIC, sTM, and TPAI-C were 0.991, 0.973, 0.809, and 0.722, respectively. In particular, the sensitivity, specificity, positive predictive value, and negative predictive value for TAT and PIC were all above 90%. For the differential diagnosis of mild–moderate and severe OHSS, the AUCs for TAT, PIC, and TPAI-C were 0.736, 0.735, and 0.818, respectively. The cutoff values of TAT, PIC, and TPAI-C for the differential diagnosis of mild–moderate and severe OHSS were 11.5 ng/mL, 2.4 μg/mL, and 5.8 ng/mL, respectively. Based on these cutoff values, eight cases of mild–moderate OHSS exceeded the cutoff values, two of which developed to severe OHSS in the following days. However, of the remaining 17 cases of mild–moderate OHSS patients with negative biomarkers, none subsequently developed severe OHSS.

Conclusions: TAT, PIC, sTM, and TPAI-C can be used as sensitive biomarkers in the diagnosis of OHSS. Meanwhile, TAT, PIC, and TPAI-C also displayed remarkable potential in the classification of OHSS. In addition, the levels of TAT, PIC, and TPAI-C above the cutoff values in patients with mild–moderate OHSS might predict a high risk of developing severe OHSS.

Prior Thromboembolic Disease and Assisted Reproductive Therapy

Assisted reproductive therapy (ART) increases the risk of venous thrombosis (VT) by 2- to 4-fold, whereas pregnancy increases the risk by 5- to 10-fold. Women with a history of VT undergoing ART are often suggested thromboprophylaxis. The literature is scarce and international guidelines are lacking. We made a review of the literature and base our suggestions primarily on expert opinions. We suggest women with a prior VT to use low-molecular-weight heparin as thromboprophylaxis starting from ovarian stimulation, throughout pregnancy, and 6 weeks postpartum. Assessment of VT risk should be done prior to ART. Adjustment of treatment to minimize the thrombotic risk, such as preventing ovarian hyperstimulation syndrome, single-embryo transfer, cryopreservation, and transfer of frozen embryos instead of fresh embryo in high-risk women, is suggested. Women with previous arterial thrombosis should continue aspirin during ART treatment, pregnancy, and postpartum.

Ischemic Stroke Associated With Ovarian Hyperstimulation Syndrome

BACKGROUND

Ovarian hyperstimulation syndrome (OHSS) is the most serious complication of assisted reproductive technology. Severe OHSS may be accompanied by thromboembolic events, such as pulmonary thromboembolism or acute respiratory distress syndrome. Ischemic stroke may occur in rare cases.

CASE REPORT

We report a 32-year-old woman with a recent medical history of OHSS who presented to the emergency department (ED) with acute onset of impaired consciousness. Her initial Glasgow Coma Scale score was 10 (E3V3M4). History taking and a thorough physical examination were impossible because of the patient's mental status. Additional medical history was obtained with the assistance of the patient's husband. Ischemic stroke was confirmed on diffusion-weighted magnetic resonance imaging performed after a basic examination and confirmation of normal findings on a noncontrast brain computed tomography scan. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although the incidence of cerebral infarction is low in younger patients, emergency physicians treating young women in the ED who have recently undergone fertility treatment or have been diagnosed with OHSS should be aware of the possibility of complications caused by OHSS. Specifically, if these patients complain of traditional or nontraditional neurologic symptoms during an ED visit, stroke should be strongly suspected.. This awareness will reduce the incidence of sequelae through prompt examination and treatment.

Application of non-invasive detection of peripheral vascular dysfunction in ovarian hyperstimulation syndrome (OHSS): A pilot study of clinical relevance

OBJECTIVE

The current study tested the hypothesis that vascular endothelial function, as reflected by the reactive hyperemia index (RHI), and biochemical factors, including VEGF, TNFα, CRP, inhibin A, and inhibin B, were involved in the pathogenesis of ovarian hyperstimulation syndrome (OHSS).

MATERIALS AND METHODS

This study was conducted between June 2010 and June 2012, enrolling 15 patients with OHSS and 6 healthy control subjects <45 years of age. Detailed clinical parameters were reviewed, including serum VEGF, TNFα, CRP, inhibin A, inhibin B, and hematocrit. RHI assessed by novel automatic peripheral arterial tonography was used to evaluate the vascular endothelial function.

RESULTS

Twenty-one subjects were evaluated. There was no significant difference between patients with OHSS and control subjects with respect to VEGF, TNFα, CRP, inhibin A and inhibin B. The RHI was not significantly different between patients with OHSS and control subjects (mean, 1.8 ± 0.4 vs. 1.7 ± 0.2). The hematocrit was significantly different between patients with OHSS and control subjects.

CONCLUSIONS

Our preliminary data did not reveal direct evidence of vascular endothelial dysfunction in patients with OHSS. To identify whether RHI could reflect vascular endothelial dysfunction in patients with OHSS, more cases with different severities of OHSS should be recruited in the future study.